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Dallas Caruth

EMS Education

STEMI Workbook

EMS Education Workbook Endorsed by:

_____________________________________________ ____________________________________________

Dr. Ray Fowler M.D. Dr. Robert Simonson D.O.

_____________________________________________

Dr. Suresh Chavda M.D.

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Vision and Mission of the Dallas Caruth InitiativeThe vision of the DallasCaruth Initiative is the imple-mentation of a coordinatedhealthcare system in Dallas

County. This system will pro-vide the most efficient care ofSTEMI and Non-STEMI pa-tients from symptom recogni-tion to reperfusion in a car-diac catheterization lab.

The mission of the DallasCaruth Initiative is to provideeffective education in supportof a community wide health-

care delivery system in Dal-las County aiming at reduc-ing morbidity and mortalityfor people who experience aSTEMI or Non-STEMI.

tablishing coordinated prac-

tices between EMS and hos-pital cardiac care programs.The staff of the Dallas CaruthInitiative encourage you toreturn to your station or officeand discuss with your col-leagues how you may con-tinue to develop and im-prove cardiac care in DallasCounty.

As the EMT or Paramedic

who makes initial contactwith patients each shift, youare the secret behind thesuccess of a coordinated pre-hospital STEMI program.Our goal is that each pro-vider may use the informa-tion included in this workbookto modify and improve thecare that you provide by es-

4. The provider should beable to identify patientswhom are at greater riskfor having a myocardialinfarction.

5. The provider will be ableto list the criteria for acti-vation of a Code STEMI.

6. The provider will be ableto identify means to re-duce time from patientcontact through transportto the receiving hospital.

7. The provider will be ableto describe the importancefor early activation of thehospital through phonecall and ECG transmis-sion.

8. The provider will be able

to identify the closestappropriate receivingfacility for patients suffer-ing STEMI or Non-STEMI myocardial infarc-tions.

9. The provider will be ableto describe the impor-tance of their role uponarrival at the receivinghospital including contin-ued use of the EMS ECGmonitor and use of the

EMS stretcher.

Upon completion of the DallasCaruth EMS STEMI Guide thefollowing objectives should bemet:

1. The provider should beable to name three typicaland atypical signs andsymptoms of acute coro-nary syndrome.

2. The provider should beable to identify patientswho should be selected

for 12-Lead ECG analysis.3. The provider should ableto describe the importancein properly accomplishinga rapid ECG early in thetreatment of a patient withACS.

Dallas Caruth - EMS Educational Objectives

You are the secret to success in Dallas County...

We are

collaborating to

improve

relationships

between EMS and

hospitals to reduce

time, save lives

and improve

outcomes in our

patients.

Dallas Caruth Initiative

American Heart Association

Dallas Office8200 Brookriver Drive, N-100

Dallas, Texas 75247

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Welcome to the educationmanual for EMS providersoffered through the DallasCaruth Grant and the Ameri-can Heart Association.Starting in 2010, a coordi-nated effort between the

American Heart Associationand healthcare providersacross Dallas County began.During this time the DallasCaruth Initiative has assistedin establishing a detailed andcoordinated system of carefor heart attack patientsacross Dallas County. Cur-rently 24 EMS agencies and15 hospitals are streamliningprotocols, processes andtraining to ensure that acute

myocardial infarction pa-

tients receive appropriate tri-age, rapid transport and earlyintervention in a cardiac cathe-terization lab. Specific guide-lines have been established forEMS agencies and hospitals toimprove patient outcomes for

patients suffering ST segmentelevation myocardial infarc-tions (STEMI). The informationprovided in this manual is de-signed to assist you in under-standing your role in caring forheart attack patients in DallasCounty. EMS is essential tothe development and activationof the STEMI process from themoment you make contact withyour patient through transportto the appropriate receiving

hospital. In this manual we

The process starts with E.M.S...

Caruth E.M.S. STEMI Guide

EMSProvidersGuidetoSTEMICare

will discuss the importance ofthe early ECG, proper interpre-tation, early notification of thereceiving hospital, and rapidtransport. You are participat-ing in an exciting opportunity tohave an amazing impact in the

treatment and outcomes ofheart attack victims every day.

- The importance of the Early ECG -The initial step of STEMItreatment is achieving theearly ECG in patients whohave symptoms of acutecoronary syndrome, or pa-tients whom you believe areat risk for ACS. When re-

sponding to medical emer-gencies or known chest dis-comfort calls, ensure youhave your ECG monitor withyou upon initial patient con-tact. Once you have con-firmed the patient is sufferingfrom chest discomfort, haveyour partner or first re-sponder assist you in imme-diately applying the ECGelectrodes to capture the 12-

Lead ECG as soon as possible.The 12-Lead ECG should notbe delayed because of patienttreatments and completedwhere you find your patient. Ahigh quality diagnostic ECG is

produced by ensuring properlead placement. EMS crewsshould prepare the skin forlead placement by shavingthe chest or using alcoholpads if necessary. Ensurepads are secured in the

proper anatomic locationsand ask your patient to re-main as still as possible dur-ing the capture of the 12-Lead ECG. Discuss withyour EMS crew how you canachieve early ECGs duringinitial patient contact; theearly ECG will provide clearrecognition of STEMI pa-tients.

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- Rapid Transport - Do Not Delay -

E.M.S. in the ED - Your role continues...of transport and upon arri-val to the ED. If the ED phy-sician is immediately avail-

able, they will review yourECG and will provide arapid exam of your patientto assess their respiratoryand perfusion status. EMScrews should be preparedto transport the patient tothe cardiac cath lab on theEMS stretcher if the cath

Upon arrival at the receiv-ing hospital there are sev-eral steps that may occur

depending on your patientscondition and the ability ofthe receiving hospital torapidly transport the patientto the cardiac cath lab.EMS crews should keepyour patient connected toall 10 leads on your ECGmonitor during all phases

lab is immediately availableto receive the patient. Onoccasion transport to the

cath lab may be delayeddue to your patients condi-tion or final preparation ofthe cath lab to properly re-ceive the patient. EMScrews should make thehospital staff aware if theyneed to immediately returnto service.

route and should not delaytransport for IV attempts ormedication administration.While these treatments areimportant and should beaccomplished during trans-

port, the necessary inter-vention for your patients isarterial reperfusion in a car-diac cath lab. Minimizingscene time and providingsafe rapid transport helpsto minimize heart muscle

damage from the acute MI.How can you work withyour EMS crew to reducescene time?

Following rapid recognitionand activation of the receiv-ing hospital, rapid transportof the patient from thescene to the ambulanceand rapid safe transport tothe receiving hospital is

required to ensure the bestpossible outcome. Similarto trauma victims EMScrews should focus on ac-complishing treatments en-

C A R U T H E . M . S . S T E M I G U I D E

- Transmit the ECG - Activate Code STEMI -Once you or the ECG monitorrecognizes the presence of aSTEMI, early transmissionand activation of a CodeSTEMI at the receiving hospi-tal is essential. Do you knowthe location of the closest ap-propriate receiving hospital forrapid treatment of your STEMIpatient? Similar to traumacare EMS crews must ensurethe patient is transported tothe nearest appropriate re-ceiving hospital capable ofproviding rapid treatment in acardiac cath lab. If your ECG

device is capable, transmit theECG as soon as possible to thereceiving hospital. Follow uptransmission of the ECG withphone or radio contact to ensurethe hospital is aware of yourECG transmission and requestto have a Code STEMI acti-vated. Early ECGs accom-plished by EMS personnel, andearly activation of the cardiaccath lab at the receiving facilitystarts a process that allows forhospital staff and equipment tobe properly prepared to ensureyour patient will receive the most

appropriate and rapid treatmentpossible. Allowing the hospital tobegin the STEMI process asearly as possible is paramount inminimizing damage to heartmuscle and improving patientoutcomes.

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Key Points & Frequently Asked Questions24 Hour - STEMI ReceivingHospitals in Dallas County

Baylor Heart and VascularBaylor Medical Center GarlandBaylor Medical Center IrvingDallas Medical CenterDallas Regional Medical CenterDoctors Hospital of DallasLas Colinas Medical CenterMedical City Dallas HospitalMethodist Dallas Medical CenterMethodist Richardson Medical CenterParkland HospitalTexas Health Presbyterian DallasTexas Regional Medical Center

- SunnyvaleUT Southwestern Medical Center

Signs and Symptoms ofAcute Coronary Syndrome

Typical- Chest Pressure, Discomfort, Tight-ness- Shortness of Breath- Bradycardia, Syncope, Weakness

Atypical- Nausea, physical symptoms of be-ing ill, palpitations

12 Lead ECG?

- Any patient 20 years old

or greater who experi-ences any signs or symp-toms of ACS.

Who is at risk for ACS?History of:- Cardiac Disease- Hypertension- Smoking- Diabetes- High Cholesterol- Severe Obesity- Previous history of heartattack or cardiac stents.

Will the hospital transport mypatient to the cath lab on

our EMS stretcher?

It is preferred practice for the ED staffto transport your patient directly to thecath lab while remaining on the EMSstretcher. The patient may be trans-ferred to the ED stretcher if the cathlab is still preparing to receive the pa-tient, or if the patient requires furtherstabilization prior to intervention.

Essential items to document in your patient care record- Time of initial patient contact - Time of symptom onset

(Time of Symptom Onset = when symptomsstarted that led the patient to calling 911)

- Time of ECG Transmission - Time you requested the CodeSTEMI

- Did the receiving hospital activate the cath lab?

Essentials of the 12 Lead ECG and STEMI

Inferior Anterior LateralInferior

Inferior

Lateral

Septal /Anterior Lateral

Lateral

Septal / Anterior Anterior

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911 call originates for a

patient suffering ACS

related symptoms.

Patient presents to ED with

signs and symptoms of

ACS.

EMS arrives on scene

Patient Contact Occurs

12 Lead ECG occurs

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EMS STEMI Workbook Review and Exam

Name:_________________________________ Agency Name:____________________________________

EMS Certification (circle one): EMT-B, EMT-I, EMT-P, Licensed Paramedic

Date of Completion:_____________________

1. List four signs and symptoms of acute coronary syndrome:

________________________________________________________________________________________

2. List four items if found in a patients history that would increase their risk of having acute coronary syndrome:

________________________________________________________________________________________

3. The 12-Lead ECG should be accomplished within ___________ minutes of initial patient contact.

4. What is the criteria to activate Code STEMI when ST segment elevation is found on a 12-Lead ECG?

________________________________________________________________________________________

5. Describe two ways in which EMS crews may reduce on-scene times of STEMI patients to the closest mostappropriate PCI capable hospital:

________________________________________________________________________________________

________________________________________________________________________________________

6. List three essential items to be included in your patient care record for STEMI patients:

________________________________________________________________________________________

How were you administered this education workbook? (circle one) Supervisor - Educator Other____________

Did you find this workbook useful, and will you be able to integrate the information included into your treatmentof patients with acute coronary syndrome?

________________________________________________________________________________________

Please provide suggestions for topics you would like to see presented at our upcoming AHA Dallas Caruth 2012Conference: _______________________________________________________________________________

Please include any additional comments on how we may continue to improve treatment of heart attack victims inDallas County:__________________________________________________________________________________________________________________________________________________________________________________

EMS STEMI Workbook Evaluation