Getting Pumped About STEMI And Cardiogenic Shock
Getting Pumped About STEMIand Cardiogenic ShockJune 20, 2017Amy Shepard MS, RN, ACNS-BC, CCRN-KSTEMI/ Cardiogenic Shock Program ManagerUniversity Hospital
ObjectivesBy the end of this presentation, participants will beable to: Describe the process for a STEMI through thecontinuum of care. Verbalize time sensitive treatments in the care ofa STEMI patient Verbalize EMS roles in caring for the STEMIpatient.
Statistics Heart Disease remainsto be the No. 1 cause ofdeath in the US.American Heart Association, 2017
Statistics (cont.)Every 40 secondsan American willhave a heart attack.American Heart Association, 2017
Statistics (cont.) About 790,000 people in theUS have heart attacks eachyear. Of those, about114,000 people will die.American Heart Association, 2017
Statistics (cont.) Average age at the firstheart attack is 65.3 yearsfor males and 71.8 years forfemales.American Heart Association, 2017
Why is the ST Segment so Important? The ST Segment represents the section of the complexin which the ventricles are between electricaldepolarization and repolarization. It is a key indicator as to whether the patient may beexperiencing ischemic insult or injury to the myocardium
STEMI Criteria ST elevation at the J point in at least 2contiguous leads. Men 2 mm Women 1.5 mm in V2-V3 1 mm in other contiguous chest leads orthe limb leads ST depression in V1-3 without STelevation in other leads may indicate aposterior myocardial infarctionAmerican College of Cardiology 2013
What causes a STEMI? ST segmentElevationMyocardialInfarction 1. STEMIs are associated with the build up of plaquewhich ruptures in the coronary arteries. 2. This stimulates platelets to stick together/aggregateand vessels near the rupture to constrict 3. If the unstable area becomes totally blocked by aclot, also called a thrombus, a STEMI is occurring.
Ruptured PlaqueNon-ST Elevated Myocardial InfarctionST Segment Myocardial Infarction
Symptoms of a Heart AttackMore SubtleWell-Known Pressure, squeezingor fullness in chest Pain radiating to thearms.American Heart Association 2015 NauseaShortness of BreathFatigueJaw painBack painStomach painLight headedness
Women’s Symptoms Extreme FatigueLower chest / upper abdominal painNausea/VomitingShortness of BreathLight headednessDizzinessUpper back painAmerican Heart Association Mission Lifeline 2015
“Time is Muscle”American Heart Association, 2011
ECG Then and Now
Leads with Corresponding WallInvolvement
Reciprocal ChangesLeads opposite injured area may show ST depression dueto two leads viewing the MI from opposite angles.Inferior (II, III and aVF) V leadsLateral (V5-6, I, and aVL) II, III, and aVFRV noneAnterior wall (V1-4) II, III and aVFPosterior wall (V7-9) V1-3of 12-lead when ST elevation is present is indicative ofreciprocal changes.Note: Reciprocal ST depression will have a positive Twave
What About Right Sided ECG’s? Right sided ECG’s are performed to helpdiagnose Right Ventricular MyocardialInfarction. ECG leads are placed in the mirror imageon the right side of the chest as comparedto the left side of the chest. Elevation in the right sided leads you cansuspect a right sided infarct. V4R is the most sensitive and specific lead
Right Sided ECG’s (cont). If you have a patient that has definite STsegment elevation, it is best to load theminto the ambulance and get them to theCath Lab ASAP. Do not delay patient transport to perform aright sided ECG.
Right Sided ECG
Posterior Wall MI Posterior MI’s are associated with inferiorwall MI’s and Right Ventricular Infarcts. With normal lead placement, a posteriorECG will present as ST segmentdepression in the septal leads V1 and V2.
Posterior ECG If ST segment depression is noted in V1and V2, suspect Posterior Wall MI. Why ST depression and not elevation? Do not delay transport to obtain a posteriorECG.
Posterior ECG’s V6 connects to V9 V5 connects to V8 V4 connects to V7
Complications From STEMI Ventricular Septal DefectPapillary muscle rupture or dysfunction,Cardiac free wall ruptureVentricular AneurysmLV outflow tract obstructionLV or RV Failure with CardiogenicShock
Guidelines for Transfer First Medical Contact TimeECG TimeSystem activation/call for transportTransfer outMedication Administration
PCI Time Benchmarks Transport to a PCI Capable Facility:Ideal First Medical Contact (FMC)-to-devicetime of 90 minutes or less. Transport from a Non–PCI-capableFacility to a PCI Capable Facility:FMC-to-device time system goal of 120minutes or less.*18–21 (Level of Evidence: B)American Heart Association Mission Lifeline, 2012
What is First Medical Contact? First Medical Contact (FMC) is the time whenthe patient is first evaluated by either EMS oranother health care professional prior to arrivalat the PCI facility. For EMS cases, the FMC time is when thehealth care provider is at the patient. For arrival by private vehicle it is the arrival timeto the ED The 90/120 minute clock starts at the time ofFMC.ACC/NCDR, GWTG, 2007
Transfer Considerations Receiving ER is placed on STEMI alertThe cath lab makes a room availableThe ICU staff ensures a bed is readyMed Flight is activated if needed– Weather impacts response times
EMS Barriers Resources – 12 Lead ECG machineequipment and training, lack oftransmission capabilities, personnel Not always possible to get ALS or airtransport to get patient to PCI center
EMS Barriers Continued Weather
Safety First!Infographic courtesy of EMS.gov
EMS Responsibilities Obtain 12 Lead ECG within 5 minutes –preferred, 10 minutes benchmark of firstmedical contact. If transmission capabilities exist, transmit ECGto nearest hospital IMMEDIATELY If transmission capabilities do not exist, notifyreceiving hospital that you are bringing in asuspected STEMI. Limit scene time to 15 minutes.
EMS Responsibilities (cont.) Provide copies of the run report to hospitaland upload to database within 24-48hours. Provide hospital providers with a thoroughhandoff. Always send cardiac arrest rhythmstrips and 12 leads with patient to thehospital.
Tips for Referring Hospitals Obtain ECG within 5 minutes of patient arrival 5 Minutes STEMI ECG to decision, contact PCICenter and transport within 5 minutes of obviousSTEMI ECG. Goal: Door in door out 30 Minutes
Tips for Referring Hospitals (cont.) If ECG does not meet STEMI criteria:perform serial 12 leads every 15 minutesto monitor for evolving STEMI or if patientcondition changes. Contact cardiology for a consult. This canbe done by calling the UW Access Center. If transport is delayed due to weather oravailability, consider thrombolytic therapy. Goal: Door to needle 30 Minutes
Tips for Referring Hospitals (cont.) If transport is delayed due to weather oravailability, consider thrombolytic therapy. Goal: Door to needle 30 Minutes Send copies of all documentation fromcurrent ED visit and EMS documentation –Including all pre-hospital and inhospital significant rhythms strips
Tips for Referring Hospitals (cont.) Discontinue IV drips Explain to patients what is happening andthat things will be moving fast. Send along family information if theinformation is readily available.
Quality Feedback will be provided within 24 to 48hours. Feedback can only be provided ifdocumentation is available to obtain timesand details of the case. Expect longer waittimes for feedback if documentation is notcompleted in a timely manner. Beneficial to review cases with all staff
Transfer Considerations Receiving ER is placed on STEMI alertThe cath lab makes a room availableThe ICU staff ensures a bed is readyMed Flight is activated if needed– Weather impacts response times
Regional Field Activation ProtocolUWHC Regional EMS Field Activated STEMI Transport ProtocolAccess Center *green indicates responsibilitiesGround TransportMed Flight TransportEMS calls Med Flight with fieldactivated STEMI via 911 dispatchYesMed FlightavailableNoDirect Heart Line(UW Access Center)800-472-0111 Med Flight calls Access Center (AC)emergency line @ 890-6102 with the followingscript:“This is Med Flight Dispatch calling to activate theHeart Attack Team and the InterventionalCardiologist for a field activation STEMI byEMS service & ETA. EMS will call theDirect Heart Line with a report once we lift off withthe patient”Med Flight toinform EMSFollow groundtransport process Med Flight to coordinate intercept with EMS. Med Flight to call hospital with eta updates. Med Flight to admit the patient when thepatient arrives. AC calls paging @ 262-0000 to activate the Heart Attack Team &provides the following info:1) Which EMS ambulance service is calling the STEMI2) Means of transport (Med Flight)3) ETAExample of page:“Field Activated STEMI by (EMS Service), via Med Flight, ETA (time)*Do not include Interventional Cardiologist’s name in page4) Pages Nursing Coordinator for F4M5 Bed EMS will call AC for report at the latest when Med Flight departs thescene. AC requests patient name, DOB & EMS call back #.(Keep EMS on the line and stay on the line throughout the call). AC pages Interventional Cardiologist with code “STEMI report & ACcall back #” (stay on line throughout the call). AC connects EMS with Interventional Cardiologist for pre procedurereport. AC connects EMS with CCU CTL for report (Cath lab calls unit forreport) AC enters pre-admit into Health Link for F4M5 Interventional Cardiology calls AC back to connect with EMS forpost procedure report.EMS calls Access Center (AC)with field activated STEMI AC requests patient name, DOB, EMS name, callback # & ETA. AC ask EMS to please hold, while page out HeartAttack Team and Interventionalist. AC calls paging @ 262-0000 to activate the Heart AttackTeam & provides the following info:1) Which EMS ambulance service is calling the STEMI2) Means of transport (by ground)3) ETAExample of Page:“Field Activated STEMI by (EMS Service) via ambulance, ETA(time)*Do not include Interventional Cardiologist’s name inpage4) Pages Nursing Coordinator for F4M5 Bed AC pages Interventional Cardiologist on call withcode “STEMI call & AC call back #”. AC connects Interventionalist for report(stay on the line throughout call). AC connect EMS with CCU CTL for report(stay on the line throughout call). AC enters pre-admit in HL for F4M5. AC notifies EDC or CTL @ 262-2398 of ground STEMI& ETA. InterventionalCardiology callsAC back toconnect withEMS for postprocedure report. CTL to confirm cath lab status with EMSwhen EMS contacts ED via radio 10 minutes out. EDC or CTL to update ETA via heart attack page. Page to include: “update ETA on EMS groundSTEMI”. EDC admits patient upon arrival using theexisting pre-admit entered by the AC
Cardiogenic Shock
What is Cardiogenic Shock?Cardiogenic shock is when theheart is unable to pump enoughblood to meet the body’s needs.
Statistics Cardiogenic shock complicating AMIresults in 5-15% which equalsapproximately 40,000-50,000 people in theUS per year. Leading cause of death in AMI withmortality rates of 40-50%Thiele, Ohman, Desch, Eitel, de Waha, (2015).
Causes of Cardiogenic Shock Myocardial InfarctionMyocarditisEndocarditisWeakened heart from any causeArrhythmiasTamponadePulmonary Embolism
Symptoms Systolic BP of 90mmHG Elevated left-sided filling pressures Impaired organ tissue perfusion asevidenced by:– Altered mental status– Oliguria– Cool, clammy skin– Elevated serum lactate levels
Assessment Mental Status– Is the patient alert and oriented or confusedand/or lethargic? Vital Signs– Is the SBP or 90– Heart rate and rhythm– Respiratory status Breathing fast and labored or normalOxygen saturation
Assessment (cont.) Physical assessment– Cardiac and Pulmonary auscultation New Murmurs or rales– Peripheral vascular assessment Cool and clammy to the touch Strength of peripheral pulses– Urine output Is it adequate?
Treatments Oxygen, Bi-PAP, CPAP, or intubation ifnecessary Inotropes Vasopressors Mechanical circulatory assist device
What are Mechanical CirculatorySupport H
Systematic Approach
STEMI / Cardiogenic ShockCase Study
The Story 49 y.o. male with a positive family history of heartdisease, obesity, and seizure disorder who began toexperience chest pain after dinner which was associatedwith vomiting and diaphoresis. His mother heard himcollapse, so she ran to help. Unfortunately she wasunable to move him. She used her Life Alert to summonhelp. The patient did not receive CPR until the EMSarrived (amount of time without CPR 5-10 minutes). Hewas found to be in VF and was shocked once and thenwent into PEA.
EMS Radio Call into UW
EMS ECG at 1952
EMS Treatment CCR upon arrival Rhythm VF defibrillated, remained in VFCompressions resumed High flow oxygen via NRB IV Left AC due to failed IO Fluid bolus 1mg Epi Glucose checked
EMS Treatment (cont.) Defib charged – patient in PEA, chargeddumped, compressions resumed Organized rhythm with pulse, agonalrespirations. Patient moved to stretcher.BVM to assist respirations. 12 lead done en route to UW whichrevealed anterior STEMI
ED Treatment 12 Lead upon arrivalSecond IV placedIntubationPropofolCooling blanketsPatient sent to CT scan to rule out headbleed.
Cardiac Catheterization Staff involved:– 2 Physicians– 2 RNs and 1 Cardiovascular Tech– Consent is obtained Patient prep:– ECG, pulse oximetry, BP– Table is only 22 inches wide (holds 500 lbs.) Procedure:– Sterile drape placed– Access (Radial or Femoral)– Interventional guide inserted– Wire inserted into culprit vessel– Coronary balloon, stent balloon or aspiration catheter inserted– Goal Cath door to balloon inflation (DBT) 25 minutes
Coronary Angiogram
Angioplasty and Thrombectomy
Stenting
Cath Lab Interventions 100% Proximal Left Anterior Descending 3.0mm x 38mm drug-eluting stent placed Patient developed acute stent thrombosiswhile still in the Cath Lab, so twoadditional drug-eluting stents needed to beplaced. Cardiohelp (ECMO) placed Swan-Ganz and cooling catheter inserted
100% LAD(Different Patient)
Stented LAD(Different Patient)
Left Anterior DescendingCulprit LesionCase Study n
Hospital Course 5/15 - Patient’s right foot became ischemic dueto large cannulas from ECMO. HE was takenback to the Cath Lab for revision from VA ECMOto veno-venus. IABP placed to off load the LV.Temporary bypass of SFA with arterial to arterialbypass. 5/19 – ECMO decannulated 5/21 – Extubated and following commands 5/31 – Discharged to rehab facility
Arrivedin CathLab1stDeviceDeployed2110Arrivedto UW2004Patient19521930placedDepartScene1935911At csffefrsaCall2051Pre-Hospital to Cath Lab Time LineFMC toDevice 95 Minutes
Key Points High Quality CPR is vital to patient survival Transmit STEMI ECG’s IMMEDIATELY toreceiving center to expedite patient care Time is critical for STEMI and CardiogenicShock patients Detailed handoffs and providing alldocumentation from the field are essentialto expedite continuity of care.
Key Points (cont.)Teamwork is the key tosuccess!
References American Heart Association. (2017). Heart Disease and Stroke Statistics2017 At-a-Glance. Retrieved from /@sop/@smd/documents/downloadable/ucm 491265.pdf American Heart Association. (2015). Hard to recognize heart attacksymptoms. Retrieved from ymptoms of heart disease in women/hard-to-recognize-heartattack-symptoms/ American Heart Association. (2012). Regional systems of caredemonstration project: Mission Lifeline STEMI systems accelerator(version 5.0). Duke University
References (cont.) American Heart Association. (2011). STEMI Provider Manual. United Statesof America. Thiele, H., Ohman, E. M., Desch, S., Eitel, I., de Waha, S. (2015).Management of cardiogenic shock. European Heart Journal, 36, 1223-1230
American Heart Association, 2017 . Every 40 seconds an American will have a heart attack. Statistics (cont.) . Cardiogenic shock is when the heart is unable to pump enough blood to meet the body’s needs. What is Cardiogenic Shock? Cardiogenic shock complicating AMI
To standardize emergency department management of ST elevation myocardial infarction (STEMI) across the province by reinforcing the STEMI reperfusion targets and best practices to improve patient outcomes. . It is the leading cause of death in North America in both men and women Atherosclerosis: buildup of a material .
ECG in STEMI Definition of STEMI –New ST elevation at the J point in two contiguous leads of 0.1 mV in all leads other than leads V2-V3 –For leads V2-V3 the following cut points apply: 0.2 mV in men
ICD-10 Case Studies & Documentation Tips Ghazala Sharieff MD, MBA Corporate Director, Physician Outreach and Medical Management 2015. ICD 10- The Hard Way I21 ST elevation (STEMI) and non-ST elevation (NSTEMI) myocardial infarction I21.0 ST elevation (STEMI) myocardial infarction of anteriorFile Size: 554KB
Time is Critical in STEMI Care Time and Mortality in STEMI Patients 15.4 23.3 28.1 30.8 0 5 10 15 20 2
STEMI System of Care Plan Contra Costa County Emergency Medical Services Agency December 2019, v.1 . FP01 – 12-Lead ECG serve as an advanced life support skill guideline for obtaining, utilizing, and transmitting . patient populati
EKG goals - within 10 minutes of arrival. STEMI alert/call system (DSPR.5): — Standardized process -single activation — Catheterization laboratory team activation, if available — Collaboration with EMS to coordinate pre-hospital care, STEMI alert/notification
Centrifugal machine tool pumps 50/60 Hz . Table of contents 2 MTB 1. General description 3 Introduction 3 Applications 3 Special features 3 2. Identification 4 . Selection of product 11 Pump size 11 Efficiency 11 Shaft seal materials 11 7. Pumped liquids 12 Pumped liquids 12 List of pumped liquids 12 8. Curve charts 13
Spring Awakening [1891/1906]. Translated by Jonathan Franzen. Faber & Faber 2007. [on loan from NYU Berlin] o Oskar Kokoschka. Murderer, Hope of Women In: Plays and Poems [1907/1910. ]. Translated by Michael Mitchell. Ariadne Press 2001. pp. 21 – 28. [course reader] o David F. Kuhns. German Expressionist Theatre: The Actor and the Stage .
