SFGH Criteria for STEMI Activation Clinical and EKG concern for STEMI? Definite Uncertain Pathway 1: Immediate STEMI Activation Ongoing chest pain or symptoms of ACS AND EKG with one of the following: NEW ST elevation at in at least 2 contiguous leads ≥2 mm in men or ≥1.5 mm in women in leads V2–V3 ≥1 mm in other contiguous chest leads or the limb leads Absence of left ventricular hypertrophy or LBBB (2) NEW posterior ST elevation MI ST depression in ≥2 precordial leads (V1–V4) AND ≥1 mm ST elevation in ≥2 contiguous posterior leads (V7–V9) VF/VT Cardiac Arrest with ST Elevations on post-arrest EKG, and with return of a pulse within 10 min (no prolonged resuscitation) Pathway 2: Call Cardiology Fellow Urgently May Activate Catheterization Lab After Consultation Chest pain or symptoms of ACS But EKG non-diagnostic though concerning for STEMI: (1) LBBB with concerning symptoms for STEMI (2) Concern for STEMI but Difficult to Interpret EKG due to: - LVH - ST elevation in aVR or V1 only - Paced Rhythm - Wellens Pattern - J-Point Elevation - Tall T-waves - Brugada Pattern - Atrial Tachyarrhythmia Patients with STEMI and ANY of the following: Hypertension with SBP>200 mmHg or DBP>130 Concurrent/Recent stimulant usage with associated AMS or Severe Agitation Unclear Goals of Care or Patient Unwilling (or uncooperative) Cardiac Arrest with ROSC with prolonged resuscitation time (>10 min) Concern for Active Intracranial Process, or Active Bleeding Complete resolution of pre-hospital STEMI EKG and symptoms (repeat EKGs) Activate CATH LAB 415-327-2284 EM Physician actions: ASA 325mg oral chewed ± Atorvastatin 80 mg oral x1 Initiate discussion with patient about cardiac catheterization Nursing staff actions: 2 large bore IVs IV NS @ TKO Stat labs Give/document meds O2 2L Zoll pads Defibrillator, O2, IV pump for transport Patient stickers EMS record in chart Fax EKG to on-call Cardiology Fellow: 1(855)289-7477 THEN page the on-call Cardiology Fellow (see daily list for correct pager) and inform of faxed EKG Cardiology Fellow actions: Obtains consent Communicates to ED when catheterization lab is ready If the EM attending physician does not accept the cardiology fellow’s recommendations, the EM attending physician can consult with the cardiology attending physician directly