Optimising STEMi Care- Role of Nurses and Paramedics Dr. Ganesh Veerasekar, MBBS, MPH (UK), FRSPH (UK) Epidemiologist, Kovai Medical Center and Hospital Coimbatore, Tamilnadu, India

Burden of heart disease In 2008 the leading cause of mortality across the globe is due to Cardio Vascular Disorder, which accounted for about 17 million or 48% of over all Non communicable disease (NCD) deaths. (Courtesy- Global status report on non communicableDisease-who-2010)

WHAT is STEMI? St Elevation Myocardial Infarction A deadly disease caused by sudden shut down of blood supply to a part of the heart But can be readily addressed if reperfusion to the damaged area is established through proper reperfusion techniques- Thrombolysis +/- Angioplasty Time is a crucial factor

Nurses and paramedics? Ambulance staff Emergency Department nurses Emergency department support staff Critical care nurses First Medical Contact- in most of the scenarios Frequent Contact with patients

Pharmaco-invasive - 3-24 hours Factors and timelines Pharmaco-invasive - 3-24 hours

Factors and timelines Beneficial Time frames:- Door to Needle time- Less than 30 minutes Door to balloon time-Less than 90 minutes Pharmaco Invasive (Thrombolysis + PCI)- 3-24 hrs

Must have qualities Objective skill sets:- Subjective skill sets:- Early analysis of the clinical symptom Excessive Sweating, chest discomfort, nausea, radiating pain to left arm or jaw, epigastric pain, syncope early identification of st Elevation Should be well qualified to identify ST elevation in ECG Subjective skill sets:- Readiness to work in a team Active and vibrant nature

ECG:- Tips New ST elevation at the J-point in two contiguous leads with the cut-off points: ≥0.2 mV in men or ≥ 0.15 mV in women in leads V2–V3 and/or ≥ 0.1 mV in other leads. On standard ECG paper 0.1 mV is represented by a deflection of 1 mm Or one small block in vertical axis

ECG:- Tips http://www.clinicaljunior.com/cardiologyecg.html

Example from our Experience Tamilnadu STEMI Project: EMRI Pick Up A 51 year old male smoker. Chest pain at 4.00 AM on 19th July. 108-ambulance called at 5.00 AM. Ambulance (Karur) arrived at scene at 5.20 AM. 1st ECG taken at 5.29 AM. STEMI confirmed at 5.34 AM. Patent shifted to Amaravathi Hospital, Karur (Spoke Hospital) at 6.10 AM.

Tamilnadu STEMI Project: EMRI Pick Up ECG Taken in the Ambulance at 05:29 AM.

Tamilnadu STEMI Project: EMRI Pick Up Thrombolysis initiated at 06:15 AM and completed at 07:15 AM Post lysis ECG at 9:54 AM showed Failed thrombolysis Ambulance called and IFT Transport start at 11.15 AM  Hub hospital (KMCH, Coimbatore) arrival at 02.20 PM

Tamilnadu STEMI Project: EMRI Pick Up PCI started at  03.10 PM Femoral access

Tamilnadu STEMI Project: EMRI Pick Up Right coronary artery stented with Bare Metal Stent (BMS) PCI completed at 15.34 PM

Tamilnadu STEMI Project: EMRI Pick Up Patient was doing well and got discharged on 22nd July. This is a great case that illustrates the immense benefit of this program.

Pharmaco-invasive - 3-24 hours Factors and timelines Pharmaco-invasive - 3-24 hours

Our experience Patient symptom onset to fmc time- 1 hour 20 mins Fmc to ecg identification-14 mins Fmc to thrombolysis time- 55 mins Hospitalisation to thrombolysis (D to N) time- 5 mins Total ischemia time- 2 hours 15 mins Hub hospital door to balloon time- 55 mins Total time onset to complete treatment- 11 hours 34 mins

How was this possible? Efficient Ambulance staff Coordination between Ambulance staff and hub hospital cardiologist Coordination between ambulance staff and spoke hospital nurses Efficient spoke hospital nurses-thrombolysis on arrival Well coordinated transfer from spoke to hub hospital by ambulance staff and excellent monitoring during transit Coordinated effort of emergency and cath lab nurses at hub hospital

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