1. 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
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 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)
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