3/28/2018

CODE STEMI
Rapid Response to Acute
Myocardial Infarction
a nursing perspective

What we’ll cover in next 90 minutes

• Definitions
• Clinical features and differentiating ACS
• ECGs
• Management-STEMI CODE
• Complications

1
 3/28/2018

WHO Country Health Profiles 2012: Indonesia

2
 3/28/2018

Definition of Myocardial Infarction

Acute myocardial
infarction is defined as
myocardial cell death
due to prolonged
myocardial ischemia

Acute Coronary Syndrome

• Acute Coronary Syndrome (ACS) refers to a spectrum of clinical
presentations ranging from those for ST-segment elevation
myocardial infarction (STEMI) to presentation found in non ST-
segment elevation myocardial infarction (NSTEMI) or in unstable
angina.
• It almost always associated with rupture of an atherosclerotic plaque
and partial or complete thrombosisofthe infarct-related artery.

3
 3/28/2018

Acute Coronary Syndrome

4
 3/28/2018

Diagnosis of acute MI

At least 2 of the following

• Ischemic symptoms
• Diagnostic ECG changes
• Serum cardiac marker
elevations

Initial assessment of patient

suspected ACS

5
 3/28/2018

ACS Classification

Hamm CW, et al. European Heart Journal (2011) 32, 2999–3054

Clinical Features

Source: app.pulsenotes.com

6
 3/28/2018

Pain assesment

Mnemonic, such as PQRST can be

used to asses patients chest pain:
• P (Provoke)
• Q (Quality)
• R (Radiation)
• S (Severity)
• T (Timing)

Electrocardiogram
• The most important
• Serial ECG is routinely
• Classify ACS
• Determine severity and prognosis

7
 3/28/2018

Electrocardiogram
• The most important
• Serial ECG is routinely
• Classify ACS
• Determine severity and prognosis

Cardiac Enzymes

Cardiac Troponin level

increase within 3-12 hours
from the onset of chest
pain, peak 24-28 hours, and
return to baseline over 5-14
days.

8
 3/28/2018

Risk Factors
Modifiable Non-Modifiable
• Smoking • Increasing age
• Obesity • Gender
• Diet • Ethnicity
• Lack of exercise • Family history
• High serum cholesterol • Diabetes?
• Hypertension
• Diabetes?

Complications following STEMI

Mitral regurgitation due to ischemic
papillary muscle. Papillary muscle
Acute Bradyarrhythmia due to sinus rupture due to necrosis is the most Chronic pericarditis due to
Myocardial bradycardia or AV block. AV block common mechanical complication autoimmune reaction towards
should be expected with inferior of myocardial infarction myocardial protein released into
Infarction infarction blood (Dressler Syndrome)

24 hours 3 days 2 weeks

Potentially life-
threatening ventricular
arrhythmias (VT and VF)
due to acute ischemia.
Cardiogenic shock. Highly
dependent on infact size.
Affect 5-6% of STEMI and
3-4% of NSTEMI.
Ventricular septal rupture. Life-threatening ventricular
Typically anterior arrhythmias (VT, VF) due to
infarction. remodeling of myocardium may
occur any time after acute
Rupture of left ventricular myocardial infarction. Dependent
free wall. on infart size and presence of
heart failure, both of which
increase cardiac remodeling.

Atrial fibrillation may occur any time after myocardial infarction, especially if left atrium is enlarged
Heart failure or left ventricular dysfunction may occur any time after acute myocardial infarction.

9
 3/28/2018

Code STEMI
Where minutes count

Reperfusion Therapy
• Primary PCI (Percutaneous coronary intervention)
The preferred reperfusion strategy in
patient with STEMI within 12 hours.
Rescue PCI after failed thrombolysis
• Fibrinolytics.
Recommended within 12 hours of symptom
onset if primary PCI cannot be performed
within 120 min from STEMI diagnosis and
there are no contraindications.

10

Modes of patient presentation, components ischaemic time and flowchart for
reperfusion strategy selection
Emergency Management
EMS assessment and care
and hospital preparation
- Monitor, support ABCs
Symptom - Administer OANM if needed
sugesstive - Obtain 12 lead ECG
of - Notified hospital should mobilize
infaction hospital resources to respond to
STEMI
- If considering prehospital
fibrinolysis, use fibrinolysis
checklist
3/28/2018
Emergency assessment (<10 minutes)
- Check vital sign; evaluation oxygen saturation
- Establish IV acces
- Perform brief, targeted history, physical examination
- Review/complete fibrinolytic checklist; check
contraindication
- Obtain initaial cardiac marker levels, initial electrolyte
and coagulation studies
- Obtain portable chest x-ray (< 30 minutes)
Immediate ED general treatment
- If oxygen sat < 90%, start oxygen at 4 L/min, titrate
- Aspirin 160-325 mg
- Nitroglycerin sublingual or spray
- Morphine IV if discomfort not relieved by nitriglycerin
11
 3/28/2018

Long--term therapies for STEMI

Long
• Lifestyle interventions and risk factor control:
• Soking cessation
• Diet,alcohol, and weight control
• Exercise-based cardiac rehabilitation
• Resumption of activities
• Blood pressure control
• Adherence to treatment
• Antithrombotic therapy: Aspirin, DAPT
• Beta-blockers
• Lipid lowering therapy

What Nurses should do?

• Nurses play a important role in the early care of acute myocardial
infarction
• Often the first to be contacted by patient
• What nurses should do:
- Can perform and interpret the ECG
- Alert EMS
- Administer analgetic and antithrombotic drug (including fibrinolytic)
- Undertake defibrillation if needed

12
 3/28/2018

Code STEMI

• Rapid notification for STEMI patients

• Standarized process – improve quality of care
• Improve time to reperfusion
• Initiate team responses

Who’s on the Code STEMI Responses

Team?
• Emergency department
(physician and nurse)
• Interventional Cardiologist
• Critical care (CCU) nurse
• Clinical Administrator
• 24/7 Cathlab Team

13
 3/28/2018

Conclusion
• Acute coronary syndrome is a common and potentially life-threatening condition
associated with coronary heart disease
• Primary percutaneous coronary intervention within 12 hours of symptom onset is
the first-line treatment
• Pharmacological management in the acute phase focuses on pain relief and
prevention of further clot formation while minimising the risk of bleeding
• After discharge from hospital, patients need secondary prevention involving
medications, cardiac rehabilitation and lifestyle changes
• Nurses play a crucial role in delivering care and psychological support at all stages
of the patient journey
• Be sure that you and everyone on your ED Department Team recognize that Code
STEMI is a “seconds-to-minutes” emergency requiring your immediate attention
and intervention in order to achieve the best outcome.

14