This document provides information on STEMI, NSTEMI, and STEMI mimics for paramedics. It discusses the importance of accurate 12-lead ECG interpretation for identifying STEMIs to reduce door-to-balloon times and improve outcomes. It outlines criteria for calling a "Code STEMI" to activate the cardiac catheterization lab as well as situations where a "Medical Stat" or routine transport would be more appropriate based on the 12-lead findings. The goal is to minimize false STEMI activations while still rapidly identifying true STEMIs.

1. STEMI, N-STEMI, and everything else Ada County Paramedics Block Training April 2008

5. Disclosure Statement

7. All Hail the Great S-T Segment (or …all you wanted to know about the ST segment but didn’t know to ask…)

8. Understanding the ST segment

13. T-Wave Changes in Ischemia Peaked, Symmetrical T-Waves

14. T-wave changes in Ischemia Inverted T-waves

15. T-Wave Changes In Ischemia Tall, symmetrical T-Waves With ST Elevation

17. Types of ST Depression

20. S-T changes and their location?

21. Cardiac Anatomy in Relation to Coronary Artery Right coronary artery Septal wall V 1 -V 2 Left anterior descending artery Anterior wall V 3 -V 4 Left main coronary artery Circumflex artery Lateral wall I, aVL, V 5 -V 6

22. Associations Between Changes on 12-Lead ECG and Cardiac Anatomy aVF inferior III inferior V 3 anterior V 6 lateral aVL lateral II inferior V 2 septal V 5 lateral aVR I lateral V 1 septal V 4 anterior

24. Inferior MI Localization aVF inferior III inferior V 3 anterior V 6 lateral aVL lateral II inferior V 2 septal V 5 lateral aVR I lateral V 1 septal V 4 anterior

27. Lateral MI Localization aVF inferior III inferior V 3 anterior V 6 lateral aVL lateral II inferior V 2 septal V 5 lateral aVR I lateral V 1 septal V 4 anterior

28. Lateral MI

29. Septal MI Localization aVF inferior III inferior V 3 anterior V 6 lateral aVL lateral II inferior V 2 septal V 5 lateral aVR I lateral V 1 septal V 4 anterior

31. Inferior MI Localization aVF inferior III inferior V 3 anterior V 6 lateral aVL lateral II inferior V 2 septal V 5 lateral aVR I lateral V 1 septal V 4 anterior

32. Inferior MI

35. STEMI, N-STEMI, and STEMI Mimics

37. Spectrum of CAD No ST elevation ST elevation Unstable angina NSTEMI STEMI Stable angina Source (Photos): Davies MJ. Heart . 2000;83:361-366. CAD = coronary artery disease; NSTEMI = non-ST-segment elevation myocardial infarction; STEMI = ST-segment-elevation myocardial infarction. ACUTE CORONARY SYNDROMES

41. The basics of doing the 12 lead

42. The Basic 12 Lead

43. Lead Placement for a Right-sided ECG

44. The Right Ventricular Leads

46. Posterior ECG?

47. The importance of serial 12 leads

49. STEMI MIMICS

64. Potassium Level: 6.1 mEq/L

65. Potassium Level: 7.2 mEq/L

66. Potassium Level: 9.1 mEq/L

68. Potassium Level: 2.5 mEq/L

69. Potassium Level: 1.5 mEq/L

70. Potassium Level: 0.9 mEq/L

79. Key to this is Pre-Hospital Cardiac Triage And accurate 12 lead interpretation! DON’T TELL ANYONE, BUT EMS HAS BEEN DOING 12 LEADS FOR ALMOST 40 YEARS!!!

80. First field 12 lead Seattle Medic One Circa 1969

82. The KEYMASTER and the GATEKEEPER? 12 Leads!!!!

83. Time to Treatment in PCI (Nallamothu 2007 NEJM 357:1631) What this means: Beyond a D2B ≤90 Minutes… Every 15-minutes of Delay  Mortality

84. Why the big push for PCI????? Better Outcomes, Lower Mortality, Less Complications

87. Understanding the Intervals Onset of symptoms of STEMI 9-1-1 EMS dispatch EMS on-scene Call 9-1-1 Call fast ACP S2B: S/S Onset to Balloon E2B: EMS to Balloon C2B: Call to Balloon D2B: Door to Balloon Hospital B A L L O O N R2R: Recognition (12 lead) to Re-perfusion

92. CODE STEMI is the “Level 1 Trauma” of the Cardiac World “Medical Stat” is the Level II and Level III

94. CAN WE DO BETTER? (and what happens if we don’t???????)

98. 3 Levels of Notification CODE STEMI Medical STAT Business as Usual Routine Radio report

102. STEMI, Medical SAT, or Other? Click for answer

104. STEMI, Medical SAT, or Other?

105. STEMI, Medical SAT, or Other? Click for answer

106. STEMI, Medical SAT, or Other? Click for answer

107. STEMI, Medical SAT, or Other?

108. STEMI, Medical SAT, or Other?

109. STEMI, Medical SAT, or Other?

110. STEMI, Medical SAT, or Other?