Case summary:

An ALS crew responded to a 60s man with difficulty breathing.  The crew found the patient pale and lightheaded.  They obtained the following vital signs and an EKG:

Vitals: BP 125/90,  HR 59,  RR 18,  Sat 96%

The crew extricated the patient to the ambulance and re-assessed the patient.  He reported he was feeling worse so they repeated the 12-lead (about 15m after the first 12-lead):

The crew noted that this 12-lead was showing ST elevations in V1-V2 as well as depressions in II, III, aVF and V6.  The correctly identified that this patient was having a STEMI and transmitted the EKG to the nearest STEMI center and began transport.  The crew obtained a 3rd EKG two minutes after the one they just obtained which showed much more dramatic ST changes:

The crew was able to get the patient to the receiving facility in stable condition and the patient went right of to the cath lab for ongoing care. 

Highlights of the case:

You can never obtain too many 12-lead EKGs.

This patient’s first EKG did not show ST segment elevation, yet he still was having an occlusive MI the entire time.  12-lead EKGs are incredibly cheap to obtain and can show immediately life-threatening problems.  If you are ever wondering if you should obtain a 12-lead or not (or a repeat 12-lead), the answer is always yes!  Sometimes it takes time for the 12-lead to show ST elevation, and while the patient is having an active MI, it is possible that the ST elevation simply has not shown up yet.  Our goal is to make the diagnosis of STEMI as early as possible.  Specific situations where you should consider obtaining a repeat 12-lead is if the first EKG shows something concerning such as hyperacute T waves or concerning ST depressions or T wave inversions.  Another situation would be if the patient has a really good story for an MI such as crushing chest pain with risks factors, diaphoresis, radiation of the pain and vomiting.  The last situation is if the patient develops new or worsening symptoms.  The reason that this crew re-checked the 12-lead was because the patient reported he felt worse and by doing this, they diagnosed STEMI as early as possible which is key to good outcomes for these patients.

The goal in MI care is to minimize time between first medical contact and opening the block vessel.

The American Heart Association emphasizes and tracks a metric known as the first medical contact to balloon inflation time.  This is the time between when EMS arrives on scene and when a patient is in the cath lab with blocked vessel open inside the heart by the cath balloon.  The goal is to have this number under 90 minutes, but in reality we want this number to be as low as possible in order to save as much heart as possible.  A lot needs to happen in order to have the balloon inflated inside the heart.  EMS needs to obtain a 12-lead showing STEMI, then transmit it to the hospital.  While the patient is being transported to the hospital, the cath team needs to be notified and if after hours, they all need to drive into the hospital.  The patient needs to be stable enough to go to the cath lab, be moved there, and the cath wire needs to be inserted into the patient and moved to the correct place before opening the balloon.  This is a ton of things that needs to happen.  Our job in EMS is to do what we can to minimize this time.  The best way we can do this is by obtaining 12-lead EKGs early and often.  This means that we should almost always obtain one within a couple minutes of patient contact and prior to extrication.  If we ever obtain a 12-lead EKG that shows STEMI, the next most important thing is to transmit the EKG so that the cath team can be mobilized.  If we can transmit prior to extrication, we should do that to so that more things are happening in parallel instead of in series.  Lastly, we should prioritize wheels rolling to the hospital over giving anticoagulants since getting the patient to the cath lab quicker is more important than getting these meds on board.  The only exception to these rules would be if the patient is in need of an airway or is in cardiogenic shock and needs immediate resuscitation.  This crew immediately notified the receiving facility once they diagnosed STEMI in order to get the patient to the cath lab as quickly as possible.