Case summary:

An ALS crew responded to 70s woman who had chest pain.  They found the patient with unlabored, regular respirations but was clammy, diaphoretic and had left sided chest pain radiating to the jaw.  Within two minutes of patient contact they obtained the 12-lead shown below that showed an inferior wall ST elevation myocardial infarction (STEMI) and transmitted it to the nearby STEMI center to activate the cath lab. 

The crew obtained vitals which were:

Vitals: BP 73/51,  HR 46,  RR 14  O2 sat: 97%

The crew extricated the patient to the rig and immediately started transport to the receiving facility.  They were able to get wheels rolling 12 minutes after patient contact.  While in route to the hospital, they obtained an IV and gave aspirin.  They also spoke with online medical control and received the order to give heparin and ticagrelor.  Patients vitals were also re-assessed during transport and were found to be:

Vitals: BP 98/47,  HR 63,  RR 146 O2 sat: 97%

The crew arrived at the STEMI center and handed off car to the emergency department team.  The patient was then taken directly to the cath lab for treatment of her occlusive myocardial infarction (MI).

Highlights of the case:

The goal in STEMI is to minimize time between first medical contact and balloon opening in the cath lab.

This patient was having an inferior wall STEMI given her EKG showed ST elevations in II, III, and aVF as well as reciprocal changes in I and aVL.  The goal in MI is to get the patient to a center capable of performing percutaneous coronary intervention (PCI).  This is where an interventional cardiologist feeds a wire through arteries to the heart to find the blocked coronary blood vessel and then open up the blockage often with a balloon.  When the balloon opens the vessel, blood can start perfusing the infarcted heart and can prevent further tissue death.  This is where the first medical contact to balloon time comes from.  The earlier we get the patient to this procedure, the less heart that dies permanently.  The clock starts the second we arrive on scene, even before we diagnose STEMI with an EKG.  For this reason, we should obtain a 12-lead EKG on all patients that could be having a STEMI prior to ever moving the patient since the earlier we diagnose STEMI, the better. 

We should always remember the symptoms of an MI that are not chest pain.  These symptoms can include upper abdominal pain, nausea, vomiting, shortness of breath, fatigue, generalized weakness, amongst other symptoms.  These atypical symptoms are more common in elderly patients, woman, and diabetic patients.  Once we diagnose STEMI, the next thing we should do is transmit it to the STEMI center so that they can start mobilizing the cath lab while we are extricating and transporting.  It is better to do things in parallel instead of in series since this will decrease the time to balloon, which is our ultimate goal.  If we wait until after extrication to call in the STEMI, it will lead to the cath lab team being that much further from being ready to provide definitive care to the patient.  

This crew obtained an EKG within 2 minutes of patient contact to confirm STEMI and then immediately called it in to mobilize the cath team.  They then deferred all other treatments until after wheels were rolling towards the hospital to not delay definitive care in the cath lab.   This crews decision making shaved a lot of time off of the first medical contact to balloon time and in term preserved as much of the patients heart as possible.  This was fantastic EMS care!