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

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WHO Country Health Profiles 2012: Indonesia

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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.

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Acute Coronary Syndrome

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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

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ACS Classification

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

Clinical Features

Source: app.pulsenotes.com

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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

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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.

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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- Cardiogenic shock. Highly Ventricular septal rupture. Life-threatening ventricular
threatening ventricular dependent on infact size. Typically anterior arrhythmias (VT, VF) due to
arrhythmias (VT and VF) Affect 5-6% of STEMI and infarction. remodeling of myocardium may
due to acute ischemia. 3-4% of NSTEMI. 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.

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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.

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Modes of patient presentation, components ischaemic time and flowchart for

reperfusion strategy selection

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

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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

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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

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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.

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