BLS – Chest Pain Flashcards
General Directive
In situations involving a patient with chest pain that is believed to be of a non-traumatic origin, the paramedic shall:
- consider potential life/limb/function threats, such as,
a. acute coronary syndrome/acute myocardial infarction (e.g. ST-segment elevation myocardial infarction [STEMI]),
b. dissecting thoracic aorta,
c. pneumothorax, tension pneumothorax/other respiratory disorders (e.g. pneumonia),
d. pulmonary embolism, and,
e. pericarditis; - acquire a 12-lead electrocardiogram, in accordance with the ALS PCS; and
- perform, at a minimum, a secondary survey to assess,
a. chest, for
i. subcutaneous emphysema,
ii. accessory muscle use,
iii. urticaria,
iv. indrawing,
v. shape,
vi. symmetry, and
vii. tenderness;
b. lungs, for decreased air entry and adventitious sounds (e.g. wheezes, crackles), through auscultation,
c. abdomen, as per the Abdominal Pain (Non-traumatic) Standard,
d. neck, for tracheal position and jugular vein distension, and
e. extremities, for leg/ankle edema.
STEMI Hospital Bypass Protocol
What will the paramedic assess if they suspect a STEMI? (1.)
- assess the patient to determine if they meet all of the following indications:
a. ≥18 years of age;
b. experience chest pain or equivalent consistent with cardiac ischemia or myocardial infarction;
c. the time from onset of the current episode of pain <12 hours; and
d. the 12-lead electrocardiogram (ECG) indicates an acute myocardial infarction/STEMI, as follows:
i. At least 2 mm ST-elevation in leads V1-V3 in at least two contiguous leads; AND/OR
ii. At least 1 mm ST-elevation in at least two other anatomically contiguous leads; OR
iii. 12-lead ECG computer interpretation of STEMI and paramedic agrees.
STEMI Hospital Bypass Protocol
What are contraindications to STEMI Bypass? (2.)
- if the patient meets the criteria listed in paragraph 1 above, assess the patient to determine if they have any of the following contraindications:
a. The patient is CTAS 1 and the paramedic is unable to secure the patient’s airway or ventilate;
b. 12-lead ECG is consistent with a Left Bundle Branch Block (LBBB), ventricular paced rhythm, or any other STEMI imitator;
c. Transport to a hospital capable of performing percutaneous coronary intervention (PCI) ≥60 minutes from patient contact;
d. The patient is experiencing a complication requiring primary care paramedic (PCP) diversion, as follows:
i. Moderate to severe respiratory distress or use of continuous positive positive airway pressure (CPAP);
ii. Hemodynamic instability (e.g. due to symptomatic arrhythmias or any ventricular arrhythmia) or symptomatic SBP <90 mmHg at any point; or
iii. VSA without return of spontaneous circulation (ROSC).
e. The patient is experiencing a complication requiring ACP diversion, as follows:
i. Ventilation inadequate despite assistance;
ii. Hemodynamic instability unresponsive to advanced care paramedic (ACP) treatment or not amenable to ACP management; or
iii. VSA without ROSC.
STEMI Hospital Bypass Protocol
When can we still ask the PCI to consider transport? (3.)
- notwithstanding paragraph 2(c), 2(d), and 2(e) above, attempt to determine if the interventional cardiology program at the PCI centre will still permit the transport to the PCI centre;
2(c) - ≥60 minutes from pt contact
2(d) - complications requiring PCP diversion
2(e) - complications requiring ACP diversion
STEMI Hospital Bypass Protocol
What do you do if the patient can go to the PCI? (4.)
- if the patient does not meet any of the contraindications listed in paragraph 2 above OR the interventional cardiology program permits the transport to the PCI centre as per paragraph 3 above, inform the CACC/ACS of the need to transport to a PCI centre;
a. provide the PCI centre the following information as soon as possible:
b. that the patient is a “STEMI patient”;
c. the patient’s initials;
d. the patient’s age;
e. the patient’s sex;
f. the patient’s;
g. infarct territory and/or findings on the qualifying ECG;
h. estimated time of arrival; and
i. catchment area of the patient pickup.
STEMI Hospital By-Pass Protocol
What information needs to be provided upon arrival to the PCI? (5.)
- upon arrival at the PCI centre, in addition to the requirements listed in the Transfer of Responsibility for Patient Care Standard, provide the following information to the PCI centre staff:
a. time of symptom onset;
b. time of ROSC, if applicable;
c. hemodynamic status;
d. medications given and procedure;
e. history of acute myocardial infarction/PCI/Coronary artery bypass graft, if applicable;
f. a copy of the qualifying ECG; and
g. a copy of the Ambulance Call Report in accordance with the Ontario Ambulance Documentation Standards.
If the patient’s ECG normalizes after initiating the STEMI Bypass Protocol, should you continue to follow it?
Yes.
“Note: Once initiated, continue to follow the STEMI Hospital Bypass Protocol even if the ECG normalizes after the initial assessment.”
BLS Chest Pain Guidelines
What should a paramedic do once a STEMI is confirmed?
- Once a STEMI is confirmed, the paramedic should apply defibrillation pads due to the potential for lethal cardiac arrhythmias.
BLS Chest Pain Guidelines?
Which arm is the preferred site to establish IV access?
- If intravenous access is indicated and established as per the Advanced Life Support Patient Care Standards, then the left arm is the preferred site.
BLS Chest Pain Guidelines
Should a patient who becomes STEMI positive enroute to a non-PCI destination be evaluated for STEMI bypass?
- If the ECG becomes STEMI-positive en route to a non-PCI destination, the patient should still be evaluated under this STEMI Hospital Bypass Protocol.
BLS Chest Pain Guidelines
If the PCI can’t accept the patient, can you consider an alternate PCI?
- If, in a rare circumstance, the PCI centre that it cannot accept the patient (e.g. equipment failure, multiple STEMI patients), then the paramedic may consider transport to an alternative PCI centre as long as they still meet the STEMI Hospital Bypass Protocol.
