STEMI

Question 1

When would you treat with Prehospital thrombolysis?

Answer 1

• Time to PCI >1hr
• All inclusion criteria met
  AND
• No exclusion criteria met

Question 2

When would you treat as per Urgent transport to PCI?

Answer 2

• Time to PCI <1 hr
  OR
• Not suitable for PHT

Question 3

What needs to be completed with prehospital thrombolysis?

Answer 3

• ALS paramedics MUST call cardiology consult service (CSS) prior to thrombolysis
• MICA paramedics MUST call CSS where any relative C/I are present
• IVC access x 2, NaCl TKVO
• Complete checklist and read information statement to patient
• Tenecteplase IV bolus
• Heparin IV bolus 4000 IU
• • Repeat Heparin IV bolus 1000 IU at 1 hour intervals

Tenecteplase doses
<60kg 6000IU
60-69kg 7000 IU
70-79kg 8000 IU
80-89kg 9000 IU
>90kg 10000 IU
***Patients >75 yrs - dose must be halved

• Capture a rpt ECG 30/60 prior to arrival and transmit with notification
• Aim to transport to pt to closest PCI facility (in consult with clinician)

Question 4

What do paramedics need to complete with urgent transport to PCI?

Answer 4

• Paramedics must call CCS if there is any uncertainty regarding STEMI diagnosis, thrombolysis, incl if paramedic believed monitor interpretation to be incorrect where
  Pt may be eligable for PHT
• ALS paramedics MUST call CCS prior to administering heparin
• Do not delay transport
• Heparin bolus IV 4000 IU
• Rpt 1000 IU at 1 hr intervals
• Capture 12 lead ECG 30 mins prior to arrival and transmit with notification

Question 5

Recite the STEMI CPG

Question 6

What do you do if STEMI symptoms are greater than 12 hours?

Answer 6

Continue management as per ACS and transport with notification

Question 7

What is the exclusion criteria for thrombolysis for a STEMI?

Answer 7

If the patient has had the following in the past 3 months:

• Major surgery (abode, chest, brain, spine or joint replacement)
• Significant head injury
• Major trauma
• GI bleed in the past month
• Current bleeding disorder/active bleeding
• Taking anticoagulants
• Allergy to tenecteplase or gentamicin?

If in doubt consult CSS

Question 8

What is the inclusion criteria for thrombolysis for a STEMI?

Answer 8

The patient can ONLY be given thrombolysis if BOTH of the following inclusion criteria apply:

- Symptom onset <12 hours ago
AND
- Monitor identified STEMI
OR
- 12 lead ECG showing ST elevation in two or more contiguous leads:

> 2.5mm ST elevation in leads V2-3 in men aged < 40 years
OR
2mm ST elevation in leads V2-3 in men aged > 40
OR
1.5mm ST elevation in leads V2-3 in women
OR
1mm in other leads
New onset LBBB

Question 9

What are relative contraindications for commencing thrombolysis?

Answer 9

If any of these apply call CCS before proceeding with thrombolysis

• > 75 yrs
• pt with non-compressible vascular puncture (recent organ biopsy or IV central line)
• Hx of liver disease
• SBP > 160 OR DBP > 110
• HR > 120
• Low body weight
• Active peptic ulcer
• Anaemia
• Possibility of acute pericarditis OR subacute bacterial endocarditis
• Pt who has receive traumatic or prolonged CPR (>10mins)
• Pregnant or within 1 week post party

Question 10

What do you need to do in post thrombolysis care?

Answer 10

• Reassess perfusion, conscious state
• 12 lead ECGs at least every 15 minutes - note time, number in series and pain score
• Check potential bleeding sites (e.g. cannulation, PR, GI, and oral and conjunctival mucous membranes)