You have 90 minutes to restore blood flow.

Step 1: Obtain EKG and Call STEMI Alert

* This activates ED resources as well as cath lab, interventional cardiology, etc

Step 2: Stop the Platelets

* Dual anti-platelet therapy* Aspirin 325mg chewed (or PR)* Plavix 600mg (not usually given in ED)* Complicates management if patient needs CABG

Step 3: Stop the Coagulation Cascade

* Heparin 60 units/kg (MAX 4000 units)

Step 4: Patient Should (Ideally) Be Going to Cath Lab By Now

* If you DON’T have cath lab* Option 1: 30 minutes to give thrombolytics* Option 2: 120 minutes to get them to a different hospital with cath lab

Sgarbossa Criteria

* Left bundle branch block (LBBB)* PLUS* Concordant ST elevation (>1mm) in leads with positive QRS* OR* Concordant ST depression (>1mm) in leads with negative QRS* Typically V1-V3* OR* Severely discordant ST elevation (>5mm) in leads with negative QRS

“MONA”

* Morphine 4mg IV q5min PRN pain is appropriate if patient actually HAS pain* Oxygen has been shown to worsen outcomes if given indiscriminately* Not ideal to be giving supplemental O2 when SaO2 is 100%* Nitroglycerine* Nitroglycerine 0.4 mg SL q5min* OR* Nitroglycerin 10mcg/min drip (will need to be titrated UP)* For comparison… * 0.4 mg SL nitroglycerine releases approximately 80mcg/min* Contraindications* Inferior/Right heart infarction* Patients usually preload dependent* Nitro drops preload* Sildenafil (Viagra)* Can cause sudden/severe drop in blood pressure* Hypotension

Additional Reading

* Round 3 – Chest Pain (EM Clerkship)* The Death of MONA in ACS: Part 1 – Morphine (REBEL EM)* The Death of MONA in ACS: Part 2 – Oxygen (REBEL EM)* The Death of MONA in ACS: Part 3 – Nitroglycerine (REBEL EM)* The Death of MONA in ACS: Part 4 – Aspirin (REBEL EM)