GG.3.26 STEMI Bypass Protocol

PURPOSE

To ensure a consistent and standardized practice for the activation of STEMI bypass/alert by Manitoulin-Sudbury DSB Paramedics.

Health Sciences North houses the Cardiac Catheterization Laboratory for Manitoulin and Sudbury districts. It is located at the Ramsey Lake site at the Centre Tower on the 3rd floor. Access to this area of the hospital is gained through the ED garage, north tower, north entrance (alternative entrance to ED doors).

APPLICATION

• Paramedics
• Paramedic Superintendents

PROCEDURE
 
Background

Development of the Provincial STEMI Hospital Bypass Protocol has been made in consultation with Cardiac Care Network (CCN), the Ontario Association of Paramedic Chiefs (OAPC), the Ontario Base Hospital Group Executive Committee (OBHG-Executive), Ontario Medical Advisory Committee (OBHG-MAC) and ORNGE.

Procedure

• Bypass to the Health Sciences North Cardiac Catheterization Laboratory, or Emergency Department shall be initiated where clinical criteria and geographic inclusion is met. The geographic inclusion is in Section 3.
•   
• Patients presenting with borderline/unclear ST segment elevation, any STEMI mimics, pre/post cardiac arrest (not cardiogenic shock related) or who weigh greater than 250kg (550 pounds) shall be transported directly to the closest Emergency Department for further assessment. (Patients that are greater than 250 kg (550 pounds) exceed the max allowable weight for the procedure table) 
• STEMI Bypass directly to the HSN Cath Lab will only be applicable on Monday to Friday between the hours of 0730 and 17:00. During evening hours (12 Lead acquired after 17:00), weekends and statutory holidays, all STEMI positive patients who meet the geographic inclusion criteria shall be transported under a STEMI Alert to the Health Sciences North Emergency Department. The HSN Cath Lab will be activated by the ED physician upon consultation with the transporting paramedics. 
• The potential bypass to HSN’s Cath Lab shall be initiated once a 12 Lead ECG completed by Paramedics reveals a positive STEMI. The Cath Lab remains the most appropriate destination even if the ECG normalizes after administration of oxygen and/or symptom relief medications. 
• Positive STEMI patients presenting in suspected cardiogenic shock should be transported directly to the Cath Lab regardless of pre-arrest status. If CPR is in progress, the patient will be transported to the closest ED. CACC must be advised if patient status changes to VSA to ensure the Cath Lab can be notified that Paramedics will be proceeding to the Emergency Department. 

Clinical Assessment:
 
In situations in which the Paramedic suspects that the patient is suffering from a STEMI, the Paramedic shall: 

1.Immediately, notify the CACC by portable radio of the STEMI Alert finding.  

2.Assess the patient to determine if they meet all of the following inclusion criteria:

• _ >18 years of age;     
• experiencing chest pain current or resolved consistent with cardiac ischemia or myocardial infarction; 
• the time from onset of the current episode of pain <12 hours; 

AND

• 12-lead ECG indicates an acute AMI/STEMI, as follows: 
• At least 2 mm ST-elevation in leads V1-V3 in at least two contiguous leads; OR
• At least 1 mm ST-elevation in at least two other anatomically contiguous leads; OR
• 12-lead ECG computer interpretation of STEMI and paramedic agrees. 

3.If the patient meets the inclusion criteria listed, assess the patient to determine if they have any of the following exclusion criteria

• The Paramedic is unable to secure the patient's airway or ventilate; 

or

• 12-lead ECG is consistent with any STEMI mimics such as:
  • Bundle Branch Blocks (Right and Left) 
  • Left Ventricular Hypertrophy 
  • Ventricular Pacemaker Rhythms
  • Pericarditis 
  • Hyperkalemia
  • Hypokalemia
  • Digitalis Effect 
  • Benign Early Repolarization (BER)
  • Patients weighing greater than 250kg or 5501b

transport directly to closest Emergency Department 

• If a Manitoulin-Sudbury Paramedic is outside of geographic inclusion criteria and the clinical inclusion criteria are met, the patient shall be transported to the closest Emergency Department. 

Reasons for diversion to the closest Emergency Department are as follows: 

• Moderate to severe respiratory distress or use of CPAP
• Hemodynamic instability (e.g. due to symptomatic arrhythmias or ventricular arrhythmia) or symptomatic SBP <90mmHg unresponsive to treatment 
• VSA without ROSC 

STEMI Process: 

If the patient meets all indications and does not have any exclusionary criteria: 

• Paramedics shall initiate a "STEMI Alert" via portable or vehicle radio as soon as a STEMI is confirmed. Communication to CACC will be limited to "STEMI ALERT" and estimated arrival time to the HSN.   
• CACC shall immediately notify the Cath Lab. Once Cath Lab is notified and bypass is confirmed, CACC will relay the confirmation to the transporting paramedics via radio. 
• In the event of any communication failure, or should Paramedics have any doubts about inclusion, the patient will be transported to the closest Emergency Department. 

During evenings, weekends and statutory holidays, the Cath Lab will be activated by the HSN ED Physician, following a patch and STEMI confirmation. 

4.While Health Sciences North is the ED destination for specific areas of Manitoulin-Sudbury districts, the STEMI Bypass program will allow for other paramedics to divert from the closest Emergency Department. 

• Paramedics shall initiate a "STEMI Alert" and prepare for transport to HSN where the following geofencing is met.
  • Areas, west of Greater Sudbury inclusive of Espanola.
  • Areas, east of Greater Sudbury.
  • Areas, north of Greater Sudbury to the Watershed. 
  • Areas, south of Greater Sudbury to intersection of Highway 69 and 522. 

REFERENCE

BLS PCS v. 3.4
ALSPCS v. 5.3
Ontario STEMI Bypass Protocol version 1
Health Sciences North Centre for Prehospital Care STEMI Triage Guideline