12 Lead Transmission: Sharpening Our Skill

Written by: Kevin Mackey MD, FAEMS, FACEP

Medical Director Sacramento Regional Fire Services

kmackey@srfecc.ca.gov

Introduction

12 Lead transmission is a vitally important tool that, when used appropriately, sets in motion a series of events that drastically

decreases time to definitive treatment for patients suffering from a ST Elevation

Myocardial Infarction

STEMI detection by any computerized interpretive algorithm is not accurate enough

for activating the cath lab without ECG overread. The AHA Guidelines 2015 recommend against it,

as well. The cardiac monitor algorithms are intended to

be used as a STEMI screening tool by providing a second opinion.

Introduction

12 Lead transmission is a tool with two primary purposes in the prehospital environment: 1. Early alerting of cardiac cath labs to

prepare for a critically ill patient 2. Diagnostic guidance

Primary Role: Early Notification

• Caring for a STEMI patient requires a wide variety of hospital personnel and resources. Some of these include: – ED nurses/doctors/techs – Radiology techs – Laboratory techs – Cardiac cath lab nurses/doctors/techs – ICU nurses/doctors – Environmental services

• So early notification is important to get this army of people prepared to care for this very ill patient

Secondary Role of Transmission: Diagnostic Guidance

• On rare occasions, a paramedic might need the assistance of a physician to evaluate a rhythm to offer input, support and guidance about patient care

• These events are exceptionally rare, thanks to the great training that the paramedics all receive and the experience that they have

What We Will Discuss

• How to use this training presentation • Review of SCEMSA recent policy revision on 12

lead transmission • Discuss examples of LP 12, LP 15, and Zoll X

Series 12 leads that SHOULD be transmitted • Examples with explanations of 12 lead

transmissions that are likely unnecessary to transmit

How To Use This Training

• This training is MANDATORY for all Firefighter Paramedics in SCEMSA and must be completed by February 1st, 2018

• Please read the content of every slide carefully!

• Send feedback/questions directly to Dr. Mackey, Sacramento Regional Fire Medical Director(kmackey@srfecc.ca.gov)

New SCEMSA Policy 8827

• A 12 Lead is INDICATED for the following: – Discomfort or pain of Suspected Cardiac Origin – Symptomatic Bradycardia – Symptomatic Tachycardia – CONSIDERED (not required) for Upper Abdominal

Pain – CONSIDERED (not required) in patients 40 years or

older with atypical signs or symptoms of Acute Coronary Syndrome

New SCEMSA Policy 8827

• A 12 Lead showing STEMI shall be TRANSMITTED to the STEMI Alert receiving facility when technologically feasible (which should be ALL the time, in Sacramento County) or when requested

• A 12 lead can also be transmitted for a MEDICAL CONSULT

Summary of NEW policy

1. Acquire a 12 lead when appropriate 2. Transmit ONLY those 12 leads that read

+STEMI (to be discussed in a couple slides) 3. Option to transmit for a MEDICAL CONSULT if

the paramedic requires guidance about treating an arrythmia (ie: unclear if the rhythm is Ventricular Tachycardia or Rapid Atrial Fibrillation)

STEMI EKG EXAMPLES

LifePak 12 STEMI EKG

The image part with relationship ID rId2 was not found in the file.

LifePak 12 Interpretation

LifePak 15 STEMI EKG

LifePak 15 Interpretation

Zoll X Series

Zoll X Series Interpretation

Summary of the KEY Features • LifePak 12

***ACUTE MI SUSPECTED***

• LifePak 15

***MEETS ST ELEVATION MI CRITERIA***

• ZOLL X Series ***STEMI***

Summary of the KEY Phrases in the Interpretation

• LifePak 12 ***ACUTE MI SUSPECTED***

• LifePak 15

***MEETS ST ELEVATION MI CRITERIA***

• ZOLL X Series ***STEMI***

Note: When a STEMI is detected, it is both PRECEDED and FOLLOWED by one or

more Asterisks (***) If there is NO Asterisk, IT IS NOT A STEMI !!!

Look for the Stars!

• Any interpretation preceded and followed by Asterisks (***) is a STEMI.

• STEMI is the ONLY interpretation that is preceded and followed by ***

• STEMI is the ONLY EKG that REQUIRES transmission to a hospital

When do I Transmit?

• When a STEMI is read in the interpretation (as indicated by the asterisks (***)

• When a paramedic needs on-line medical control advice about interpretation and treatment of a cardiac rhythm

• No other 12 leads need to be transmitted, but ALL 12 leads should be left with the hospital staff AND placed in the electronic PCR (when possible)

NO * means NO STEMI!

NON-STEMI EKG EXAMPLES

“Concerning” Language in the Interpretation

• The Following is a partial list of computer interpretations that might sound concerning, but ARE NOT a STEMI – “Possible Infarct, age undetermined” – “May be due to Myocardial Ischemia” – "Suggests myocardial ischemia” – “Axis Deviation” – “Abnormal ECG **Unconfirmed**” – “Consider acute ischemia” – “Abnormal finding for 40+ year old”

Examples of “STEMIs” that Aren’t Really STEMIs

”Fake” STEMI’s

• Cardiac monitors can only interpret what is provided to it

• Artifact is the #1 reason why a monitor would interpret a rhythm as a STEMI, when it is not a true STEMI. Non-ischemic EKG changes is #2

• Please correct lead problems, once you identify them, and then REACQUIRE the 12 lead again

Contents of the STEMI ALERT

• The STEMI Alert should contain the following information: – Situation:

• Identification of the call as a “STEMI Alert.” • Estimated time of arrival in _______ minutes for STEMI. • Patient age and gender • Confirm ECG states ***Acute MI*** or ***Acute MI

Suspected*** or ***STEMI*** • If patient elects to go to a facility that is not a STEMI

designation receiving center • Any urgent patient concerns (pertinent history and/or

abnormal vital signs).

Bottom Line

1. Transmit only those 12 Leads that read : – ***Acute MI Suspected*** – ***Meets ST Elevation MI Criteria*** – *******Acute MI******* – Note: Three or More *** Appear in FRONT and

AFTER the key phrase

2. Notify the STEMI Receiving Center EARLY, preferably when the 12 lead is transmitted

Thank you!