(a) Assessment of the Heart Attack Patient. - (i) EMS providers shall maintain a high index of suspicion that a patient may be suffering a myocardial infarction or acute coronary syndrome when the patient presents with signs or symptoms that include, but are not limited to:
- (A) A prior history of myocardial infarction, acute coronary syndrome, or other cardiac related health problems;
- (C) Pain or discomfort in other areas of the body (e.g. arm, jaw or epigastrium) of suspected cardiac origin;
- (H) Atypical or unusual symptoms, particularly in women, the elderly, and diabetic patients;
- (I) Congestive heart failure (CHF);
- (ii) The 12-lead ECG is the primary diagnostic tool that identifies an ST segment elevation myocardial infarction (STEMI). EMS providers shall acquire a 12-lead ECG, and transmit the recording as soon as possible for all patients.
(b) Triage of the Heart Attack Patient. Heart attack patients shall be triaged to the most appropriate facility based on the index of suspicion formed by the cumulative assessed findings.
(c) Treatment of the Heart Attack Patient. The care provided by EMS providers shall be directed toward reducing the following time factors: - (i) The time between the first indication of a myocardial infarction or acute coronary syndrome and the administration of aspirin;
- (ii) The time between the arrival on scene to the time of 12-lead ECG acquisition;
- (iii) The time between 12-lead ECG acquisition and transmission of the recording;
- (iv) The time between 12-lead ECG acquisition and the identification of a STEMI;
- (v) The time between the identification of a STEMI and notification of the findings to the receiving facility;
- (vi) The time between the onset of a STEMI patient's symptoms and their ultimate arrival at a PCI center;
- (vii) The time between EMS agency notification and the time of activation of a cardiac catheterization laboratory;
- (viii) The time between arrival at the PCI center and the time of cardiac catheterization (door-to-balloon time);
- (ix) The time between prehospital 12-lead ECG acquisition and the time of cardiac catheterization (ECG-to-balloon time).
(d) ALS personnel shall assess the patient's cardiac rhythm utilizing a cardiac monitor and 12-lead ECG and treat in accordance with the appropriate local protocols and standing orders.
(e) If the patient is dyspneic, hypoxemic, or has obvious signs of heart failure and there are no other contraindications, EMS providers shall perform the following to the extent allowed by the individual's scope of practice: - (i) Titrate oxygen therapy to achieve an oxygen saturation of greater than or equal to 94%;
- (ii) Administer aspirin - chewable, non-enteric-coated, 160 to 325 mg is preferred;
- (iii) Establish intravenous access;
- (iv) Transmit a 12-lead ECG at the earliest opportunity for remote interpretation or confirmation by a physician;
- (v) Provide advance notification as soon as possible to the receiving hospital for patients identified as having STEMI;
- (vi) Perform serial ECGs and make copies of all ECGs available to treating personnel at the receiving hospital, whether they are presented in hard copy or transmitted from the field;
- (vii) Administer nitroglycerin (tablets or spray) every three to five minutes as long as the patient's systolic blood pressure remains greater than 100mmHg.
- (A) Nitrates in all forms are contraindicated in patients with a systolic blood pressure less than 90 mmHg, in patients with suspected right ventricular infarction, or when patients have taken an erectile dysfunction medication within 24 hours, or within 48 hours of the use of tadalafil (Adcirca, Cialis);
- (viii) Analgesia is indicated in STEMI when chest discomfort is unresponsive to nitrates. Morphine should be used with caution in unstable angina due to an association with increased mortality.
(f) Transport of the Heart Attack Patient. Ambulance destination decisions shall be preferential based on the following descending order of preference and capability: - (i) Heart Attack Receiving Center or a hospital with a PCI facility;
- (ii) Heart Attack Referring Center;
- (iii) A hospital with an emergency department.
048-15 Wyo. Code R. § 15-5