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60 Second Read "Paddling the STEMI"

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As a kid I loved getting into the cookie jar. I thought I was pretty sneaky, but I would always get caught. To make it worse, when mom asked me if I had gotten into the cookie jar - I lied and said no. As a result of fibbing I got a paddling. Really mom just used a plastic spoon until one day it broke when she was paddling my brother (he deserved it).

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After identifying a STEMI (OMI) I place my pads in the AP position, which requires me to take off at least V1 and V2, possibly V3 and V4 depending on the style of your pads. Doing this one move can save you precious seconds if the patient goes into VF. 

Patients identified to have a STEMI within the field have around a 4-6% likelihood of going into a VF arrest while under the care of pre-hospital providers (Felder, 2019).

This allows providers to be very sensitive, but not specific, by placing pads on all STEMIs. That’s okay in my book because we decrease the amount of time to defibrillation in those 4-6% of patients.

Two studies looked at the pads on strategy. Osei-Ampofo et al (2016) published a case review of two patients. The pads-off strategy took 2 min 42 sec from arrest to shock. The pads-on strategy took 27 seconds. Both people woke up very shortly after being defibrillated.

The second study by Felder et al (2019) did a retrospective chart review. There were 446 patients identified as a STEMI within the field. 11 people went into cardiac arrest. The pads-off strategy averaged 72 seconds while the pads-on took 17 seconds.

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The shocking thing was out of both studies only two people showed any signs of decompensation. 11 out of 13 people appeared stable just prior to going into cardiac arrest. Providers were unable to differentiate which people were going to code. 

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To be sensitive (and caring) provider should consider premptively placing defib pads on all patients where occlusion myocardial ischemia/infarction is suspected.

 

Felder, S., VanAarsen, K., & Davis, M. (2019). Decreasing time to first shock: Routine application of defibrillation pads in prehospital STEMI. CJEM, 1–4. https://doi.org/10.1017/cem.2019.408

Osei-Ampofo, M., Cheskes, S., Byers, A., Drennan, I., Buick, J., & Verbeek, P. (2015). A Novel Approach to Improve Time to First Shock in Prehospital STEMI Complicated by Ventricular Fibrillation. Prehospital Emergency Care20(2), 278–282. https://doi.org/10.3109/10903127.2015.1076100

Ryan, D., Craig, A. M., Turner, L., & Verbeek, P. R. (2013). Clinical Events and Treatment in Prehospital Patients with ST-segment Elevation Myocardial Infarction. Prehospital Emergency Care17(2), 181–186. https://doi.org/10.3109/10903127.2012.744783

Siudak, Z., Birkemeyer, R., Dziewierz, A., Zmudka, K., Dubiel, J., & Dudek, D. (2011). Out-of-hospital cardiac arrest in patients treated with primary PCI for STEMI. Long-term follow up data from EUROTRANSFER registry. Resuscitation,83(3), 303–306. https://doi.org/10.1016/j.resuscitation.2011.09.007

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