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Immediate priorities
STEMI first 10 minutes
Resuscitation bay criteria
Ongoing chest pain with hypotension
Altered mental status
Refractory hypoxemia
Ventricular tachycardia or fibrillation
Time zero definitions
Symptom onset time
First medical contact time
ED arrival time
Monitoring and access
Cardiac monitor with defibrillator pads
Two large bore IV lines
Point of care glucose
Continuous pulse oximetry
Reperfusion pathway selection
Reperfusion decision
Primary PCI pathway
PCI capable target (FMC to device 90 minutes)
Class I recommendation for timely primary PCI when feasible
Door to balloon target 90 minutes for ED arrival at PCI center
Transfer target (FMC to device 120 minutes)
If expected delay beyond target, fibrinolysis consideration
Early transfer for rescue PCI after lysis
Fibrinolysis pathway
Symptom onset within 12 hours
Greatest benefit within first 2 to 3 hours
Class I recommendation when PCI delay is excessive and no contraindications
Door to needle target 30 minutes
Immediate contraindication screen
Post lysis ECG reassessment at 60 to 90 minutes
Hemodynamics and oxygenation
Physiologic targets
Oxygen
SpO2 target 90 to 94 percent
Routine oxygen avoided if SpO2 90 percent or higher
Oxygen escalation for respiratory distress or hypoxemia
Ventilation support triggers
Pulmonary edema with work of breathing
Hypercapnia on ABG with elevated PaCO2 (mmHg)
Blood pressure and perfusion
Avoid hypotension
SBP under 90 mmHg
Signs of shock
Avoid excessive afterload reduction
RV infarct suspicion
Aortic stenosis suspicion
Complication recognition and escalation
Immediate threats
Malignant arrhythmias
Defibrillation for VF or pulseless VT
ACLS immediate shock
Post ROSC STEMI pathway continuation
Bradycardia with hypotension
Atropine escalation
Transcutaneous pacing readiness
Cardiogenic shock
Cold clammy extremities
Lactate elevation
Oliguria
Early cath lab activation for shock with STEMI
Mechanical complications
New loud murmur with pulmonary edema
Acute MR from papillary muscle rupture
VSD consideration
Tamponade concern
POCUS pericardial effusion
Hypotension with JVP elevation
PITFALLS
Missed STEMI patterns
Posterior MI equivalents
ST depression V1 to V3 with tall R waves
Posterior leads V7 to V9 ST elevation 0.5 mm or higher
LBBB paced rhythm
Modified Sgarbossa criteria use
Avoid false reassurance from nondiagnostic ECG wording
Delayed reperfusion
Prolonged triage time
ECG within 10 minutes target
Repeat ECG with persistent symptoms
Aortic dissection mimic
Avoid fibrinolysis if dissection concern
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.