You have 90 minutes to restore blood flow.

Step 1: Obtain EKG and Call STEMI Alert

  • This activates ED resources as well as cath lab, interventional cardiology, etc

Step 2: Stop the Platelets

  • Dual anti-platelet therapy
    • Aspirin 325mg chewed (or PR)
    • Plavix 600mg (not usually given in ED)
      • Complicates management if patient needs CABG

Step 3: Stop the Coagulation Cascade

  • Heparin 60 units/kg (MAX 4000 units)

Step 4: Patient Should (Ideally) Be Going to Cath Lab By Now

  • If you DON’T have cath lab
    • Option 1: 30 minutes to give thrombolytics
    • Option 2: 120 minutes to get them to a different hospital with cath lab

Sgarbossa Criteria

  • Left bundle branch block (LBBB)
  • PLUS
  • Concordant ST elevation (>1mm) in leads with positive QRS
  • OR
  • Concordant ST depression (>1mm) in leads with negative QRS
    • Typically V1-V3
  • OR
  • Severely discordant ST elevation (>5mm) in leads with negative QRS


  • Morphine 4mg IV q5min PRN pain is appropriate if patient actually HAS pain
  • Oxygen has been shown to worsen outcomes if given indiscriminately
    • Not ideal to be giving supplemental O2 when SaO2 is 100%
  • Nitroglycerine
    • Nitroglycerine 0.4 mg SL q5min
    • OR
    • Nitroglycerin 10mcg/min drip (will need to be titrated UP)
      • For comparison…
        • 0.4 mg SL nitroglycerine releases approximately 80mcg/min
    • Contraindications
      • Inferior/Right heart infarction
        • Patients usually preload dependent
        • Nitro drops preload
      • Sildenafil (Viagra)
        • Can cause sudden/severe drop in blood pressure
      • Hypotension

Additional Reading