Stroke and mi management in emergency er….with pnemonics

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I now have solid content from Rosen's Emergency Medicine and Fuster's The Heart. Let me compile the complete answer with all mnemonics.

Stroke & MI: Emergency Management with Mnemonics

PART 1: ACUTE ISCHEMIC STROKE

Recognition - "BE-FAST"

Letter	Meaning
B	Balance - sudden loss
E	Eyes - sudden vision change
F	Face drooping
A	Arm weakness
S	Speech difficulty
T	Time to call 911

Classic older version: FAST (Face, Arm, Speech, Time)

Initial ER Assessment - "ROSIER" Score

(Recognition Of Stroke In the Emergency Room)

Item	Points
Loss of consciousness/syncope	-1
Seizure	-1
Asymmetric facial weakness	+1
Asymmetric arm weakness	+1
Asymmetric leg weakness	+1
Speech disturbance	+1
Visual field defect	+1
Score >0 = likely stroke

Immediate ER Management - "TIME IS BRAIN"

"DONT" - Initial stabilization before specific treatment:

Letter	Meaning
D	Dextrose (check glucose - treat hypoglycemia)
O	Oxygen (maintain SpO2 >94%)
N	Naloxone (if opioid overdose suspected)
T	Thiamine (before dextrose)

tPA/Alteplase Eligibility - "SMART"

Letter	Meaning
S	Symptoms onset <4.5 hours
M	Mild-moderate deficit (NIHSS documented)
A	Age ≥18 (no upper age cutoff per current guidelines)
R	Rule out hemorrhage (CT head negative)
T	Target BP <185/110 before giving tPA

tPA dose: 0.9 mg/kg IV (max 90 mg) - 10% as bolus, rest over 60 min

tPA Contraindications - "NO tPA"


N	No anticoagulants (recent therapeutic heparin/warfarin)
O	Onset >4.5 hours OR unknown
t	Trauma/surgery within 3 months (head or major)
P	Prior stroke + diabetes combo
A	Active bleeding / intracranial hemorrhage

BP Management in Acute Ischemic Stroke

No tPA planned: Only treat if BP >220/120 mmHg; reduce ~15% over 24 hours
tPA planned: Must get BP <185/110 before dosing, maintain <180/110 after
Agents of choice: Labetalol (20 mg IV bolus q10 min) or Nicardipine (5-15 mg/hr IV)
Avoid sodium nitroprusside (raises ICP)

(Rosen's Emergency Medicine)

Mechanical Thrombectomy (Large Vessel Occlusion)

Consider in all eligible patients with LVO within 24 hours of last known well (extended window with DAWN/DEFUSE-3 criteria)
NIHSS ≥6, CT perfusion showing salvageable tissue

Hemorrhagic Stroke (ICH) BP Target

Systolic >220: Rapid IV reduction
Systolic 150-220: Target SBP 140 mmHg
Use nicardipine/labetalol/clevidipine

PART 2: ACUTE MI (STEMI/NSTEMI)

Recognition - "CHEST PAIN"

Letter	Meaning
C	Characteristic: crushing, pressure, radiating
H	History: prior CAD, risk factors
E	ECG: ST elevation, new LBBB, reciprocal changes
S	Sweating, nausea, vomiting
T	Troponin elevation
P	Pulse oximetry / BP check
A	Age/sex risk
I	Imaging (CXR, echo)
N	Note time of symptom onset

Initial ER Management - "MONA" (classic) + "BATMAN"

Classic MONA:

Letter	Meaning	Notes
M	Morphine	Use cautiously - may worsen outcomes in some ACS
O	Oxygen	Only if SpO2 <90%
N	Nitrates	Sublingual NTG → IV if ongoing pain; avoid if RV infarct
A	Aspirin	162-325 mg chewed immediately

Extended - "BATMAN" (modern ACS bundle):

Letter	Meaning
B	Beta-blocker (oral, avoid IV in acute decompensation)
A	Aspirin 325 mg
T	Ticagrelor or clopidogrel (P2Y12 inhibitor - dual antiplatelet)
M	Morphine (judicious) / Monitor continuously
A	Anticoagulation (UFH/enoxaparin/bivalirudin)
N	Nitrates

STEMI Reperfusion Strategy - "4 Ds"

(from Rosen's Emergency Medicine)

D	Meaning
Door	Events before arrival / prehospital
Data	ECG within 5-10 min of arrival
Decision	STEMI diagnosis + therapy decision
Drug/Device	Fibrinolytic drug OR balloon catheter across lesion

Goal: Door-to-balloon (PCI) <90 min | Door-to-needle (fibrinolysis) <30 min

PCI vs Fibrinolysis Decision - "PPCI Preferred If..."

PCI available within 120 min of first medical contact
Cardiogenic shock
Fibrinolysis contraindicated
Large anterior STEMI / high-risk features

Fibrinolysis if PCI not timely available: Agents: Alteplase (tPA), Reteplase, Tenecteplase, Streptokinase

Anticoagulation in STEMI - "HAB"

Agent	Setting
H	Heparin (UFH) - most common, 70-100 U/kg bolus for pPCI
A	Alteplase/fibrinolytic setting - UFH or enoxaparin
B	Bivalirudin - HIT patients or alternative to UFH

(Fuster and Hurst's The Heart, 15th Ed)

Antiplatelet Therapy - "DAPT"

Dual AntiPlatelet Therapy:

Aspirin 325 mg loading → 81 mg daily
P2Y12 inhibitor: Ticagrelor (preferred) or Clopidogrel or Prasugrel

Give loading dose BEFORE PCI!

STEMI Contraindications to Fibrinolysis - "BASH"

Letter	Meaning
B	Bleeding history (active/recent intracranial)
A	Aortic dissection suspected
S	Surgery/trauma within 3 weeks
H	Hypertension uncontrolled (>180/110)

Nitroglycerin Absolute Contraindications - "SHoP"


S	Sildenafil/PDE5 inhibitor use within 24-48 hrs
H	Hypotension (SBP <90)
P	(Right ventricular) infarct (inferior STEMI with RV involvement)

QUICK COMPARISON TABLE

Feature	Acute Stroke	Acute MI (STEMI)
Time window	<4.5 hrs (tPA) / <24 hrs (thrombectomy)	<12 hrs (PCI optimal)
Key drug	tPA (alteplase)	Aspirin + P2Y12 + heparin
Imaging	CT head immediately	12-lead ECG immediately
BP target (no intervention)	<220/120 (permissive)	Control if hypertensive
BP target (pre-procedure)	<185/110 (tPA)	<180/110
Reperfusion	IV tPA or mechanical thrombectomy	Primary PCI (preferred) or fibrinolysis
Antiplatelets	Aspirin 325 mg (after 24 hrs if tPA given)	Aspirin + P2Y12 immediately

MASTER MNEMONIC - "STROKE" vs "HEART"

STROKE (Ischemic):

S - Sugar check (glucose)
T - Time onset (<4.5 hrs for tPA)
R - Rule out hemorrhage (CT)
O - O2 if SpO2 <94%
K - Keep BP permissive (unless tPA)
E - Evaluate LVO → thrombectomy

HEART (MI):

H - Heparin + anticoagulation
E - ECG in 10 min (diagnose STEMI)
A - Aspirin 325 mg + P2Y12
R - Reperfusion (PCI <90 min / lysis <30 min)
T - Troponin + monitoring

Sources:

Rosen's Emergency Medicine - ACS and stroke ER management chapters
Fuster and Hurst's The Heart, 15th Ed - STEMI antiplatelet/anticoagulation protocols
Bradley and Daroff's Neurology in Clinical Practice - Acute stroke treatment guidelines

Ecg in mi in ER things to know must from basics

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I now have comprehensive textbook content and real ECG images. Let me compile the complete answer.

ECG in MI - Everything You Must Know (Basics to ER)

1. THE BASICS: ECG PAPER & MEASUREMENTS

ECG paper speed = 25 mm/s

1 small box = 0.04 sec (40 ms) horizontally = 0.1 mV vertically
1 large box = 0.20 sec (200 ms) = 0.5 mV

The Normal ECG Wave Sequence: "PQRST"

P = atrial depolarization
PR interval = 0.12-0.20 sec (3-5 small boxes)
QRS = ventricular depolarization (<0.12 sec)
ST segment = early repolarization (should be on the isoelectric line)
T wave = ventricular repolarization

2. SEQUENTIAL ECG CHANGES IN MI - "HOT Q"

The ECG changes in MI follow a time-based sequence:

Time	Change	What It Means
Minutes	Hyperacute T waves (tall, peaked, symmetric)	Very earliest sign - subendocardial injury
1-4 hrs	ST elevation (convex/tombstone)	Transmural injury - STEMI
Hours	T wave inversion	Ischemia/evolving infarct
6-24 hrs	Q waves develop (pathologic)	Myocardial necrosis
Days-weeks	ST normalizes, Q waves persist	Old/evolving MI

Mnemonic: "H-I-Q-T" (Hours-Injury-Ischemia-Quilts of necrosis)

Hyperacute T → ST Elevation → T inversion → Q waves

3. STEMI DIAGNOSTIC CRITERIA (Must Memorize)

ST Elevation Thresholds (ACC/AHA):

Leads	ST Elevation Required
V2-V3 (men ≥40 yr)	≥2 mm
V2-V3 (men <40 yr)	≥2.5 mm
V2-V3 (women)	≥1.5 mm
All other leads	≥1 mm in ≥2 contiguous leads

Mnemonic: "2-2.5-1.5-1" (V2-V3 men / V2-V3 young men / V2-V3 women / all others)

Must be in ≥2 contiguous leads to diagnose STEMI

4. LOCALIZATION BY LEADS - THE MOST IMPORTANT TABLE

(from Tintinalli's Emergency Medicine)

Territory	Leads with ST Elevation	Culprit Vessel
Anteroseptal	V1, V2 (±V3)	LAD (proximal)
Anterior	V1, V2, V3, V4	LAD
Anterolateral	V1-V6, I, aVL	LAD (proximal)
Lateral (High)	I, aVL	Circumflex or Diagonal
Inferior	II, III, aVF	RCA (80%) or LCx (20%)
Inferolateral	II, III, aVF + V5, V6	RCA or LCx
Posterior	Tall R in V1-V2, ST depression V1-V3	RCA or LCx
Right Ventricle	ST elevation II,III,aVF + V3R-V6R	RCA (proximal)

Mnemonic to remember leads: "I See Pretty Leads, A Really Intelligent Physician"

Inferior = II, III, aVF
Septal = V1, V2
Anterior = V3, V4
Lateral = V5, V6, I, aVL

5. REAL ECG EXAMPLES FROM TEXTBOOKS

Anterolateral STEMI (Rosen's Emergency Medicine)

Proximal LAD occlusion - ST elevation in V1-V4 (anterior) and I, aVL, V5, V6 (lateral):

Anterolateral STEMI ECG showing ST elevation in anterior and lateral leads

High Lateral MI (I and aVL elevation - Circumflex/D1 occlusion)

ST elevation in leads I and aVL with reciprocal changes in II, III, aVF:

High lateral MI ECG showing ST elevation in leads I and aVL

Inferior MI with Reciprocal Changes

Marked ST elevation in II, III, aVF - classic reciprocal ST depression in I and aVL:

Inferior STEMI ECG with reciprocal changes in leads I and aVL

Posterior MI - Leads V8, V9

ST elevation visible in posterior leads V8, V9 (subtle but diagnostic):

Posterior MI ECG showing ST elevation in V8 and V9

6. RECIPROCAL CHANGES - "THE MIRROR RULE"

Reciprocal changes = ST depression in leads facing the opposite wall.

Primary STEMI	Reciprocal Depression Seen In
Inferior (II, III, aVF)	I, aVL
Anterior (V1-V4)	II, III, aVF (occasionally)
Lateral (I, aVL)	II, III, aVF

Why they matter: Reciprocal changes indicate a LARGER infarct, increased mortality, and higher risk of cardiogenic shock (Tintinalli's; Rosen's).

7. POSTERIOR MI - "THE INVISIBLE INFARCT"

The posterior wall has no direct leads in standard 12-lead ECG. You must recognize it from mirror image changes in V1-V3:

Mnemonic "HURT" in V1-V2 = Posterior MI:

Letter	Finding
Horizontal	ST depression (not sloped)
Upright	T wave (should be inverted normally if ischemic)
R wave	Tall, wide R wave (>0.04 sec)
Tall R/S	Ratio >1 in V1-V2

Confirm with posterior leads: V7 (left mid-axillary), V8 (left posterior axillary), V9 (left paraspinal) - look for ≥0.5 mm ST elevation.

8. RIGHT VENTRICULAR (RV) MI - "CRITICAL PEARL"

Always occurs with inferior STEMI
Present in ~30-40% of inferior MIs
Clue: ST elevation greater in lead III than lead II + ST elevation in V1

How to diagnose: Get right-sided leads (V3R-V6R)

ST elevation ≥0.5 mm in V4R = diagnostic

Clinical triad of RV infarct:

Hypotension + Elevated JVP + Clear lungs (Kussmaul's sign)

ER Management rule:

AVOID nitrates - they drop preload and will cause cardiovascular collapse in RV infarct! GIVE IV fluids (500-1000 mL NS bolus) to maintain RV filling pressure.

9. PATHOLOGIC Q WAVES

(Washington Manual of Medical Therapeutics)

Q waves = myocardial necrosis (irreversible cell death)

Criteria for pathologic Q wave:

In V2-V3: ≥0.02 sec (1 small box) wide, or any QS complex
In other leads: ≥0.03 sec wide AND ≥0.1 mV deep, in ≥2 contiguous leads
Isolated Q in lead III or V1 = normal variant (don't panic)

Important:

New Q waves alone are NOT an indication for thrombolysis if ST is normalized
Always compare with an old ECG to determine chronicity

10. STEMI EQUIVALENTS - "NOT JUST ST ELEVATION"

Some STEMIs do NOT show classic ST elevation. Know these:

Pattern	What It Means
New LBBB	STEMI equivalent (if truly new) - but <10% have AMI
De Winter T waves	Tall, upright T with ST depression in V1-V6 = proximal LAD occlusion (no elevation!)
Wellens' syndrome	Biphasic or deep T inversion in V2-V3 = critical LAD stenosis (post-ischemia)
aVR ST elevation	Left main or proximal LAD occlusion (global ischemia)
Posterior ST depression V1-V3	Posterior STEMI (mirror image - see above)

Mnemonic "DWWA":

De Winter = LAD proximal occlusion (no STE)
Wellens = Threatened LAD (critical stenosis)
Wide new LBBB = STEMI equivalent
AVR elevation = Left main/proximal LAD

11. ST ELEVATION MIMICS - MUST RULE OUT

(Washington Manual of Medical Therapeutics)

Mnemonic "PHELP B":

Letter	Mimic
P	Pericarditis (saddle-shaped, diffuse STE, PR depression)
H	Hyperkalemia (peaked T, widened QRS, sine wave)
E	Early repolarization (J-point notching, usually young males)
L	LVH with strain pattern
P	PE (Pulmonary embolism - S1Q3T3 pattern)
B	Brugada syndrome (V1-V2 coved ST elevation)

Key differentiator for Pericarditis vs STEMI:

Feature	Pericarditis	STEMI
ST shape	Saddle/concave up	Convex/tombstone
PR segment	Depressed (pathognomonic)	Normal
Leads affected	Diffuse (all except aVR)	Regional
Reciprocal changes	None	Present
Q waves	No	Yes (later)

12. ER ECG PROTOCOL - "10-MINUTE RULE"

Goal: ECG within 10 minutes of patient arrival for ALL chest pain

Step-by-step ER ECG approach:

1. RATE     → Normal (60-100), Tachy, Brady
2. RHYTHM   → Regular? P before every QRS?
3. AXIS     → Normal (-30° to +90°)
4. INTERVALS → PR, QRS, QTc
5. ST/T     → Elevation? Depression? Inversion?
6. Q WAVES  → Pathologic?
7. COMPARE  → Old ECG (most important!)

Mnemonic: "RRAISTQ-C" = Rate, Rhythm, Axis, Intervals, ST, T waves, Q waves, Compare

13. QUICK-FIRE PEARLS FOR ER

Pearl	Rule
Inferior MI → always get right-sided leads	Rule out RV infarct
Inferior MI → ST III > ST II	Suggests RCA occlusion
Inferior MI → ST II > ST III	Suggests LCx occlusion
ST depression V1-V3 + upright T	Think posterior MI
aVL reciprocal change	Strong marker of inferior STEMI
New LBBB + symptoms	Treat as STEMI until proven otherwise (use Sgarbossa criteria)
Serial ECGs	If first ECG non-diagnostic but high suspicion, repeat at 15-30 min
Right-sided ECG	Get V4R - ST elevation ≥0.5 mm = RV MI confirmed
ST elevation in aVR	Left main occlusion - highest risk patient

14. SGARBOSSA CRITERIA (for LBBB + suspected MI)

When LBBB is present, standard STEMI criteria don't apply. Use Sgarbossa:

Criterion	Points
ST elevation ≥1 mm concordant with QRS (in same direction)	5
ST depression ≥1 mm in V1, V2, or V3	3
ST elevation ≥5 mm discordant with QRS (in opposite direction)	2

Score ≥3 = highly suggestive of AMI in LBBB

Modified Sgarbossa: discordant STE/QRS ratio >0.25 is more specific than the 5mm cutoff.

Sources:

Tintinalli's Emergency Medicine: A Comprehensive Study - ECG chapter (Table 49-4, 49-5)
Rosen's Emergency Medicine - Anatomic localization of AMI, posterior/RV MI sections
Washington Manual of Medical Therapeutics - ST elevation differential diagnosis and Q wave criteria

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