The capability for advanced cardiovascular life support (ACLS) crews to perform a 12-lead ECG in the prehospital setting has been expanding throughout healthcare worldwide over the past several decades. This has been helped along by several organizations including the American College of Cardiology Foundation (ACCF), American Heart Association Task Force (AHA), and the European Society of Cardiology (ESC). These have all released policies recommending that a 12-lead ECG per performed at the point of first medical contact (FMC) for patients with signs or symptoms consistent with acute ST-elevation myocardial infarction (STEMI). This is defined as a 12-lead ECG that is performed by a paramedic on an ACLS unit that is either interpreted in the field or transmitted to a hospital emergency department or coronary care unit (CCU) for interpretation.
The ultimate goal of the prehospital ECG is to generate an early diagnosis of STEMI and ensure that the patient is managed appropriately given the location of the patient and the capability of local healthcare facilities. Preferably, patients should be transported to a percutaneous coronary intervention (PCI)-capable center with a goal of FMC of a definitive intervention in 90 minutes or less. This can mean bypassing closer, non-PCI capable hospitals. However, if it is impossible to reach FMC to a device in less than 120 minutes, the patient will require fibrinolytic therapy, if eligible. AHA and ACCF recommendations leave this decision to the discretion of the emergency medical service (EMS) providers to make it to a PCI-capable hospital promptly or to head to the nearest hospital for fibrinolytic therapy. Early fibrinolytic therapy has been shown beneficial in reducing morbidity and mortality in patients with acute STEMI who cannot reach a PCI-capable center. In the United States, this is primarily performed at rural, non-PCI-capable facilities. Several European countries including the United Kingdom have produced numerous studies showing that fibrinolytic therapy performed in the field, by a trained paramedic, with a physician or in conjunction with a physician at a nearby facility reviewing the prehospital ECG can be safe and significantly decrease reperfusion time in an acute STEMI. This is not widely adopted in the United States due to the lack of funding and training in rural areas where this would see the most benefit.
Therefore, the prehospital, 12-lead ECG is an important tool that can be considered in triaging a patient with symptoms concerning for an acute STEMI and transport the patient either to the nearest non-PCI capable hospital, directly to a PCI-capable hospital, or directly to the nearest cardiac catheterization laboratory (CCL).