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Given that pre-hospital research doesn't always demonstrate favorable outcomes for our patients, it seems that the EMS world has been given another opportunity. The most recent (2004) guidelines for the treatment of STEMI were published in this month's Annals of Emergency Medicine. Many things remain the same, but the guidelines call for an expanded scope for the nation's EMS providers. Time is indeed muscle. The most interesting section talked about establishing realistic protocols for the administration of thrombolytics in the field. Since door to reperfusion time is an important predictor of outcome, the ACC/AHA feels that empowering medics to deliver such lifesaving care may be a necesary step. The most practical application of these guidelines, it would seem, would be to train rural EMS providers in the administration of retevase. Also discussed was the principle of paramedic triage. Based on the patient's presentation and history, some people benefit from transport to a hospital capable of interventional treatment (stent/cath/etc). The implication is that the closest facility may not always be the appropriate one for the patient suffering from an ST elevation MI. Another EMS specific recommendation was to train virtually all paramedics in the art of initial and continous 12 lead EKG monitoring. Clearly, the paramedics ability to recognize acute and ongoing EKG changes might increase the patient's chances of getting to a cath lab within a reasonable time. Its probably a good time to have discussions about the following with your respective medical directors:
1. The practicality of pre hospital thrombolysis in your service area. If long transport times are a reality, then it might be appropriate to investigate some retevase protocols.
2. Obtaining 12 lead EKGs on all transport trucks for identification of STEMI patients
3. Off line use of morphine for the control of cardiac pain. Our service didn't have to ask, but many still require on line MCP approval prior to MS04 administration. The new ACC/AHA guidelines reiterate MSO4 as the analgesic of choice for cardiac CP
4. Revision of protocol to reflect transport to the closest APPROPRIATE facility. The ability to reperfuse ischemic tissue is of prime importance; certain patient subsets benefit from cath vs. drugs. In some cases, EMS agencies might consider transporting to a tertiary referral facility instead of the closest ED....
I'll post a link to the ACC/AHA 2004 guidelines when I find 'em. Any thoughts? Are there many other services currently utilizing prehospital thrombolytic protocols? Is everybody on the same boat with the 12-lead EKG strategies?
-PuSh
1. The practicality of pre hospital thrombolysis in your service area. If long transport times are a reality, then it might be appropriate to investigate some retevase protocols.
2. Obtaining 12 lead EKGs on all transport trucks for identification of STEMI patients
3. Off line use of morphine for the control of cardiac pain. Our service didn't have to ask, but many still require on line MCP approval prior to MS04 administration. The new ACC/AHA guidelines reiterate MSO4 as the analgesic of choice for cardiac CP
4. Revision of protocol to reflect transport to the closest APPROPRIATE facility. The ability to reperfuse ischemic tissue is of prime importance; certain patient subsets benefit from cath vs. drugs. In some cases, EMS agencies might consider transporting to a tertiary referral facility instead of the closest ED....
I'll post a link to the ACC/AHA 2004 guidelines when I find 'em. Any thoughts? Are there many other services currently utilizing prehospital thrombolytic protocols? Is everybody on the same boat with the 12-lead EKG strategies?
-PuSh