# Pre Hospital Troponin Testing



## ceames (Feb 3, 2009)

What's everyones thoughts on this? Our service is looking into it. We have some areas that require over an hour of transport to the hospital or we can fly them.


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## Wyoming Medic (Feb 3, 2009)

I think it is great if it can be done.  Typically our jurisdiction uses the Istat tester.  It seems to work OK but I am still not convinced.

The question is, what are you going to do with the findings?  Relay them to the receiving facility?  My concern is that people may be treating the Istat and not the symptoms that the patient presents with.

I try and treat every medical from a cardiac standpoint.  I try to rule it out and treat from there (diferential diagnosis).  Even though I may have this feeling deep down that it is not a cardiac I will typically attach a monitor and take a peek.  Reffered pain and such is spooky.  While the Istat will be another test that one can use for the treatment it is also another tool that can give false data and lead to incorrect patient care.  And it is another tool that may lead to medics only being able to read the machine and forget how to spot cardiac problems in their patient.

Just my .2 cents.  If it can be implimented by seasoned medical staff and can be used for what it is, a tool, then YES.  Go for it.

Wy medic


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## BossyCow (Feb 3, 2009)

Friend of mine was a patient in the back of my rig a short time ago. She was having a non-stemi MI that was only diagnosed by her elevated troponin levels. Hers was caught in the ER, not in the field but having that info would have speeded her care up by several hours.


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## Wyoming Medic (Feb 3, 2009)

BossyCow said:


> Friend of mine was a patient in the back of my rig a short time ago. She was having a non-stemi MI that was only diagnosed by her elevated troponin levels. Hers was caught in the ER, not in the field but having that info would have speeded her care up by several hours.



Out of curiosity, what were the symptoms that led to the cardiac monitor being placed on her?


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## Veneficus (Feb 3, 2009)

think i wrote about this on another site recently. 

The istat is a great device in the ED. It comes with too many logisitcal problems to be used in the field effectively.


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## downunderwunda (Feb 3, 2009)

ceames said:


> What's everyones thoughts on this? Our service is looking into it. We have some areas that require over an hour of transport to the hospital or we can fly them.




The question should be what will you do if you have a positive result.

It is one thing to test for it, but what will you be doing for the patient? IF they are looking at this introduction, then 12 lead ECG should also be onsidered, as well as Thrombolyasis, then you can have extended transports with no problems.

If you do nothing with the results, then you might as well not administer the test.


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## VentMedic (Feb 3, 2009)

What technology are you looking at?

The POC machine (iSTAT) I am familiar with needs special cartridges, stored in a refrigerator, removed in adequate time for the chill to be off before using, and takes about 15 - 30 minutes for analyzing. And, expensive with tight standards to ensure machine accuracy.

If this is to determine hospital distination with and a very long transport time, then maybe. 

However, troponin levels are not always high initially which is why serial tests are done as are EKGs. 

We use our iSTAT on Flight, CCT and Specialty regularly but with the Respiratory Therapy lab doing the CLIA paperwork and oversight for control variance. We do most of the labs except troponin. The hospitals we pick up from runs labs that can be faxed to the rec'g doctor and we our main hospital is a cath center. We rarely if ever use the iSTAT on a 911 Flight response. The iSTAT qualifies for a freestanding lab permit or license per CLIA guidelines but you do have a lot of paperwork with strict standards and each state can have its own requirements as well.


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## BossyCow (Feb 3, 2009)

Wyoming Medic said:


> Out of curiosity, what were the symptoms that led to the cardiac monitor being placed on her?



She was having chest pain, esophageal spasms which she attributed to her hx of GERD. Pain was radiating up into her jaw and ear. The medic and original RN thought it was probably gastric rather than cardiac. She was awake and talking to us through the whole thing with a maximum pain level of 7:10


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## Veneficus (Feb 3, 2009)

BossyCow said:


> She was having chest pain, esophageal spasms which she attributed to her hx of GERD. Pain was radiating up into her jaw and ear. The medic and original RN thought it was probably gastric rather than cardiac. She was awake and talking to us through the whole thing with a maximum pain level of 7:10



A female with chest pain radiating to the jaw and ear, esophageal spasms and they were suspecting GERD prior to NSTEMI???


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## ceames (Feb 3, 2009)

The thought was this; from our northern bases transport times can be 1-2+ hours to our local hospital. The Cath lab is another hour south. A positive result would buy a helicopter ride.


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## Veneficus (Feb 3, 2009)

ceames said:


> The thought was this; from our northern bases transport times can be 1-2+ hours to our local hospital. The Cath lab is another hour south. A positive result would buy a helicopter ride.



Don't know if I would base a helo ride on a positive troponin. Maybe if it was a significant positive number. But a positive result of 0.1 ng/ml might buy a telemetry bed and some thrombolytic. Cards doesn't even like when we call <0.13 ng/ml, they don't even get excited till 0.25


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## daedalus (Feb 3, 2009)

The replacement cartridges are just so expensive. I am on board for POC cardiac enzymes but the technology will have to advance to something like a glucometer before EMS can get its hands on it.


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## maxwell (Feb 4, 2009)

Absolutely useless.  What are you going to do with the findings?


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## BossyCow (Feb 4, 2009)

Veneficus said:


> A female with chest pain radiating to the jaw and ear, esophageal spasms and they were suspecting GERD prior to NSTEMI???



The location and the way she described the pain lead to the GERD diagnosis, plus, she kept telling us and them that she's had this before and it was exactly the same as her previous GERD events. She is in her early 40's with no cardiac history, BP about 140/80, color was good, no sweating and a normal EKG. She fooled me, the ALS medic, the intake RN and the PA, the only sign of the cardiac event was the labs.


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## Veneficus (Feb 4, 2009)

maxwell said:


> Absolutely useless.  What are you going to do with the findings?



Depending on the reading, notify a cath lab sounds like a good idea? Tell somebody so they can expedite care? 

I agree though, it is not worth the $10K plus all the problems associated with having one.


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## maxwell (Feb 4, 2009)

Veneficus said:


> Depending on the reading, notify a cath lab sounds like a good idea? Tell somebody so they can expedite care?
> 
> I agree though, it is not worth the $10K plus all the problems associated with having one.



Troponin would have no impact on field treatment.  Moreover, the cath lab needs much more data than just a troponin.  They need to see numerous ECGs (or just one if it's on the money), other important labs, and really, they'll repeat enzymes anyway - so there goes the "saving time" argument.  You also might find stuff you're not looking for.  People just might have an elevated Troponin and cost the hospital a LOT of money and the patient an unnessecary admission, cath, even CABG.  Where I come from, that's really, really bad.  And let's be honest.  EMS lab values are seldom accurate.  Let's play paramedic instead of internist.


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## Veneficus (Feb 4, 2009)

maxwell said:


> Troponin would have no impact on field treatment.  Moreover, the cath lab needs much more data than just a troponin.  They need to see numerous ECGs (or just one if it's on the money), other important labs, and really, they'll repeat enzymes anyway - so there goes the "saving time" argument.  You also might find stuff you're not looking for.  People just might have an elevated Troponin and cost the hospital a LOT of money and the patient an unnessecary admission, cath, even CABG.  Where I come from, that's really, really bad.  And let's be honest.  EMS lab values are seldom accurate.  Let's play paramedic instead of internist.



I wasn't suggesting basing decisions soley on troponin, but it is a great tool in conjunction with others. (still not suitable for prehospital which I have been saying all along) But if you have an EKG w/changes and 0.25 ng/ml cardiac troponin (which the istat is specific for) it is very compelling. Especially in places that will activate a cath lab based on EMS findings or when you have to decide to pass a facility to get to a place that can do PCI. In addition a person suspected of cardiac issues with a "positive" troponin is almost promised 12-24 hours in a hospital so unwanted admission doesn't seem reasonable for not having it. A POC troponin is a large factor in deciding admission. Chest pain w/o EKG changes, w/o troponin, is of more diagnositc value than just an EKG. 

Maybe we could play paramedic instead of ambulance driver?


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## VentMedic (Feb 4, 2009)

This might be great for the very rural areas, but one would have to remember to grab a cartridge before departing the base. But then, we are back to the argument that rural areas where it might be useful can not afford ALS or recover the costs of such an expensive piece of equipment.

There are still many more tests to be run besides EKGs and a troponin level since there are numerous other cardiac conditions that don't always give noticeable clues by those two tests alone.


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## Flight-LP (Feb 5, 2009)

maxwell said:


> Troponin would have no impact on field treatment.  Moreover, the cath lab needs much more data than just a troponin.  They need to see numerous ECGs (or just one if it's on the money), other important labs, and really, they'll repeat enzymes anyway - so there goes the "saving time" argument.  You also might find stuff you're not looking for.  People just might have an elevated Troponin and cost the hospital a LOT of money and the patient an unnessecary admission, cath, even CABG.  Where I come from, that's really, really bad.  And let's be honest.  EMS lab values are seldom accurate.  Let's play paramedic instead of internist.



I was actually on track to agree with you up until the CABG part. You have got to be kidding me that ANY interventional Radiologist or Cardiologist would bypass on a sole Troponin....................

I do agree that enzymes pre-hospital is not really a necessity, especially for transport determination. Murphy's law would immediately dictate that your positive Troponin will occur at the one time air medical cannot fly. There's $10k down the drain................

They are great for obtaining an H&H, but not too many places routinely carry and infuse whole blood or PRBC's............

BTW - Can you qualify the "seldom accurate" statement? Properly calibrated, these machines are pretty accurate, I have always found them to be pretty much on the money. Or was that a lame pot shot at Paramedics??????


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## VentMedic (Feb 5, 2009)

Flight-LP said:


> BTW - Can you qualify the "seldom accurate" statement? Properly calibrated, these machines are pretty accurate, I have always found them to be pretty much on the money. Or was that a lame pot shot at Paramedics??????


 

Read the glucose thread where some are just finding out how and why calibrations are done and how often some remember to do them. And, that is just for the glucometer. 

We have had questionable results with our iSTATs before but that also included lengthy distances from our base and cautious handling of the cartridge. Carrying the cartridge in a cooler helps in hot and humid weather but the variations in temperature can still be a factor. If the total transport takes 5 hours or more, we have to be very careful and use our clinical signs for correlation more than just relying on technology. Fixed wing also seems to treat our technology better than the helicopter and we will recal at altitude in a fixed wing.


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## Flight-LP (Feb 5, 2009)

Very good point. However, we rarely ever had a transport last longer than 2 hours, much less 5......................He!!, for a while I was in a Bell 206, couldn't carry that much fuel if we wanted to!

We also kept the cartridges in the cooler / fridge (depended on the aircraft). Ironically, right next to the Ativan................  

On to that thread now...............


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## VentMedic (Feb 5, 2009)

Flight-LP said:


> Very good point. However, we rarely ever had a transport last longer than 2 hours, much less 5......................He!!, for a while I was in a Bell 206, couldn't carry that much fuel if we wanted to!


 
Neo and Pedi transports...we do the islands, South America and Mexico occasionally as well as a couple of different states.


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## RJ80 (May 10, 2011)

Okay, okay, I know, I'm resurrecting an old thread, but I stumbled on this one while google searching some research for some troponin markers.  

I see that many of you have looked at using the IStat and like it but with limitations.  Have you considered qualitative tests instead?  That was what I was researching when I found this thread.  I'm trying to tlk my boss into spending money on these things.

www.tntdiagnostics.com/TNTProducts-Cardiac Marker Tests.php

I got a couple of samples from the company and they seem to be pretty easy to use and to store.

What do you folks think?


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## Hellsbells (May 15, 2011)

I have to admit that personally I have little experience with triponin testing. However, It seems that if there is a reliable method for testing in the prehospital environment it would be of some value. Im thinking in particular of those rural services that have protocols for on car thrombolytics. In those cases id say it would be a very valuable adjunct for therapy, again presuming there is a cost effective, quick and reliable method in place for testing.


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## systemet (May 15, 2011)

Hellsbells said:


> Im thinking in particular of those rural services that have protocols for on car thrombolytics. In those cases id say it would be a very valuable adjunct for therapy, again presuming there is a cost effective, quick and reliable method in place for testing.



The problem with that is that you thrombolyse based on the presence of STEMI, the absence of absolute contraindications, and the balance of relative contraindications and PCI availability.  

If you have a NSTEMI with positive troponin, it's usually adjunctive therapy (plavix, enoxaparin), and PCI.  While I'm sure there's probably some inhospital exception that I'm not aware of, you don't thrombolyse NSTEMIs.


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## ArcticKat (May 15, 2011)

It would be a nice confirmation to backup the STEMI and if it's a NSTEMI with elevated trops we could administrate plavix and enoxaparin.

Does anyone have those meds in their scope of practice?  We don't, but with prehospital trops it may be something we can include.

RJ80, any idea of the cost?


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## RJ80 (May 15, 2011)

The kits I got cost $13 for just a troponin test, and $18 for a combined trop/myo test.  They have a shelf life of about 18 months and can be stored at room temp.


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## systemet (May 16, 2011)

ArcticKat said:


> It would be a nice confirmation to backup the STEMI and if it's a NSTEMI with elevated trops we could administrate plavix and enoxaparin.



Agreed.  With the obvious caveat that some early STEMIs will be troponin negative, but still receive huge benefit from thrombolytics.




> ]Does anyone have those meds in their scope of practice?  We don't, but with prehospital trops it may be something we can include.



We used them in my old job.  When we had a STEMI, we faxed to a cardiologist, and then depending on resources and patient condition went direct to PCI (+ plavix + enoxaparin), or gave TNK.

The trick with this sort of thing, as I see it, is not to have the specific drugs the paramedics can administer written in a legal statute, because it takes too long to change.  If the relevant sections of whatever laws govern EMS say "the paramedic may administer IV medication", it makes it a lot easier for medical control to introduce new therapies.


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## ArcticKat (May 16, 2011)

Unfortunately our College has a very strict zero tolerance policy regarding scope of practice and protocols which are very specific and detailed.  It wasn't quite so bad in the past when our government regulated us and considered the protocols as guidelines to care and the occasional stray was considered good patient care when it was rationalized properly.

Now that we have our own licences and professional regulatory body we aren't given quite so much latitude.  I believe it's because our College is afraid of losing its training wheels and being relegated back to obscurity.


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## TxParamedic (May 16, 2011)

we are trial testing the Nanogen cardiac STATus for CK-MB, Troponin. For the most part to give the ER Doc more info to make a decision to transport to a higher level of care without waiting for labs to come back. Keeping in mind it takes us about 30 minutes to get a helo and the nearest cath lab is over an hour away by ground.


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## rexbanner (Dec 22, 2011)

Old Post! Sorry! But new info!

www . edmontonjournal.com/health/Tiny+labs+inside+Edmonton+ambulances+could+save+cardiac+patients+lives/5465578/story.html

please add the www . together since the forum wouldnt allow it since Im new. However it is clearly not spam.

Been giving TNK for about 7 or 8 years (inc trial). Now starting with this. In the future if it goes past trial it probably won't do anything prehospitally except change our destination to a hospital with PCI. Currently, as it states in the article and is often the case, NSTEMI can wait up to 3-4 days to get a cath. (We have about 10 hospitals regionally vairying in care type, but only 2 with PCI).

Dr. Welsh is very proactive and this trial "Proact" is just another example of that.


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