# 50 yo male with AMI



## HMartinho (Mar 2, 2014)

At my night shift on a ILS service (me-EMTB and a pre-hospital RN), we received a call at 7 am for a rural area. A 50 year old man with weakness, diaphoresis, and chest pain that radiates to the back and left arm. When we arrived, we found him lying in bed, being assisted by local firefighters.

Medical history: Familial hypercholesterolemia and hypertension. Denies allergies. Meds:  sinvastatin, hydrochlorothiazide+irbesartam , vitamin supplements and echinacea. 

Vitals: 
Pulse: 70 and regular
BP: 110/70
RR: 22 unlabored, simetric and regular
Pain: 7/10 -> started 1 hour ago
Pulse ox: 96% on 2 liters by nasal cannula

Physical Examination:
Skin is pale and wet. Breath sounds are normal. Heart tones: S1 and S2 present in all fields, without murmurs. 
12-lead ECG was performed, and shows STEMI.

The nurse started an IV and administered 5 mg of morphine sulfate, SL nitro, ASA PO. The hospital with cath lab has ETA of 45 minutes and the small ER 20 minutes. We and the medical supervisor, decided to transport to the hospital with cath lab. 

During transport, the patient went into cardiac arrest (rhythm was v-fib). We stop the ambulance and starded the ILS algorithm. ALS unit is unavailable. After 25 minutes (shocks, drugs, entubation ET), the rhythm was assystole, and medical supervisor ordered transport to the small ER. Upon arrival, he was pronounced dead.

What did you do differently? 
Would have continued the resuscitation procedures in the field? 

NOTE: We carry fibrinolytics in the ambulance, but the medical supervisor denied fibrinolysis.


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## chaz90 (Mar 2, 2014)

Sometimes there's nothing you can do differently. Looks like a straightforward STEMI EKG, and sounds like appropriate care was provided from the beginning. Only minor difference noticed at first glance is that I would have pronounced after working the code for 25 minutes into asystole and then transported the deceased to the ED. Any right sided EKGs done for lateral involvement? I completely agree with the PCI capable transport destination as well. Even if you would have transported to the smaller ED, seems like the patient would still have arrested based on your timeline presented. A witnessed VF arrest with immediate CPR and defibrillation is just about the best odds an arrest can ever be, but sometimes the damage is already done and the situation is too far gone. Not that I know a ton about your situation, but I can't imagine having an "ALS" unit available would have changed anything. Seems like the RN provided all of the same commonly accepted STEMI and arrest interventions.


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## Handsome Robb (Mar 2, 2014)

Sounds like a straightforward call.

This is one situation where a CPR device would have been very nice so you could have had good qualit compressions and continued to transport. Without a machine though you're basically stuck. Also if the cath lab won't do an intra-arrest cath it doesn't matter anyways. Seems like once he arrested fibrinolytics might have been worth a shot...just me though. 

I'm with Chaz, doesn't sound like there was much more you could do. I'm assuming when you talk about the "medical supervisor" you're talking about medical direction?


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## VFlutter (Mar 2, 2014)

Primary PCI is the definitive treatment for STEMI, if available. Thrombolytic therapy is a second line treatment only if PCI is not an option . Most Cardiologists will not cath a patient who has recieved lytics until 12-2hrs later, and at that point it is considerd salvage therapy. Giving lytics to patient within appropriate transport time to a cath lab only delays primary treatment.

You can give lytics intra-arrest however there is little evidence to support it. 

Our cath lab will perform PCI intra-arrest with a Lucas. Pretty cool stuff.


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## GoldcrossEMTbasic (Mar 12, 2014)

I would have to agree on all accounts. But when you see a STEMI, I would call for the bird in the sky if lifeflight is close by. Based on our protocols, the patient would indefinitely would be airlifted to the nearest cath lab STAT. But how long is it going to take for the chopper to get on scene. And the patient is already coding and CPR is being performed. But you would think that Medical Direction would order some type of meds to attempt to get a rhythm going just to stabilize the heart and we do use LUCAS's too. These are nice when you have a situation like this on our hands.


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## Tigger (Mar 12, 2014)

If you can get a helicopter to you, on the ground with patient handover and repackaging, and then off the ground to the hospital in less than 45 minutes then more power to you. That's never been possible where I work. If it's less than an hour by ground to the hospital then we go by ground, otherwise we have to launch them on the way to the call for them to be of any time saving benefit. Flight crews don't offer much that a ground crew doesn't care wise, don't fool yourself if you have ground based ALS available.


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## jrm818 (Mar 13, 2014)

Chase said:


> Primary PCI is the definitive treatment for STEMI, if available. Thrombolytic therapy is a second line treatment only if PCI is not an option . Most Cardiologists will not cath a patient who has recieved lytics until 12-2hrs later, and at that point it is considerd salvage therapy. Giving lytics to patient within appropriate transport time to a cath lab only delays primary treatment.
> 
> You can give lytics intra-arrest however there is little evidence to support it.
> 
> Our cath lab will perform PCI intra-arrest with a Lucas. Pretty cool stuff.



Will they cath asystole, or just vfib/ tach?

 Sounds like nothing more could be done for this patient.  The inter arrest PCI raises an interesting point...its very fun to proclaim " thou shalt not transport active CPR" and feel very enlightened...but with the slowly building indications that ECMO/PCI may work as therapy during refractory arrest, will we perhaps swing full circle?  Or is field ecmo coming?


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## Tigger (Mar 13, 2014)

jrm818 said:


> Will they cath asystole, or just vfib/ tach?
> 
> Sounds like nothing more could be done for this patient.  The inter arrest PCI raises an interesting point...its very fun to proclaim " thou shalt not transport active CPR" and feel very enlightened...but with the slowly building indications that ECMO/PCI may work as therapy during refractory arrest, will we perhaps swing full circle?  Or is field ecmo coming?



I don't think any one is arguing that EMS should never, without exception, transport with CPR in progress. Obviously there will be exceptions and refractory vFib is one of them in some places. Nothing is proven to improve aystole survival to discharge rates.


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## VFlutter (Mar 13, 2014)

jrm818 said:


> Will they cath asystole, or just vfib/ tach?
> 
> Sounds like nothing more could be done for this patient.  The inter arrest PCI raises an interesting point...its very fun to proclaim " thou shalt not transport active CPR" and feel very enlightened...but with the slowly building indications that ECMO/PCI may work as therapy during refractory arrest, will we perhaps swing full circle?  Or is field ecmo coming?



IIRC, they are only doing witnessed VT/VF with evidence of MI on EKG prior to arrest. The inclusion criteria may become more liberal as time goes on. 

EMCO resuscitation is starting to pick up steam in my area. Mostly for in-hospital arrests, ARDS, and refractory shock. I am sure ED ECMO is coming down the road. It is already happening at many large academic centers. Pre-hospital ECMO seems like more hassle that it's worth outside of HEMS retrieval. No way training will ever be adequate.   Our children's hospital has a fantastic transport ECMO team.


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## bmedic1681 (Mar 13, 2014)

*What did Nurse on board have available*

You stated the nurse gave medication…. Did you have a drug box on your ambulance and was this nurse an RN working under a Medical Director?


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## Tigger (Mar 13, 2014)

bmedic1681 said:


> You stated the nurse gave medication…. Did you have a drug box on your ambulance and was this nurse an RN working under a Medical Director?



It's pretty clear in his initial post that a prehospital RN is his partner. This is also not in the US....


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## bmedic1681 (Mar 13, 2014)

Which is why I asked the questions…. I was trying to determine the protocol of the agency because I have heard of other countries having similar standard of care


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## bmedic1681 (Mar 13, 2014)

Just because you are an RN in a prehospital environment does not mean you do not work under the license of an OMD who sets your standard of care


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## Medic Tim (Mar 13, 2014)

bmedic1681 said:


> Just because you are an RN in a prehospital environment does not mean you do not work under the license of an OMD who sets your standard of care




In some countries medics and RNs don't always work under physicians oversight.


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## bmedic1681 (Mar 13, 2014)

In this one they do……. Paramedics have more standing orders than Most nurses  here


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## Tigger (Mar 14, 2014)

bmedic1681 said:


> In this one they do……. Paramedics have more standing orders than Most nurses  here



And? 

I have no idea how provider licensure works in Portugal and I doubt most on this board do either. Not really sure how it's relevant either. The interventions provided are fairly similar (if a bit dated) to what occurs in this county. Who it's given by should not have much if any bearing.


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## bmedic1681 (Mar 14, 2014)

AND….. Simply trying to understand if the nurse in portugal was able to function as an RN or Paramedic would here is all….. its kinda called learning…. I would not want to tell someone I would do something differently in their part of the world simply because I was arrogant enough to think everyone follows the same rules world wide…. I know what I would do for a STEMI…. I was just trying to learn more about what they do… IE: what meds what other interventions and so forth


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## VFlutter (Mar 14, 2014)

bmedic1681 said:


> In this one they do……. Paramedics have more standing orders than Most nurses  here



Where is "here"? Almost every state that has PHRNs have a scope that is expanded compared to standard medics, along the lines of Flight RNs. I can not think of any state that has a PHRN scope less than what paramedics function at.


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## Melclin (Mar 23, 2014)

Sounds like what would have been ideal for this pt was mechanical CPR to the cath lab.

Failing that, I don't see the point of redirecting to the smaller hospital. What more are they going to do and more importantly, what happens when the pt gets ROSC? If you are willing to do CPR during transport then I don't see why you wouldn't go to the STEMI centre whether or not they do intra-arrest caths.

As far as thrombolysis goes, I think this patient needs an open coronary artery. After the initial arrest bits and pieces fail, and especially if you aren't going to go to the cath capable hospital, why not give the lytics a shot before you call it. If you are going to stop resus anyway, the "they won't take him to the lab if we lyse him" argument doesn't hold up.


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