Alan L Serve
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I've been interested in the topic of transporting a confirmed STEMI to PCI/CABG-centers or to the closest community hospital without PCI/CABG. I know the traditional guidance is to go to the PCI/CABG-center and bypass the community hospital. I've seen this in protocols and textbooks yet neither of those seem to cite any sources which indicate this is supported by the evidence. In an attempt to find something on this topic I came across "The Diagnosis And Treatment Of STEMI In The Emergency Department" by EB Medicine which publishes Emergency Medicine Practice: An Evidence-Based Approach to Emergency Medicine where there is a section on EMS bypassing community hospitals in favor of STEMI centers. Notably the article says
My takeaway on this is we either start carrying Clopidogrel (aka Plavix, an anticoagulant given for STEMIs and NSTEMIs) or fibrinolytics or GP IIb/IIIa-inhibitors or some combo of that on the ambulance and develop protocols for administering it prehospital or we start teaching our ALS providers to go to the closest ER so they can get Clopidogrel (or another anti-coagulant such as the GP IIb/IIIa inhibitors or half-dose fibrinolytics or some combo) and then continue to the PCI center.
Thoughts? Does anyone know studies which say something different? Please chime in.
-Alan
I didn't know what Facilitated PCI means but this seems to describe it rather accurately: "Facilitated PCI is the use of pharmacological therapy (usually fibrinolytic therapy or half-dose fibrinolytic therapy plus glycoprotein IIb/IIIa platelet inhibitors) administered as soon as possible after the onset of symptoms to establish early reperfusion followed by emergent transfer to a PCI facility for planned emergent PCI."sourceIn addition, a recent study compared facilitated PCI (with clopidogrel before catheterization laboratory intervention) occurring within 150 minutes to primary PCI and suggested similar outcomes.58 This finding makes it more reasonable for EMS providers to stop at non-PCI centers for early evaluation and facilitating therapy before transporting a confirmed-STEMI patient to a PCI-capable center.
Citation 58
Assessment of the Safety and Ef cacy of a New Treatment Strategy with Percutaneous Coronary Intervention (AS- SENT-4 PCI) Investigators. Primary versus tenecteplase- facilitated percutaneous coronary intervention in patients with ST-segment elevation acute myocardial infarction (AS- SENT-4 PCI): randomized trial. Lancet. 2006;367(9510):569- 578. (Prospective randomized trial; 1667 patients)
My takeaway on this is we either start carrying Clopidogrel (aka Plavix, an anticoagulant given for STEMIs and NSTEMIs) or fibrinolytics or GP IIb/IIIa-inhibitors or some combo of that on the ambulance and develop protocols for administering it prehospital or we start teaching our ALS providers to go to the closest ER so they can get Clopidogrel (or another anti-coagulant such as the GP IIb/IIIa inhibitors or half-dose fibrinolytics or some combo) and then continue to the PCI center.
Thoughts? Does anyone know studies which say something different? Please chime in.
-Alan
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