Pre Hospital Troponin Testing
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Wyoming Medic
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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
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
BossyCow
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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.
Wyoming Medic
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Out of curiosity, what were the symptoms that led to the cardiac monitor being placed on her?
downunderwunda
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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.
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.
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.
BossyCow
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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???
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
daedalus
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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.
BossyCow
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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.
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.
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?
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.
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.
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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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.