Prehospital Fibrinolysis

[skyemt]

it appears, the next wave of EMS improvements will be in the area of acute cardiac care...

hypothermic treatments have been discussed on other threads...

there is now a growing chorus for widespread prehospital fibrinolysis for STEMI patients...

what is the sentiment about this?

comments, please...

 

[Flight-LP]

In the rural arena where a cath lab cannot be accessed within an hour, then maybe. The offset to this is that you must have top notch medics administering and monitoring these patients. As we see now, many rural environments only dream of having a Paramedic on their trucks, so the feasibility is low. Rural MI's are truly pts. that you need to consider air medical for, not take them to the local podunk'n ER. Urban areas do not need them as they can generally get someone to a cath lab in a short period of time. Fibrinolytics are a temporary solution to a permanent problem, these folks need to be cath'd and revascularized.

We have a service here in the Houston area that has a Retavase protocol. I'm not sure how often they use it, but I fail to see the point in having it as they have 8 cath labs within 30 minuted of their territory...................

 

[Ridryder911]

I see less and less "clot buster" being used in both settings of prehospital and even in ER setting. We went from using it weekly to very seldom, unless the patient appears that they will not be able to survive to a cath lab.

AHA has even endorsed door to cath over fibrinolysis therapy in majority of the cases.

I doubt we will see an increasing number of fibrinolysis therapy in the prehospital setting. With the increasing number of 24 hour cath labs, and increasing number of "heart centers" cooperating with ALS EMS units and STEMI Alerts.

R/r 911

 

[akflightmedic]

I echo the above statements for the very same reasons.

The patients in the areas that would benefit the most from this usually do NOT have a medic within their area. If they do have one, I step lightly when I say this, are they experienced and knowledgeable enough to administer this powerful drug and prepared to handle all the different outcomes/side effects?

My initial thought is no they are not, but there are always exceptions as I am aware.

I participated in a field trial of this a few years back in Florida and our final decision was there was no need or benefit to having medics administer this prehospital in our setting.

When I was flying in the arctic, we did carry fibrinolytics and I did administer them a few times. However, up there, I had a flight time by PLANE from a minimum of 3-5 hours to access definitive care. There were several incidents where we had to wait much longer and we did approach the 20 hour mark on one of my patients. Normally we were in the 4 hour window, but weather changes could strand us in a village for up to a day or two.

 

[skyemt]

I see less and less "clot buster" being used in both settings of prehospital and even in ER setting. We went from using it weekly to very seldom, unless the patient appears that they will not be able to survive to a cath lab.

AHA has even endorsed door to cath over fibrinolysis therapy in majority of the cases.

I doubt we will see an increasing number of fibrinolysis therapy in the prehospital setting. With the increasing number of 24 hour cath labs, and increasing number of "heart centers" cooperating with ALS EMS units and STEMI Alerts.

R/r 911

one of my reasons for bringing this up, is the article in this months Jems...
it is "suggesting", from studies, that fibrinolytics administered within 30-60 minutes of the onset of pain are leading to better patient outcomes (survival to discharge)...

point being that many EMS systems could not get the patient to the Cath lab in that time window... they even referred to it as the "cardiac golden hour"...

i thought i'd leave the debate to those in the know, but i will be an interested reader of more opinions.

thanks.

i will not pretend to be expert on this, but i do find the debate interesting...

 

[Ridryder911]

I will read the article, but in comparison to those that make it to a cath lab the results are much higher (at least according to AHA). Thus the reason the debate of fibro vs. cath.

Most areas that I have seen in the past three to five years, has drastically reduced fibro therapy to rarely ever given if there is any possibility of cath. Most physicians will agree to take the chance of transporting to a cath lab over fibro. Usually the determination will be made of the severity of the AMI. The patients disposition of pain, cardiac markers, ECG (such as "tombstone", widowmaker, and involvement) and general clinical observation (will they make it or not). Thus the dilemma and the roll of the dice.

Like I described I have seen fibro given albeit it is now less than a quarter of the time it was given three years ago.

I first gave fibro (TpA) in the field as a FDA trial in the mid 80's. We did not even have XII lead, but performed multi 9 lead. The closest true CCU was about 25 miles and cath lab was over 60 miles away. Definitely, could tell which was placebo and which was real. No one knew much about reperfusion then and was scary the first time you witnessed it.

I know of Springfield MO EMS (where Bob Page is located) was using TKAse in certain circumstances with great results. I do not know if the protocol still exists or if they too have started using cath lab protocols too.

R/r 911

 

[Outbac1]

I know they are looking at it for here. We have one hosp with a cath lab that is as much as 5 - 6 hours from some parts of the province. It is at best 1.5 hours from my local hosp door to door by ground. Even with the use of the helicopter a quick trip to the cath lab is not a possibility for a large amt of our population. I know Halifax participated in the WEST study a couple of years ago. This involved ACPs Dx pts and giving TnK in the field and others going to the cath lab. The study leaned to the cath lab being better. However with long transport times to be considered for many they are looking at putting it on the trucks. All levels of medics now routinely do 12 lead ECGs with the ability to fax it to any hosp. At least we can now give a heads up should we suspect a cath is in our pts best interest. The ER Dr can decide to forward them on by ground or air or tnk them upon our arrival.
Maybe not the best but better than it was.

 

[Markhk]

There was an interesting study in the journal Resuscitation in Feb 2008 for the use of pre-hospital fibrinolytics immediately after return of spontaneous circulation when an MI was identified. Basically, this European study had their ambulance docs place a patient they got a pulse back on a 12-lead...if they identified a STEMI they gave streptokinase. The authors claim good results, but was an observational study -- not double blinded.

Other European studies are investigating if tPA should be given during a PEA algorithm for suspected MI when going down the differential diagnosis.

 

[MSDeltaFlt]

Some rural hospitals still give fibrinolytics due to the fact that the pt will not be able to get to any cath lab with 90 mins.

Like Flight LP said the only place that would benefit fibrinolytics would be rural EMS, but to train and maintain that level of medic training is not very cost effective. Not to mention that the cost of the fibrinolytics alone is astronomical. I believe that a bottle of tPA costs what? $3000? $6000? For one damn bottle?!? God, I hope I'm wrong, but that's what a pharmacist told me.