Thoughts on prehospital cardiac makers

[daedalus]

http://www.biomedexperts.com/Abstra...hemistry_performed_in_pre-hospital_cardiology

How would this work in your area if we had a i-STAT device for rapid detection of cardiac enzymes and other chemicals in the blood? Any foreseen value in patient outcome?

 

[akflightmedic]

Had me going for a second there...

I was thinking who the heck is MAKING prehospital cardiac anything??

Is that a new certification?

EMT-P
Certified Pre-Hospital Cardiac Maker or CPHCM for short.

 

[Dominion]

Pre-hospital cardiac making.....that's how kids are born. Always starts with the making.

 

[Melclin]

Point Of Care cardiac enzyme marker tests

I'm glad this came up, its been a pet topic of mine for a few weeks now.

In systems like ours here where there is a single EMS that basically government run and funded (partly) as are the hospitals, its much more feasible. The shift in cost from hospital to ambulance service is immense and this needs to be worked out somehow. Overall though, it improves the efficiency of pt care and reduces costs in this way. I think its just one of the many ways in which prehospital and ED care should be integrated to expedite treatment streamline the pt care.

There's little doubt that they improve turn around time (1) and shorten ED and CCU stays (2,3) to some degree without sacrificing (much) accuracy, and they're only getting quicker and more accurate. In about 7% of chest pain patients, the amount of time saved is thought to be clinically relevant (4), although it doesn't appear to affect the ultimate outcome or treatment. It stands to reason that if the whole process started in the prehospital arena these times would decrease, as would times involved in triage to appropriate facilities.

An article published in 2005 (5) argued that while the accuracy of the portable units approaches the accuracy of the labs (only to the extent that it is clinically the same for cardiac markers), no one unit does everything really required and no one method of portable analysis has yet emerged as superior.

Israel use pre-hospital cardiac markers although I've found it difficult to find much in the literature about them.

Over all I think it would be prudent to wait until cheaper testing units that do all (or as many as is possible) the tests required as stipulated in CHECKMATE study (6) are available to make it worthwhile. One day POC cardiac enzymes will be a big part of EMS and some promising work is being done with markers that appear earlier in the ischaemic cascade which would obviously be of much more use to us. Maybe waiting for this research to bear some fruit would be better. The technology and theory surrounding it, is all still a bit unsure to really go investing in large scale role outs of the technology in EMS as it stand at the moment.

1. P.O. Collinson, C. John, D.R.G. Cramp and R. Canepa-Anson, Prospective randomized controlled trial of point of care testing with central laboratory testing for cardiac enzyme measurement, Clin. Chem. 44 (1998), p. A69

2. A.J. Singer, J. Ardise, J. Gulla and J. Cangro, Point-of-care testing reduces length of stay in emergency department chest pain patients, Ann. Emerg. Med. 45 (2005), pp. 587–591.

3. C. Parvin, S. Lo and S. Deuser et al., Impact of point-of-care testing on patients' length of stay in a large emergency department, Clin Chem 42 (1996), pp. 711–717

4.Kendall J, Reeves B, Clancy M. Point of care testing: randomised controlled trial of clinical outcome. BMJ. 1998 April 4, 1998;316(7137):1052-7.

5.von Lode P. Point-of-care immunotesting: Approaching the analytical performance of central laboratory methods. Clinical Biochemistry.
2005;38(7):591-606.

6. L.K. Newby, A.B. Storrow, W.B. Gibler, J.L. Garvey, J.F. Tucker, A.l Kaplan, D.H. Schreiber, R.H. Tuttle, S.E. McNulty and E.M. Ohman , Bedside multimarker testing for risk stratification in chest pain units. The Chest Pain Evaluation by Creatine Kinase-MB, Myoglobin, and Troponin I (CHECKMATE) Study. Circulation 103 (2001), pp. 1832–1837


GOOD READING:

Yang Z, Min Zhou D. Cardiac markers and their point-of-care testing for diagnosis of acute myocardial infarction. Clinical Biochemistry. 2006;39(8):771-80.

Shebuski RJ. Utility of point-of-care diagnostic testing in patients with chest pain and suspected acute myocardial infarction. Current Opinion in Pharmacology. 2002;2(2):160-4.

 

[Melclin]

I should have read the article you posted before I replied,

I notice it talks about h-FABP testing. h-FABP is a transport molecule found in the cytosplasm of many types of cells. It is typically involved in the transport of fatty acids inside the cell but gets released in predicable amounts when the cell membrane is damaged. This means it's not specific to myocardial cells and really just means some cells, somewhere in the body have had their membranes damaged. I understand though, that there may be some type of h-FABP that is more specific to the myocardium... but nothing definite as far as I know.

I also read somewhere (I forget where) that it may have a role in the early detection of pulmonary embolisms.

 

[Aidey]

I think detecting cardiac enzymes pre-hospital could be beneficial in some systems, but it isn't something that would be practical everywhere. In systems with longer transports monitoring the pt with an I-Stat could allow the crew to relay exactaly what is going on with the pt. That way the cardiac team could be activated earlier rather than having to wait for a cardiac event to be confirmed in the ED. At the same time, there is also the risk of over use.

This is a device one of our EDs uses, it takes 15 minutes to develop, but it may have some benefits in the aforementioned long transport areas.

http://www.nanogen.com/products/cardiacstatus_tandem/

 

[wyoskibum]

My old service did a field trial on these 7 or 8 years ago. The technology wasn't as good then and we did get false positives. The ER Docs did not like it at all. Their complaint was that if we got a positive reading in the field, it would force them to run certain diagnostic tests that they might not have done without the test.

 

[mikie]

Here's a link to a similar thread

 

[daedalus]

Had me going for a second there...

I was thinking who the heck is MAKING prehospital cardiac anything??

Is that a new certification?

EMT-P
Certified Pre-Hospital Cardiac Maker or CPHCM for short.

LOL, We have been making new hearts in our rig for years!

 

[MrBrown]

Novia Scotia is doing cardiac enzymes prehospitally ... watch that space.

Like most things, the greatest benefit would probably come from the rural sector with long transport times or secondary facilities are the primary recieving hospital which are not cath lab/PCI/angipolasty capable.

Knowing how things have gone, it'll be screwed over and get put into the urban sector because hey thats where ALS is and barely get used.