Thrombolysis. Do you do it?

[Outbac1]

Well I had my inservice on Fri for field thrombolysis for STEMI. Our area is going with it on March 1st. I feel it is a big step forward for us and I'm curious as to what others think about field thrombolysis.

So my questions are:
1) How many of you have thrombolysis in your standard of care?
2) How many have it in their services standard but not your personal scope?
3) How many want it?

We have to send off the 12 Lead and confere with the recieving Dr. and have their permission before we can give the drug,(TNK)
My next questions are:
4) Do you need online permission or do you decide yourselves to give it or not?
5) Do you think it is something field paramedics should be doing?

 

[usafmedic45]

1) How many of you have thrombolysis in your standard of care?

We do.

2) How many have it in their services standard but not your personal scope?

It's in my scope of practice, oddly enough, as a flight RT. There are only a handful of us on the team. It's a case-by-case approval by our medical director. So far as I am aware, only three of us RTs have approval for this. We normally have a PA-C, EMT-P or RN on board, but should we not and have a pt having an MI or PE we can do something about it.

3) How many want it?

I do.

4) Do you need online permission or do you decide yourselves to give it or not?

Our doc prefers us to call him and confer with him, but it's pretty much our call since we don't always have an easy way to send EKGs. Personally, I'm alway going to call him and get his approval should the need arise.

5) Do you think it is something field paramedics should be doing?

Depends on the service, but generally, no.

 

[jjesusfreak01]

My system doesn't have it, doesn't need it. Transports to the hospital will rarely, if ever, take more than half an hour, and that's to cath capable centers, so unless you had a stroke, there will not be TPA in your future.

 

[NomadicMedic]

So my questions are:
1) How many of you have thrombolysis in your standard of care?
2) How many have it in their services standard but not your personal scope?
3) How many want it?

We have to send off the 12 Lead and confere with the recieving Dr. and have their permission before we can give the drug,(TNK)
My next questions are:
4) Do you need online permission or do you decide yourselves to give it or not?
5) Do you think it is something field paramedics should be doing?

We have Tenecteplase in one county's protocols. As a medic there, it's within my scope.

We have a phone consult with the Doc after transmitting a 12 lead, and he gives us the thumbs up or thumbs down. Most of the time it's dependant on transport time. We may also get orders just for Heparin or NTG or Plavix, without the thrombolytic.

In my specific case, I feel it's a perfect example of bringing the ED to the patient, rather than just hauling them to the hospital. TNKase is an amazing tool, when used correctly. Since many of my transports may be anywhere from 45 to 60 minutes before we reach a cath lab, TNKase (along with Heparin and NTG) can be the base of an effective prehospital STEMI patient care plan.

Should everybody do it? Not if the hospital is right around the corner and PCI is available. I mean, the goal is rapisd revascularization, and if you can meet the door to balloon goal of <90 minutes, you're just wasting time messing about with TNKase.

 

[Smash]

We may also get orders just for Heparin... or Plavix, without the thrombolytic.

Just to help them bleed to death?

Relatively short transport times here, Primary PCI is widely available and we bypass the ER, going straight to the lab. (Well, most of the time... sometimes that breaks down, the ER gets hold of them, and then it all goes downhill!)

 

[NomadicMedic]

Just to help them bleed to death?

Nope. The Heparin helps them bleed to life.

Influence of prehospital administration of aspirin and heparin on initial patency of the infarct-related artery in patients with acute st elevation myocardial infarction

And, an additional study showed that if you can get the Thrombolytic onboard <70 minutes after the onset of symptoms, the infarct and it's complications were lessened.

 

[Smash]

Nope. The Heparin helps them bleed to life.

Influence of prehospital administration of aspirin and heparin on initial patency of the infarct-related artery in patients with acute st elevation myocardial infarction

And, an additional study showed that if you can get the Thrombolytic onboard <70 minutes after the onset of symptoms, the infarct and it's complications were lessened.

I won't comment on the JAMA article, as it is not about what I was referring to.

I haven't got time to read all that top study at the moment, but even the abstract shows up some significant problems. The JACC article seems as if it is not really looking at heparin at all. It is examining the early administration of both heparin AND aspirin, so the question that is immediately raised is "what is actually helping, the aspirin or the heparin?" We know that aspirin does help, but it is increasingly apparent that heparin does not, so the study has a major confounder right there. The endpoint is also not particularly useful. TIMI flow does not seem to correlate to mortality or morbidity, so it's use as an endpoint is questionable.

I'll read the rest of it later, but it doesn't look flash.

Heparin reduces re-infarction and mortality in the first week, but patients treated with heparin quickly catch up to patients who aren't, and at thirty days there is no longer any difference between the two groups.

 

[NomadicMedic]

Maybe I need to read newer studies?

I hadn't seen anything showing that heparin isn't effective in the long term. I'd like to see that study you mentioned. However, I did see a small (200 patient) study from 1990 showing that the main advantage of heparin lies in the prevention of early reocclusion.*

If, as you say, "Heparin reduces re-infarction and mortality in the first week," doesn't that show it's use is a clear benefit in prevention of patient mortality, at least in the short term?

*A Comparison between Heparin and Low-Dose Aspirin as Adjunctive Therapy with Tissue Plasminogen Activator for Acute Myocardial Infarction
Judith Hsia, M.D., William P. Hamilton, M.D., Neal Kleiman, M.D., Robert Roberts, M.D., Bernard R. Chaitman, M.D., Allan M. Ross, M.D., and the Heparin—Aspirin Reperfusion Trial (HART) Investigators*

N Engl J Med 1990; 323:1433-1437November 22, 1990[/SIZE]

And as for the JAMA article, it's about the benefit of EARLY thrombolytics, which was the OP's topic of this thread, which we sort of hijacked.

 

[Smash]

If, as you say, "Heparin reduces re-infarction and mortality in the first week," doesn't that show it's use is a clear benefit in prevention of patient mortality, at least in the short term?

Well... no.

Ultimately the rate of re-occlusion, infarct and death is the same between heparin/no heparin, it's just that the heparin group don't get around to it until a month later, rather than a week later. And this same risk of mortality comes with an added bonus of a greater number of people with dangerous complications (about 1 in 25) from bleeding. Not a package deal that I'd want to be taking!

 

[jrm818]

Well thank goodness they have plavix to give instead then....

 

[thegreypilgrim]

1) How many of you have thrombolysis in your standard of care?

Don't have it.

2) How many have it in their services standard but not your personal scope?

Not in our standard, not in my scope either.

3) How many want it?

Although I cringe at saying this, it is probably not needed in our region. Transport times are quite short here, and PCI is both widely available and seems to be the preferred modality for managing MI patients.

4) Do you need online permission or do you decide yourselves to give it or not?

Like I said we don't have it, but hypothetically if we did it would undoubtedly require base contact...and would probably be denied.

5) Do you think it is something field paramedics should be doing?

Personally, the idea of firefighters here in Los Angeles administering thrombolytics is just horrifying so, no I don't think we should be doing it anyways. Speaking more generally, depending on the nature of the service I believe it could definitely be appropriate. Indeed, some of the studies I've seen taking place in the Australian EMS systems have shown that prehospital thrombolytic therapy is quite beneficial.

 

[Smash]

Well thank goodness they have plavix to give instead then....

Yeah, thank goodness for bleedex!

 

[Outbac1]

Thanks for the replies. I should have mentioned that we are 1hr 40min on the hwy from the nearest cath lab. Plus onscene time and time to travel to the hwy. That puts us an easy 2hrs + from the lab. Also we give lovenox(heprin) and plavix after the TNK.

 

[jjesusfreak01]

Thanks for the replies. I should have mentioned that we are 1hr 40min on the hwy from the nearest cath lab. Plus onscene time and time to travel to the hwy. That puts us an easy 2hrs + from the lab. Also we give lovenox(heprin) and plavix after the TNK.

As long as you screen your patients carefully (and im sure you do), this is exactly the type of system where thrombolysis should be allowed.