Thrombolytics in prehospital resuscitation

[usafmedic45]

Eur J Clin Invest. 2005 May;35(5):315-23.
International multicentre trial protocol to assess the efficacy and safety of tenecteplase during cardiopulmonary resuscitation in patients with out-of-hospital cardiac arrest: the Thrombolysis in Cardiac Arrest (TROICA) Study.
Spohr F, Arntz HR, Bluhmki E, Bode C, Carli P, Chamberlain D, Danays T, Poth J, Skamira C, Wenzel V, Bottiger BW.

Department of Anaesthesiology, University of Heidelberg, Heidelberg, Germany.

Prehospital cardiac arrest has been associated with a very poor prognosis. Acute myocardial infarction and massive pulmonary embolism are the underlying causes of out-of-hospital cardiac arrest in 50-70% of patients. Although fibrinolysis is an effective treatment strategy for both myocardial infarction and pulmonary embolism, clinical experience for this therapy performed during resuscitation has been limited owing to the anticipated risk of severe bleeding complications. The TROICA study is planned as one of the largest randomized, double-blind, placebo-controlled trials to assess the efficacy and safety of prehospital thrombolytic therapy in cardiac arrest of presumed cardiac origin. Approximately 1000 patients with cardiac arrest will be randomized at approximately 60 international study centres to receive either a weight-adjusted dose of tenecteplase or placebo after the first dose of a vasopressor. Patients can be included if they are at least 18 years, presenting with a witnessed cardiac arrest of presumed cardiac origin, and if either basic life support had started within 10 min of onset and had been performed up to 10 min or advanced life support is started within 10 min of onset of cardiac arrest. Primary endpoint of the study is the 30-day survival rate, and the coprimary endpoint is hospital admission. Secondary endpoints are the return of spontaneous circulation (ROSC), survival after 24 h, survival to hospital discharge, and neurological performance. Safety endpoints include major bleeding complications and symptomatic intracranial haemorrhage.

PMID: 15860043 [PubMed - in process]


I'm working on getting a copy of the full article but I figured I would ask what everyone thought about this.....

 

[Flight-LP]

IMHO not a great idea. For one, define a witnessed arrest and how can you substantiate it. If word gets out about this possibility, people can possibly exagerate their "witnessing" of the arrest, thus altering the study outcome. Also, to attempt further differentiation of cause beyond ACLs recommendations is an absolute waste of time on scene. Focus on resuscitation, good CPR and recommended ACLS interventions. You can lyse a possible clot all day long, but if you fail to focus on the interventions immediately required, you are basically pissing in the wind. And finally, everyones favorite issue, lets look at cost. Tenecteplase is not cheap and for most systems, not financially feasible. To sum this issue up for me, cardiac arrests that can be saved are saved sufficiently enough by current tratments available. Those that are not saved would most likely not benefit from any further interventions short of the hands of god. Hate to sound morbid, but we all know the facts and prehospital fibrinolytic administration will not change that. Just my $.02 worth, interesting find though.................Any other thoughts???

 

[Ridryder911]

I would hope I would get in the non-placebo group..(LOL) I do wonder about the benefites of post-arrest with thrombolytics. I am wondering why we (pre-hospital) have such a high incidence of pulmonary embolism(s). Is this becauses of poor diagnostics or some form of treatment regime we now perform?

Although I am an instrcutor for AHA in all levels of ECC (CPR to ACLS EPC) I am not a big supporter of the ECC standards. I use to endorse totally & thought of them as the "bible" to which national standards were based. After working in an agressive heart hospital with outstanding progressive research & interventional cardiologist physicians, I now feel differently.

Among alot of cardiologist; AHA ACLS program is considered a joke at the least. Many of them can recite & show conflicting litreature that can show major difference in treatment regime. Some of the "new" treatment being introduced has been out for several years... & we allowed patients to continue to recieve the same care until now ?

Also a post though.. TNKase is expensive, but the manufacture has a program for charity & recycle to keep cost down to EMS & ER. Which I respect the company for doing so...

Be safe,
RIdryder 911

 

[rhan101277]

I have been studying about this. How you you know that a person have a MI isn't due to them having a aortic dissection? If you give them the drug and this is the case, then the chance of them dying is great than not giving it to them. How do you decide what to do? I was thinking about a EKG, but if the dissection has caused the MI and now you see evidence of MI on EKG then what?

 

[Ridryder911]

AMI and dissections are totally separate things. An AMI (commonly known as a heart attack) is usually caused by plaque deposits causing an occlusion of blood flow (basically occlusion of the lumen of the coronary arteries). Where as dissection is similar to a weak hose that the layers actually tear apart from within (there are multiple types of aneurysms as well as AMI's). The disease, usual signs & symptoms, treatment, is NOT usually the same.

ECG's do not diagnose AMI, nor aneurysms. It takes a thorough assessment as well as adjunct tools of the ECG, etc.

One has to outweigh the risks in a short period of time. You advice the patient that they have a great chance of dying either way. One is to gamble and see if they bleed out, the other is to see if the AMI will kill them or not. Personally, I would suggest the gamble and risks. I have seen results of both...

Medicine is NOT a black & white issue. That is why so many can not make it or learn that one practices medicine. Protocols are only suggestions and even the best written ones may cause death to someone.

Life is a gamble, every day.

R/r 911

 

[rhan101277]

Yes but i thought that a dissection could lead to a MI. I know people have have them and they be there for weeks etc. I guess in the pre-hospital setting is is a gamble. But if they are in the emergency room where more tests can be done, then this should be picked up on.

 

[Ridryder911]

Actually yes & know. The complications of an dissection can lead into an AMI. If you know those that had a dissection and was only there for four weeks they were lucky, as well as lucky to be alive. This is one procedure that has a significant increase over the past few decades.

In the mid-80's-90's dissection mortality was in the mid 90-95% mortality range. It has now significantly decreased with new surgical interventions.

You will learn the significant difference between the two (as you increase your education level) as well as clinical signs that are more indicative of a dissection vs. an AMI. There are tell tale indicators that each has. True.. ocassionally one may mimick each other; that is why CT's were invented.

R/r 911