ST elevation myocardial infarction pre-hospital care: Difference between revisions

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===Immediate care===
==Symtpom to Door Time==
When symptoms of myocardial infarction occur, people wait an average of three hours, instead of doing what is recommended: calling for help immediately.<ref name=FirstAid>[http://www.nlm.nih.gov/medlineplus/ency/article/000063.htm Heart attack first aid]. [[MedlinePlus]]. Retrieved December 3, 2006.</ref><ref name="ActInTime">[http://www.nhlbi.nih.gov/actintime/index.htm Act In Time to Heart Attack Signs] - [[NHLBI]]. Retrieved December 13, 2006.</ref> Acting immediately by calling the emergency services can prevent sustained damage to the heart ("time is muscle").<ref name=TimeIsMuscle>[http://www.ehac.org/st-agnes/EHAC_LifeandDeath/TimeisMuscle.htm TIME IS MUSCLE TIME WASTED IS MUSCLE LOST]. Early Heart Attack Care, St. Agnes Healthcare. Retrieved November 29, 2006.</ref>
When symptoms of myocardial infarction occur, patients unfortunately delay seeking medical attention for a significant period. In the past this delay was almost 3 hours, but has now been shorted to 1.5 to 2.0 hours. <ref name="pmid19032997">{{cite journal |author=Gibson CM, Pride YB, Frederick PD, ''et al'' |title=Trends in reperfusion strategies, door-to-needle and door-to-balloon times, and in-hospital mortality among patients with ST-segment elevation myocardial infarction enrolled in the National Registry of Myocardial Infarction from 1990 to 2006 |journal=Am. Heart J. |volume=156 |issue=6 |pages=1035–44 |year=2008 |month=December |pmid=19032997 |doi=10.1016/j.ahj.2008.07.029 |url=http://linkinghub.elsevier.com/retrieve/pii/S0002-8703(08)00795-3}}</ref> patients often drive themselves to the hospital when instead they should call 911. <ref name="pmid10889127">{{cite journal |author=Brown AL, Mann NC, Daya M, ''et al'' |title=Demographic, belief, and situational factors influencing the decision to utilize emergency medical services among chest pain patients. Rapid Early Action for Coronary Treatment (REACT) study |journal=Circulation |volume=102 |issue=2 |pages=173–8 |year=2000 |month=July |pmid=10889127 |doi= |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=10889127}}</ref>


Certain positions allow the patient to rest in a position which minimizes breathing difficulties. A half-sitting position with knees bent is often recommended. Access to more oxygen can be given by opening the window and widening the collar for easier breathing.
==Pre Hospital Care==
 
In some countries, such as France, physicians staff mobile intensive care units and pre-hospital care can begin in the ambulance. These pre-hospital therapies in the mobile intensive care setting include glycoprtein IIbIIIa inhibition (as was studied in the On TIME 2 study), unfractionated heparin, nitroglycern, clopidogrel and non-enteric coated aspirin.  
[[Aspirin]] can be given quickly (if the patient is not [[allergy|allergic]] to aspirin); but taking aspirin before calling the [[emergency medical services]] may be associated with unwanted delay.<ref name="pmid10889127">{{cite journal |author=Brown AL, Mann NC, Daya M, ''et al'' |title=Demographic, belief, and situational factors influencing the decision to utilize emergency medical services among chest pain patients. Rapid Early Action for Coronary Treatment (REACT) study |journal=Circulation |volume=102 |issue=2 |pages=173–8 |year=2000 |month=July |pmid=10889127 |doi= |url=http://circ.ahajournals.org/cgi/pmidlookup?view=long&pmid=10889127}}</ref> Aspirin has an [[Antiplatelet drug|antiplatelet]] effect which inhibits formation of further [[thrombus|thrombi]] (blood clots) that clog arteries. [[Enteric coating|Non-enteric coated]] or soluble preparations are preferred. If chewed or dissolved, respectively, they can be [[Absorption (pharmacokinetics)|absorbed]] by the body even quicker. If the patient cannot swallow, the aspirin can be used sublingually. U.S. guidelines recommend a dose of 162 – 325 mg.<ref name="pmid15358045">{{cite journal |author=Antman EM, Anbe DT, Armstrong PW, ''et al'' |title=ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction--executive summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to revise the 1999 guidelines for the management of patients with acute myocardial infarction) |journal=J. Am. Coll. Cardiol. |volume=44 |issue=3 |pages=671–719 |year=2004 |month=August |pmid=15358045 |doi=10.1016/j.jacc.2004.07.002 |url=}}</ref> Australian guidelines recommend a dose of 150 – 300 mg.<ref name=Rossi>Rossi S, editor. [[Australian Medicines Handbook]] 2006. Adelaide: Australian Medicines Handbook; 2006. ISBN 0-9757919-2-3.</ref>
mg.
 
[[Glyceryl trinitrate (pharmacology)|Glyceryl trinitrate]] (nitroglycerin) [[sublingual]]ly (under the tongue) can be given if it has been prescribed for the patient.


==Steps to be Taken by Paramedics on Arrival at the Scene of a STEMI==
If an Automated External Defibrillator (AED) is available the rescuer should immediately bring the AED to the patient's side and be prepared to follow its instructions should the victim lose consciousness.  
If an Automated External Defibrillator (AED) is available the rescuer should immediately bring the AED to the patient's side and be prepared to follow its instructions should the victim lose consciousness.  


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Other general first aid principles include monitoring pulse, breathing, level of consciousness and, if possible, the blood pressure of the patient. In case of [[cardiac arrest]], [[cardiopulmonary resuscitation]] (CPR) can be administered.
Other general first aid principles include monitoring pulse, breathing, level of consciousness and, if possible, the blood pressure of the patient. In case of [[cardiac arrest]], [[cardiopulmonary resuscitation]] (CPR) can be administered.


===Automatic external defibrillation (AED)===
==Automatic external defibrillation (AED)==
Since the publication of data showing that the availability of [[automated external defibrillator]]s (AEDs) in public places may significantly increase chances of survival, many of these have been installed in public buildings, public transport facilities, and in non-ambulance emergency vehicles (e.g. police cars and fire engines). AEDs analyze the heart's rhythm and determine whether the rhythm is amenable to [[defibrillation]] ("shockable"), as in  [[ventricular tachycardia]] and [[ventricular fibrillation]].
Since the publication of data showing that the availability of [[automated external defibrillator]]s (AEDs) in public places may significantly increase chances of survival, many of these have been installed in public buildings, public transport facilities, and in non-ambulance emergency vehicles (e.g. police cars and fire engines). AEDs analyze the heart's rhythm and determine whether the rhythm is amenable to [[defibrillation]] ("shockable"), as in  [[ventricular tachycardia]] and [[ventricular fibrillation]].


===Emergency services===
==Emergency services==
[[Emergency medical services|Emergency Medical Services]] (EMS) Systems vary considerably in their ability to evaluate and treat patients with suspected acute myocardial infarction. Some provide as little as first aid and early defibrillation. Others employ highly trained paramedics with sophisticated technology and advanced protocols.<ref name="pmid12103258">{{cite journal |author=Morrow DA, Antman EM, Sayah A, ''et al'' |title=Evaluation of the time saved by prehospital initiation of reteplase for ST-elevation myocardial infarction: results of The Early Retavase-Thrombolysis in Myocardial Infarction (ER-TIMI) 19 trial |journal=J. Am. Coll. Cardiol. |volume=40 |issue=1 |pages=71–7 |year=2002 |month=July |pmid=12103258 |doi= |url=http://linkinghub.elsevier.com/retrieve/pii/S0735109702019368}}</ref> Early access to [[emergency medical services|EMS]] is promoted by a 9-1-1 system currently available to 90% of the population in the United States. Most are capable of providing [[oxygen]], IV access, sublingual [[nitroglycerine]], [[morphine]], and [[aspirin]]. Some are capable of providing [[thrombolysis|thrombolytic therapy]] in the prehospital setting.<ref name="pmid12103258">{{cite journal |author=Morrow DA, Antman EM, Sayah A, ''et al'' |title=Evaluation of the time saved by prehospital initiation of reteplase for ST-elevation myocardial infarction: results of The Early Retavase-Thrombolysis in Myocardial Infarction (ER-TIMI) 19 trial |journal=J. Am. Coll. Cardiol. |volume=40 |issue=1 |pages=71–7 |year=2002 |month=July |pmid=12103258 |doi= |url=http://linkinghub.elsevier.com/retrieve/pii/S0735109702019368}}</ref><ref name="pmid10819952">{{cite journal |author=Morrison LJ, Verbeek PR, McDonald AC, Sawadsky BV, Cook DJ |title=Mortality and prehospital thrombolysis for acute myocardial infarction: A meta-analysis |journal=JAMA |volume=283 |issue=20 |pages=2686–92 |year=2000 |pmid=10819952 |doi= |url=http://jama.ama-assn.org/cgi/pmidlookup?view=long&pmid=10819952}}</ref>
[[Emergency medical services|Emergency Medical Services]] (EMS) Systems vary considerably in their ability to evaluate and treat patients with suspected acute myocardial infarction. Some provide as little as first aid and early defibrillation. Others employ highly trained paramedics with sophisticated technology and advanced protocols.<ref name="pmid12103258">{{cite journal |author=Morrow DA, Antman EM, Sayah A, ''et al'' |title=Evaluation of the time saved by prehospital initiation of reteplase for ST-elevation myocardial infarction: results of The Early Retavase-Thrombolysis in Myocardial Infarction (ER-TIMI) 19 trial |journal=J. Am. Coll. Cardiol. |volume=40 |issue=1 |pages=71–7 |year=2002 |month=July |pmid=12103258 |doi= |url=http://linkinghub.elsevier.com/retrieve/pii/S0735109702019368}}</ref> Early access to [[emergency medical services|EMS]] is promoted by a 9-1-1 system currently available to 90% of the population in the United States. Most are capable of providing [[oxygen]], IV access, sublingual [[nitroglycerine]], [[morphine]], and [[aspirin]]. Some are capable of providing [[thrombolysis|thrombolytic therapy]] in the prehospital setting.<ref name="pmid12103258">{{cite journal |author=Morrow DA, Antman EM, Sayah A, ''et al'' |title=Evaluation of the time saved by prehospital initiation of reteplase for ST-elevation myocardial infarction: results of The Early Retavase-Thrombolysis in Myocardial Infarction (ER-TIMI) 19 trial |journal=J. Am. Coll. Cardiol. |volume=40 |issue=1 |pages=71–7 |year=2002 |month=July |pmid=12103258 |doi= |url=http://linkinghub.elsevier.com/retrieve/pii/S0735109702019368}}</ref><ref name="pmid10819952">{{cite journal |author=Morrison LJ, Verbeek PR, McDonald AC, Sawadsky BV, Cook DJ |title=Mortality and prehospital thrombolysis for acute myocardial infarction: A meta-analysis |journal=JAMA |volume=283 |issue=20 |pages=2686–92 |year=2000 |pmid=10819952 |doi= |url=http://jama.ama-assn.org/cgi/pmidlookup?view=long&pmid=10819952}}</ref>


With [[percutaneous coronary intervention|primary PCI]] emerging as the preferred therapy for ST segment elevation myocardial infarction, [[emergency medical services|EMS]] can play a key role in reducing [[door to balloon]] intervals (the time from presentation to a hospital [[emergency department|ER]] to the restoration of coronary artery blood flow) by performing a 12 lead [[ECG]] in the field and using this information to triage the patient to the most appropriate medical facility.<ref name="pmid16996830">{{cite journal |author=Rokos IC, Larson DM, Henry TD, ''et al'' |title=Rationale for establishing regional ST-elevation myocardial infarction receiving center (SRC) networks |journal=Am. Heart J. |volume=152 |issue=4 |pages=661–7 |year=2006 |month=October |pmid=16996830 |doi=10.1016/j.ahj.2006.06.001 |url=}}</ref><ref name="pmid18340140">{{cite journal |author=Moyer P, Feldman J, Levine J, ''et al'' |title=Implications of the Mechanical (PCI) vs Thrombolytic Controversy for ST Segment Elevation Myocardial Infarction on the Organization of Emergency Medical Services: The Boston EMS Experience |journal=Crit Pathw Cardiol |volume=3 |issue=2 |pages=53–61 |year=2004 |month=June |pmid=18340140 |doi=10.1097/01.hpc.0000128714.35330.6d |url=}}</ref><ref name="pmid16580518">{{cite journal |author=Henry TD, Atkins JM, Cunningham MS, ''et al'' |title=ST-segment elevation myocardial infarction: recommendations on triage of patients to heart attack centers: is it time for a national policy for the treatment of ST-segment elevation myocardial infarction? |journal=J. Am. Coll. Cardiol. |volume=47 |issue=7 |pages=1339–45 |year=2006 |month=April |pmid=16580518 |doi=10.1016/j.jacc.2005.05.101 |url=}}</ref>In addition, the 12 lead ECG can be transmitted to the receiving hospital, which enables time saving decisions to be made prior to the patient's arrival. This may include a "cardiac alert" or "STEMI alert" that calls in off duty personnel in areas where the [[Coronary catheterization|cardiac cath lab]] is not staffed 24 hours a day.<ref>Rokos I. and Bouthillet T., [http://www.stemisystems.org/PDF/STEMIsystems_issue2.pdf "The emergency medical systems-to-balloon (E2B) challenge: building on the foundations of the D2B Alliance,"] ''STEMI Systems'', Issue Two, May 2007. Accessed June 16, 2007.</ref>  Even in the absence of a formal alerting program, prehospital 12 lead ECGs are independently associated with reduced door to treatment intervals in the emergency department.<ref name=Cannon_176>Cannon CP at al. ''Management of Acute Coronary Syndromes''. p. 176. New Jersey: Humana Press, 1999. ISBN 0-89603-552-2.</ref>
With [[percutaneous coronary intervention|primary PCI]] emerging as the preferred therapy for ST segment elevation myocardial infarction, [[emergency medical services|EMS]] can play a key role in reducing [[door to balloon]] intervals (the time from presentation to a hospital [[emergency department|ER]] to the restoration of coronary artery blood flow) by performing a 12 lead [[ECG]] in the field and using this information to triage the patient to the most appropriate medical facility.<ref name="pmid16996830">{{cite journal |author=Rokos IC, Larson DM, Henry TD, ''et al'' |title=Rationale for establishing regional ST-elevation myocardial infarction receiving center (SRC) networks |journal=Am. Heart J. |volume=152 |issue=4 |pages=661–7 |year=2006 |month=October |pmid=16996830 |doi=10.1016/j.ahj.2006.06.001 |url=}}</ref><ref name="pmid18340140">{{cite journal |author=Moyer P, Feldman J, Levine J, ''et al'' |title=Implications of the Mechanical (PCI) vs Thrombolytic Controversy for ST Segment Elevation Myocardial Infarction on the Organization of Emergency Medical Services: The Boston EMS Experience |journal=Crit Pathw Cardiol |volume=3 |issue=2 |pages=53–61 |year=2004 |month=June |pmid=18340140 |doi=10.1097/01.hpc.0000128714.35330.6d |url=}}</ref><ref name="pmid16580518">{{cite journal |author=Henry TD, Atkins JM, Cunningham MS, ''et al'' |title=ST-segment elevation myocardial infarction: recommendations on triage of patients to heart attack centers: is it time for a national policy for the treatment of ST-segment elevation myocardial infarction? |journal=J. Am. Coll. Cardiol. |volume=47 |issue=7 |pages=1339–45 |year=2006 |month=April |pmid=16580518 |doi=10.1016/j.jacc.2005.05.101 |url=}}</ref>In addition, the 12 lead ECG can be transmitted to the receiving hospital, which enables time saving decisions to be made prior to the patient's arrival. This may include a "cardiac alert" or "STEMI alert" that calls in off duty personnel in areas where the [[Coronary catheterization|cardiac cath lab]] is not staffed 24 hours a day.<ref>Rokos I. and Bouthillet T., [http://www.stemisystems.org/PDF/STEMIsystems_issue2.pdf "The emergency medical systems-to-balloon (E2B) challenge: building on the foundations of the D2B Alliance,"] ''STEMI Systems'', Issue Two, May 2007. Accessed June 16, 2007.</ref>  Even in the absence of a formal alerting program, prehospital 12 lead ECGs are independently associated with reduced door to treatment intervals in the emergency department.<ref name=Cannon_176>Cannon CP at al. ''Management of Acute Coronary Syndromes''. p. 176. New Jersey: Humana Press, 1999. ISBN 0-89603-552-2.</ref>


===Wilderness first aid===
==Wilderness first aid==
In [[wilderness first aid]], a possible heart attack justifies [[patient evacuation|evacuation]] by the fastest available means, including [[MEDEVAC]], even in the earliest or precursor stages. The patient will rapidly be incapable of further exertion and have to be carried out.
In [[wilderness first aid]], a possible heart attack justifies [[patient evacuation|evacuation]] by the fastest available means, including [[MEDEVAC]].


===Air travel===
==STEMI Management Durng Air travel==
Certified personnel traveling by commercial aircraft may be able to assist an MI patient by using the on-board [[first aid kit]], which may contain some cardiac drugs (such as [[glyceryl trinitrate]] spray, [[aspirin]], or [[opioid]] painkillers) and [[oxygen]]. Pilots may divert the flight to land at a nearby airport. [[Cardiac monitors]] are being introduced by some airlines, and they can be used by both on-board and ground-based physicians.<ref name="pmid11090520">{{cite journal |author=Dowdall N |title="Is there a doctor on the aircraft?" Top 10 in-flight medical emergencies |journal=BMJ |volume=321 |issue=7272 |pages=1336–7 |year=2000 |month=November |pmid=11090520 |pmc=1119071 |doi= |url=http://bmj.com/cgi/pmidlookup?view=long&pmid=11090520}}</ref>
Certified personnel traveling by commercial aircraft may be able to assist an MI patient by using the on-board [[first aid kit]], which may contain some cardiac drugs (such as [[glyceryl trinitrate]] spray, [[aspirin]], or [[opioid]] painkillers) and [[oxygen]]. Pilots may divert the flight to land at a nearby airport. [[Cardiac monitors]] are being introduced by some airlines, and they can be used by both on-board and ground-based physicians.<ref name="pmid11090520">{{cite journal |author=Dowdall N |title="Is there a doctor on the aircraft?" Top 10 in-flight medical emergencies |journal=BMJ |volume=321 |issue=7272 |pages=1336–7 |year=2000 |month=November |pmid=11090520 |pmc=1119071 |doi= |url=http://bmj.com/cgi/pmidlookup?view=long&pmid=11090520}}</ref> If there is no pharmacotherapy provided by the airline, soemtimes other passengers will have in their possession cardiac medications that can be of use. If the patient is [[hypotensive, they should be placed in trendelenberg position]].


==References==
==References==

Revision as of 20:42, 25 April 2009

Myocardial infarction
ICD-10 I21-I22
ICD-9 410
DiseasesDB 8664
MedlinePlus 000195
eMedicine med/1567  emerg/327 ped/2520

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Symtpom to Door Time

When symptoms of myocardial infarction occur, patients unfortunately delay seeking medical attention for a significant period. In the past this delay was almost 3 hours, but has now been shorted to 1.5 to 2.0 hours. [1] patients often drive themselves to the hospital when instead they should call 911. [2]

Pre Hospital Care

In some countries, such as France, physicians staff mobile intensive care units and pre-hospital care can begin in the ambulance. These pre-hospital therapies in the mobile intensive care setting include glycoprtein IIbIIIa inhibition (as was studied in the On TIME 2 study), unfractionated heparin, nitroglycern, clopidogrel and non-enteric coated aspirin. mg.

Steps to be Taken by Paramedics on Arrival at the Scene of a STEMI

If an Automated External Defibrillator (AED) is available the rescuer should immediately bring the AED to the patient's side and be prepared to follow its instructions should the victim lose consciousness.

If possible the rescuer should obtain basic information from the victim, in case the patient is unable to answer questions once emergency medical technicians arrive (if the patient becomes unconscious). The victim's name and any information regarding the nature of the victims pain will useful to health care providers. Also the exact time that these symptoms started, what the patient was doing at the onset of symptoms, and anything else that might give clues to the pathology of the chest pain. It is also very important to relay any actions that have been taken, such as the number or dose of aspirin or nitroglycerin given, to the EMS personnel.

Other general first aid principles include monitoring pulse, breathing, level of consciousness and, if possible, the blood pressure of the patient. In case of cardiac arrest, cardiopulmonary resuscitation (CPR) can be administered.

Automatic external defibrillation (AED)

Since the publication of data showing that the availability of automated external defibrillators (AEDs) in public places may significantly increase chances of survival, many of these have been installed in public buildings, public transport facilities, and in non-ambulance emergency vehicles (e.g. police cars and fire engines). AEDs analyze the heart's rhythm and determine whether the rhythm is amenable to defibrillation ("shockable"), as in ventricular tachycardia and ventricular fibrillation.

Emergency services

Emergency Medical Services (EMS) Systems vary considerably in their ability to evaluate and treat patients with suspected acute myocardial infarction. Some provide as little as first aid and early defibrillation. Others employ highly trained paramedics with sophisticated technology and advanced protocols.[3] Early access to EMS is promoted by a 9-1-1 system currently available to 90% of the population in the United States. Most are capable of providing oxygen, IV access, sublingual nitroglycerine, morphine, and aspirin. Some are capable of providing thrombolytic therapy in the prehospital setting.[3][4]

With primary PCI emerging as the preferred therapy for ST segment elevation myocardial infarction, EMS can play a key role in reducing door to balloon intervals (the time from presentation to a hospital ER to the restoration of coronary artery blood flow) by performing a 12 lead ECG in the field and using this information to triage the patient to the most appropriate medical facility.[5][6][7]In addition, the 12 lead ECG can be transmitted to the receiving hospital, which enables time saving decisions to be made prior to the patient's arrival. This may include a "cardiac alert" or "STEMI alert" that calls in off duty personnel in areas where the cardiac cath lab is not staffed 24 hours a day.[8] Even in the absence of a formal alerting program, prehospital 12 lead ECGs are independently associated with reduced door to treatment intervals in the emergency department.[9]

Wilderness first aid

In wilderness first aid, a possible heart attack justifies evacuation by the fastest available means, including MEDEVAC.

STEMI Management Durng Air travel

Certified personnel traveling by commercial aircraft may be able to assist an MI patient by using the on-board first aid kit, which may contain some cardiac drugs (such as glyceryl trinitrate spray, aspirin, or opioid painkillers) and oxygen. Pilots may divert the flight to land at a nearby airport. Cardiac monitors are being introduced by some airlines, and they can be used by both on-board and ground-based physicians.[10] If there is no pharmacotherapy provided by the airline, soemtimes other passengers will have in their possession cardiac medications that can be of use. If the patient is hypotensive, they should be placed in trendelenberg position.

References

  1. ↑ Gibson CM, Pride YB, Frederick PD; et al. (2008). "Trends in reperfusion strategies, door-to-needle and door-to-balloon times, and in-hospital mortality among patients with ST-segment elevation myocardial infarction enrolled in the National Registry of Myocardial Infarction from 1990 to 2006". Am. Heart J. 156 (6): 1035–44. doi:10.1016/j.ahj.2008.07.029. PMID 19032997. Unknown parameter |month= ignored (help)
  2. ↑ Brown AL, Mann NC, Daya M; et al. (2000). "Demographic, belief, and situational factors influencing the decision to utilize emergency medical services among chest pain patients. Rapid Early Action for Coronary Treatment (REACT) study". Circulation. 102 (2): 173–8. PMID 10889127. Unknown parameter |month= ignored (help)
  3. ↑ 3.0 3.1 Morrow DA, Antman EM, Sayah A; et al. (2002). "Evaluation of the time saved by prehospital initiation of reteplase for ST-elevation myocardial infarction: results of The Early Retavase-Thrombolysis in Myocardial Infarction (ER-TIMI) 19 trial". J. Am. Coll. Cardiol. 40 (1): 71–7. PMID 12103258. Unknown parameter |month= ignored (help)
  4. ↑ Morrison LJ, Verbeek PR, McDonald AC, Sawadsky BV, Cook DJ (2000). "Mortality and prehospital thrombolysis for acute myocardial infarction: A meta-analysis". JAMA. 283 (20): 2686–92. PMID 10819952.
  5. ↑ Rokos IC, Larson DM, Henry TD; et al. (2006). "Rationale for establishing regional ST-elevation myocardial infarction receiving center (SRC) networks". Am. Heart J. 152 (4): 661–7. doi:10.1016/j.ahj.2006.06.001. PMID 16996830. Unknown parameter |month= ignored (help)
  6. ↑ Moyer P, Feldman J, Levine J; et al. (2004). "Implications of the Mechanical (PCI) vs Thrombolytic Controversy for ST Segment Elevation Myocardial Infarction on the Organization of Emergency Medical Services: The Boston EMS Experience". Crit Pathw Cardiol. 3 (2): 53–61. doi:10.1097/01.hpc.0000128714.35330.6d. PMID 18340140. Unknown parameter |month= ignored (help)
  7. ↑ Henry TD, Atkins JM, Cunningham MS; et al. (2006). "ST-segment elevation myocardial infarction: recommendations on triage of patients to heart attack centers: is it time for a national policy for the treatment of ST-segment elevation myocardial infarction?". J. Am. Coll. Cardiol. 47 (7): 1339–45. doi:10.1016/j.jacc.2005.05.101. PMID 16580518. Unknown parameter |month= ignored (help)
  8. ↑ Rokos I. and Bouthillet T., "The emergency medical systems-to-balloon (E2B) challenge: building on the foundations of the D2B Alliance," STEMI Systems, Issue Two, May 2007. Accessed June 16, 2007.
  9. ↑ Cannon CP at al. Management of Acute Coronary Syndromes. p. 176. New Jersey: Humana Press, 1999. ISBN 0-89603-552-2.
  10. ↑ Dowdall N (2000). ""Is there a doctor on the aircraft?" Top 10 in-flight medical emergencies". BMJ. 321 (7272): 1336–7. PMC 1119071. PMID 11090520. Unknown parameter |month= ignored (help)

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