ST elevation myocardial infarction pre-hospital care: Difference between revisions
Brian Blank (talk | contribs) No edit summary |
Brian Blank (talk | contribs) No edit summary |
||
| Line 41: | Line 41: | ||
===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="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> 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.<ref name="ACC_AHA_STEMI"/> 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 | [[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="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> 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.<ref name="ACC_AHA_STEMI"/> 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> | ||
Revision as of 18:11, 11 February 2009
| Myocardial infarction | |
| ICD-10 | I21-I22 |
|---|---|
| ICD-9 | 410 |
| DiseasesDB | 8664 |
| MedlinePlus | 000195 |
| eMedicine | med/1567 emerg/327 ped/2520 |
| Cardiology Network |
 Discuss ST elevation myocardial infarction pre-hospital care further in the WikiDoc Cardiology Network |
| Adult Congenital |
|---|
| Biomarkers |
| Cardiac Rehabilitation |
| Congestive Heart Failure |
| CT Angiography |
| Echocardiography |
| Electrophysiology |
| Cardiology General |
| Genetics |
| Health Economics |
| Hypertension |
| Interventional Cardiology |
| MRI |
| Nuclear Cardiology |
| Peripheral Arterial Disease |
| Prevention |
| Public Policy |
| Pulmonary Embolism |
| Stable Angina |
| Valvular Heart Disease |
| Vascular Medicine |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Associate Editors-In-Chief: Cafer Zorkun, M.D., Ph.D. [2]
Please Join in Editing This Page and Apply to be an Editor-In-Chief for this topic: There can be one or more than one Editor-In-Chief. You may also apply to be an Associate Editor-In-Chief of one of the subtopics below. Please mail us [3] to indicate your interest in serving either as an Editor-In-Chief of the entire topic or as an Associate Editor-In-Chief for a subtopic. Please be sure to attach your CV and or biographical sketch.
Immediate care
When symptoms of myocardial infarction occur, people wait an average of three hours, instead of doing what is recommended: calling for help immediately.[1][2] Acting immediately by calling the emergency services can prevent sustained damage to the heart ("time is muscle").[3]
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.
Aspirin can be given quickly (if the patient is not allergic to aspirin); but taking aspirin before calling the emergency medical services may be associated with unwanted delay.[4] Aspirin has an antiplatelet effect which inhibits formation of further thrombi (blood clots) that clog arteries. Non-enteric coated or soluble preparations are preferred. If chewed or dissolved, respectively, they can be 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.[5] Australian guidelines recommend a dose of 150 – 300 mg.[6]
Glyceryl trinitrate (nitroglycerin) sublingually (under the tongue) can be given if it has been prescribed for the patient.
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.[5] Early access to EMS is promoted by a 9-1-1 system currently available to 90% of the population in the United States.[7] Most are capable of providing oxygen, IV access, sublingual nitroglycerine, morphine, and aspirin. Some are capable of providing thrombolytic therapy in the prehospital setting.[8][9]
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.[10][11][12]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.[13] 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.[14]
Wilderness first aid
In wilderness first aid, a possible heart attack justifies 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.
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.[15]
References
- ↑ Heart attack first aid. MedlinePlus. Retrieved December 3, 2006.
- ↑ Act In Time to Heart Attack Signs - NHLBI. Retrieved December 13, 2006.
- ↑ TIME IS MUSCLE TIME WASTED IS MUSCLE LOST. Early Heart Attack Care, St. Agnes Healthcare. Retrieved November 29, 2006.
- ↑ 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) - ↑ 5.0 5.1 Antman EM, Anbe DT, Armstrong PW; et al. (2004). "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)". J. Am. Coll. Cardiol. 44 (3): 671–719. doi:10.1016/j.jacc.2004.07.002. PMID 15358045. Unknown parameter
|month=ignored (help) - ↑ Rossi S, editor. Australian Medicines Handbook 2006. Adelaide: Australian Medicines Handbook; 2006. ISBN 0-9757919-2-3.
- ↑
- ↑ 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) - ↑ 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.
- ↑ 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) - ↑ 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) - ↑ 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) - ↑ 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.
- ↑ Cannon CP at al. Management of Acute Coronary Syndromes. p. 176. New Jersey: Humana Press, 1999. ISBN 0-89603-552-2.
- ↑ 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)
External links
- Risk Assessment Tool for Estimating Your 10-year Risk of Having a Heart Attack - based on information of the Framingham Heart Study, from the United States National Heart, Lung and Blood Institute
- Heart Attack - overview of resources from MedlinePlus.
- Heart Attack Warning Signals from the Heart and Stroke Foundation of Canada
- Regional PCI for STEMI Resource Center - Evidence based online resource center for the development of regional PCI networks for acute STEMI
- STEMI Systems - Articles, profiles, and reviews of the latest publications involved in STEMI care. Quarterly newsletter.
- American College of Cardiology (ACC) Door to Balloon (D2B) Initiative.
- American Heart Association's Heart Attack web site - Information and resources for preventing, recognizing and treating heart attack.