Prehospital thrombolytics

[medic28]

I'm sitting here with a paramedic student who just asked my thoughts on prehospital thrombolytics. I thought I'd pose the question to every one here. Do you use them, and if not why. Thanks guys.

[RyanEMVFD]

We don't carry them here. Don't have an opinion on them since I had to learn them in EMT-I class and haven't gone over them yet in medic school.

I don't know of any services around here that carry them. The flight services around here might. I'll have to look into that.

[IAMedic]

Our medical director won't let us use them because our protocols call for a CT scan or neuro consult to be conducted before thrombolytics can be given, which is fine with me and everyone else. Besides, rarely are we farther than 10 minutes from the hospital. If we can't get them to surgery within the three hour period, it's usually not our fault. It's usually because pt's wait three hours before calling us thinking it will eventually go away.

[swanny]

This has been under consideration for remote sites on the trans-Alaska Oil Pipeline for at least the last 13 years. Our medical director has thus far not authorized thrombolytics because he feels that administration requires more trained hands than we have available. Each site only has 1 medic, and all assistance comes from medically untrained pipeline workers. He primary concern is that managing multiple drips on top of all other patient care considerations is more than one person should be required to handle alone.

Frequency of need is also a consideration - thus far we've rarely treated patients for an active MI, only one or two a year line wide (the line is 800 miles long). On the other hand he recognizes that we do have an aging work force (and aging medics), so the issue comes up for discussion and reconsideration annually.

Personally I don't have strong feelings either way, but my station is only an hour and 1/2 to town either by ground or helicopter reponse (both ways).

Swanny

[emtp2031]

We dont use them here either in the field....but by the time my grandkids..if I ever have them....are old enough to be paramedics Maryland may allow them to use it!!! :hehe:

[Nate]

We are hardly very far from a hospital, they are expensive, and our medical director doesn't allow us to carry them. I think they might be in the works, I'm not for sure.

[locomedic21]

Yep any where we go were only 10 minutes max from a hospital so not in our protocol either. do we have any alaskan medics here? i worked with one for a short time then he went back they had standing orders for everything he told me. im sure they have it.

[hageremtp]

CHEST PAIN - SUSPECTED MYOCARDIAL INFARCTION
Obtain 12 Lead EKG (or modified 9 Lead)
Transmit / Notify Hospital of any EKG with signs of ischemia / infarct

4 Chewable Baby Aspirin p.o.
if patient not already on daily ASA dosage

Nitroglycerine 0.4 mg SL , repeat every 5 mins.
(Systolic BP must be at least 100 mmHg)
and / or

Establish Nitroglycerine (Tridil) IV Drip
Start @ 5 ug/min & titrate to maintain a systolic BP of 100 mm/Hg or greater

IV of Normal Saline 500cc KVO
Draw Blood (red, blue, & purple)
Establish an additional IV Line as time & manpower allows

If Pain is Unrelieved by Nitroglycerine, Administer Morphine Sulfate 2 mg. IVP
(May administer up to a total of 20 mg. in 2 mg. increments)

All patients with suspected AMI
Lopressor 5mg IVP every 5 min up to 15mg
HR must be > 60, Systolic pressure > 100mm/hg

Treat any dysrhythmias as per protocols

Load & Transport

Complete Thrombolytic Screening History Checklist

If patient has positive EKG Changes (ST elevation in 2 or more connected leads), is less than 70 years of age, the symptoms are less than six (6) hours in duration, no contraindications exist, & ETA to Hospital is greater than 20 minutes,
** Consider administration of TNKase (use weight/dose chart to determine dose) **

**(Requires Consultation with Medical Director/Control @ receiving facility)**

[hageremtp]

Forgot to add this:

Patient Selection Criteria for Fibrinolytic Therapy

Patients Name: ______________
Patients Weight; _____________
Onset of chest Pain; __________

TREATMENT CRITERIA
_____ Presentation consistent with AMI Chest, arm, jaw, neck, or back Pain longer than 30 min. Nausea, diaphoresis
_____ECG evidence of MI q waves do not preclude treatment
_____ Recent onset of acute MI symptoms disease
_____ Subacute bacterial endocarditis.
*exception if pain has been intermittent or there is evidence of ongoing ischemia

CONTRADICTIONS
_____ Active bleeding
_____ History of CVA
_____ Recent (within 2mo) intercranial or intraspinal surgery or trauma
_____ Intracranial neoplasm, arteriovenous malformation or aneurysm.
_____ Known Bleeding diathesis
_____ Severe uncontrolled hypertension
WARNINGS
_____ Recent major surgery, e.g., coronary artery bypass graft, OB delivery, organ biopsy, previous puncture of non-compressible vessels.
_____ Cerebrovascular disease
_____ Recent gastrointestinal or genitourinary bleeding
_____ Recent Trauma
_____ Hypertension: systolic BP 180mm Hg and/or diastolic BP 110mm Hg
_____ High likelihood of left heart thrombus,e.g., mitral stenosis with atrial fibrillation
_____ Acute pericarditis
_____ Hemostatic defects, including those secondary to severe hepatic or renal disease
_____ Severe hepatic dysfunction
_____ Pregnancy
_____ Diabetic hemorrhagic retinopathy or other hemorrhagic ophthaimic cond.
_____ Septic thrombophlebitis or occluded AV cannula at seriously infected site.
_____ Advanced age of 75.
_____ Patients currently receiving oral anticoagulants, e.g., warfarine sodium
_____ Recent administration of GP II/IIa inhibitors.
_____ Any other condition in which bleeding constitutes a significant hazard or would be particularly difficult to Manage because of its location

[medic18lt]

not a chance with our protocol... Our Doc has two protocols one for the county ems folks and one for the city...the county guys get more toys to play with. In the city its all about money only private service runs EMS in the city. I need to get away from this Private EMS crap :bang: and find a place I can do what I am trained we don't even cary compazine, or versed... witch i can cary when I run county.

[firemedicak]

Unlike Swanny ;) , I come from the civilized regions of Alaska. No ground transport services in the SouthCentral areas use thrombolytics to my knowledge. The local fixed- and rotatry-wing medevac services may, but we only work with the choppers and it's strictly trauma related.

While we have a couple of stations that can have transport times up to an hour depending upon weather conditions and location of the incident, the local medical community and our medical director have never been very interested in utilizing prehospital thrombolytics.

But then again, medicine is like taxes. It's guarenteed to change every year.

[volparamedic]

We aren't allowed in Knox Co but the Rural Metro division in Loudon Co does use it. Our transport times are so short with 7 hospitals locally. They have a much longer transport time. It is very strict protocols and require a lot of time with the patient.

[emmit233]

a neighboring county here uses TNkASE. They have fairly strict protocols and have over 30 minute transports at times. One of my classmates worked FT for that service as a Basic. He got to see a reperfusing rythym as a medic student. He now works FT for that service as a medic...what a great thing to see as a student I think. :beer: