EMS Administration of Fibrinolytics to STEMI Patients

The benefit of prehospital care

 

 
 
 

Keith Wesley, MD, FACEP | | Monday, February 25, 2008


Review of: Smalling RW, Giesler GM, Julapalli VR, et al: "Pre-hospital reduced-dose fibrinolysis coupled with urgent percutaneous coronary intervention reduces time to reperfusion and improves angiographic perfusion score compared with prehospital fibrinolysis alone or primary percutaneous coronary intervention: Results of the PATCAR pilot trial." Journal of the American College of Cardiology. 50(16):1612-1614, 2007.

The Science

I don't usually comment on science reported only in editorial remarks. However, this correspondence in the Journal of the American College of Cardiology caught my attention because it was only this past year that I and several other experts were asked whether we believed in any benefit from reduced dose fibrinolytics being administered by EMS.

The data presented was from a pilot trial of an on-going wider study. The question is, "Does the administration of a half-dose of retaplase by EMS significantly affect the time to reperfusion and subsequent angiographic perfusion scores when compared to fibrinolysis alone, primary coronary intervention (PCI) instead of EMS retaplase, or in combination with PCI?"

The study identified 60 ST-segment Elevation Myocardial Infarction (STEMI) patients. Of these 60, 46 were determined to be candidates for fibrinolytic therapy. All were given 10 units of retaplase, IV heparin and oral aspirin. They were then randomized to either receive a second, 10-unit does of retaplase (Group A) or urgent catheterization with PCI (Group B). The remaining 14 non-fibrinolytic eligible patients (Group C) along with an additional 13 patients who arrived by EMS agencies not participating in the study were taken immediately to PCI.

A summary of their findings shows that Group B patients were significantly more likely to have good to excellent perfusion by the time of catheterization, less ischemia as indicated by shorter times to reperfusion, and improved survival.

Interestingly, 68% of patients crossed over from Group A to rescue PCI for persistent symptoms, ST-segment elevation or hemodynamic instability. Less than 50% of these had good to excellent perfusion at catheterization. This suggests that routine PCI immediately after prehospital fibrinolysis, irrespective of clinical setting, should be the standard of care.

The Street

I stand corrected on the opinions I voiced this past year at EMS Expo. The findings of this pilot study will need to be verified with the full trial, but if they hold up I believe we ll have sufficient evidence to support the administration of fibrinolytics by EMS.

This study underscores the importance of beginning the process now to develop STEMI programs to ensure that EMS can acquire 12-leads, either interpret them or have them interpreted remotely, and deliver the patient to the nearest PCI-capable center.

Additionally, a vital component will be the ability of EMS providers to determine which patients are eligible for fibrinolytics by obtaining an accurate history and using stringent protocols to drive quality patient care. Each of these components must be in place before you launch your STEMI program. The ultimate goal is improved patient outcomes, but the process of getting there will require education, funding and cooperation of all interested stakeholders.

I'm excited about the future of STEMI research. This is the kind of study that truly measures the potential impact of EMS.




Connect: Have a thought or feedback about this? Add your comment now
Related Topics: Patient Care

 
Author Thumb

Keith Wesley, MD, FACEP

Keith Wesley, MD, FACEP, is the Minnesota State EMS medical director and the EMS medical director for HealthEast Ambulance in St. Paul, Minn. and and can be reached at drwesley@emsconsulting.net.

BROWSE FULL BIO & ARTICLES >

What's Your Take? Comment Now ...

Featured Careers & Jobs in EMS





 

Get JEMS in Your Inbox

 

Fire EMS Blogs


Blogger Browser

Today's Featured Posts

 

EMS Airway Clinic

Innovation & Progress

Follow in the footsteps of these inspirational leaders of EMS.
More >

Multimedia Thumb

Maryland Pool Chemical Leak Sends 35 Campers to Hospitals

Patients transported to four area hospitals.
Watch It >


Multimedia Thumb

Pennsylvania Ambulance Catches Fire

Investigators look into cause of fire.
Watch It >


Multimedia Thumb

Stolen Florida Ambulance Back in Service

Rig was stolen from outside of ER.
Watch It >


Multimedia Thumb

Ambulance Service Returns to Illinois City

Fire district picks up after ATS Medical Services.
Watch It >


Multimedia Thumb

Hands On July 2014

Check out the latest products and innovations in JEMS.
More >


Multimedia Thumb

Wounded Veteran Resiliency

Marine is one of many in quality of life study.
More >


Multimedia Thumb

National EMS Memorial Bike Ride 2014

Over 50 riders honor those killed in the line of duty in 2013.
More >


Multimedia Thumb

LMA MAD Nasal™

Needle-free intranasal drug delivery.
Watch It >


Multimedia Thumb

Braun Ambulances' EZ Door Forward

Helps to create a safer ambulance module.
Watch It >


Multimedia Thumb

The AmbuBus®, Bus Stretcher Conversion Kit - EMS Today 2013

AmbuBus®, Bus Stretcher all-hazards preparedness & response tool
Watch It >


More Product Videos >