New Cards Guidelines from ACC/AHA

[pushinepi2]

Given that pre-hospital research doesn't always demonstrate favorable outcomes for our patients, it seems that the EMS world has been given another opportunity. The most recent (2004) guidelines for the treatment of STEMI were published in this month's Annals of Emergency Medicine. Many things remain the same, but the guidelines call for an expanded scope for the nation's EMS providers. Time is indeed muscle. The most interesting section talked about establishing realistic protocols for the administration of thrombolytics in the field. Since door to reperfusion time is an important predictor of outcome, the ACC/AHA feels that empowering medics to deliver such lifesaving care may be a necesary step. The most practical application of these guidelines, it would seem, would be to train rural EMS providers in the administration of retevase. Also discussed was the principle of paramedic triage. Based on the patient's presentation and history, some people benefit from transport to a hospital capable of interventional treatment (stent/cath/etc). The implication is that the closest facility may not always be the appropriate one for the patient suffering from an ST elevation MI. Another EMS specific recommendation was to train virtually all paramedics in the art of initial and continous 12 lead EKG monitoring. Clearly, the paramedics ability to recognize acute and ongoing EKG changes might increase the patient's chances of getting to a cath lab within a reasonable time. Its probably a good time to have discussions about the following with your respective medical directors:

1. The practicality of pre hospital thrombolysis in your service area. If long transport times are a reality, then it might be appropriate to investigate some retevase protocols.

2. Obtaining 12 lead EKGs on all transport trucks for identification of STEMI patients

3. Off line use of morphine for the control of cardiac pain. Our service didn't have to ask, but many still require on line MCP approval prior to MS04 administration. The new ACC/AHA guidelines reiterate MSO4 as the analgesic of choice for cardiac CP

4. Revision of protocol to reflect transport to the closest APPROPRIATE facility. The ability to reperfuse ischemic tissue is of prime importance; certain patient subsets benefit from cath vs. drugs. In some cases, EMS agencies might consider transporting to a tertiary referral facility instead of the closest ED....

I'll post a link to the ACC/AHA 2004 guidelines when I find 'em. Any thoughts? Are there many other services currently utilizing prehospital thrombolytic protocols? Is everybody on the same boat with the 12-lead EKG strategies?

-PuSh

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[v-tach]

I am a volunteer EMT in Hunterdon County, NJ, and the local hospital's paramedic service does administer thrombolytics (Retavase) en route to the hospital. I have also seen them give morphine for cardiac chest pain.

 

[12R34Y]

In Iowa one of the rural services has been giving thrombolytics in the field for many years. I think in late 90's.

The service I worked for many years would have absolutely NO need for prehospital thrombolytics. We had about 22 hospitals in the metro area and even our farthest outlying calls were still only 20 minutes to the hospital usually. Almost all of the facilities were capable of cardiac cath as well.

We have been doing prehopsital 12-leads since about 1995. I've got a whole file cabinet full of some awesome evolving MI's. We would transmit them on scene or enroute to the hospital and go directly to the cath lab at some places bypassing the ED.

We really had a great system in place.

I think more importantly than training paramedic in prehospital thrombolytics would be to train urban systems (where most of the people in the country are) to have protocols to do prehospital twelve leads and go DIRECTLY to the cath lab bypassing the ED.

interesting topics.

later

 

[pushinepi2]

...I think more importantly than training paramedic in prehospital thrombolytics would be to train urban systems (where most of the people in the country are) to have protocols to do prehospital twelve leads and go DIRECTLY to the cath lab bypassing the ED...

That's a great idea. The time window has further narrowed according to the recent recommendations. The problem isn't necessarily buy-in from cardiologists and emergency providers. A major obstacle to overcome is a lack of resources. I can recall several occasions in which the ED team agreed upon a, "hot MI" but couldn't transfer the patient immediately upstairs for one reason or another. The new guidelines shift the burden (as it should be shifted) to cardiac cath lab physicians and staff... there's lots of pressure to meet the, "door to balloon" time benchmark.

Did any of your services utilize a cardiac alert or similar protocol to alert the ED and cardiologist(s) of your arrival? Or was the paramedics med-com report and 12 lead enough to get the ball rolling?

 

[12R34Y]

That's a great idea. The time window has further narrowed according to the recent recommendations. The problem isn't necessarily buy-in from cardiologists and emergency providers. A major obstacle to overcome is a lack of resources. I can recall several occasions in which the ED team agreed upon a, "hot MI" but couldn't transfer the patient immediately upstairs for one reason or another. The new guidelines shift the burden (as it should be shifted) to cardiac cath lab physicians and staff... there's lots of pressure to meet the, "door to balloon" time benchmark.

Did any of your services utilize a cardiac alert or similar protocol to alert the ED and cardiologist(s) of your arrival? Or was the paramedics med-com report and 12 lead enough to get the ball rolling?

We would give our radio report to the ED and they would also see our 12 lead we faxed them. If they were impressed then they would call the cath lab and cardiologist prior to our arrival so that they could at least start coming in to the hospital if it was 0300 in the am. During the daytime hours however, the cath lab is usually open and running and there are plenty of cardiologists to be found in house already.

later

 

[deleted6669]

"I have also seen them give morphine for cardiac chest pain."-vtach

no offense but I think everywhere in the country has done this for >10 years....I last worked as a medic in 1992 and we were doing it then.....


also a general side note ....I think the cutting edge medic 1 team in seattle has been giving thrombolytics for > 10 yrs in the field (as well as starting subclavian lines and doing a lot of other wild stuff)

 

[Apollyon]

Given that pre-hospital research doesn't always demonstrate favorable outcomes for our patients, it seems that the EMS world has been given another opportunity. The most recent (2004) guidelines for the treatment of STEMI were published in this month's Annals of Emergency Medicine.

3. Off line use of morphine for the control of cardiac pain. Our service didn't have to ask, but many still require on line MCP approval prior to MS04 administration. The new ACC/AHA guidelines reiterate MSO4 as the analgesic of choice for cardiac CP

Something ironic as hell...one of the authors of the Annals article is a cardiologist here at Duke, who was on-call one night when I called to admit a patient. After 10mg of morphine, he told me to stop with it, and keep going with the nitro, since the morphine can mask the pain by just snowing the pt. and putting the pt to sleep. On the plus side, I take Dr. Roe as one of the 3 smartest people here at Duke (along with Vic Tapson in pulmonary/critical care - he is the tip of the spear with PIOPED II, and Carmelo Graffagnino in neurology), which is saying something.

 

[pushinepi2]

Something ironic as hell...one of the authors of the Annals article is a cardiologist here at Duke, who was on-call one night when I called to admit a patient. After 10mg of morphine, he told me to stop with it, since the morphine can mask the pain by just snowing the pt... and putting the pt to sleep. On the plus side, I take Dr. Roe as one of the 3 smartest people here at Duke....

??? I guess it goes to show you that we all have our habits. That's right up there with not giving morphine to patients with suspected appendicities because you're afraid of masking abdominal pathology. I'm sure we're also all in agreement that releif of pain with NTG is virtually diagnostic for cardiac ischemia? LOL. Thanks for the irony.



-Push (in the morphine)

 

[Apollyon]

??? I guess it goes to show you that we all have our habits. That's right up there with not giving morphine to patients with suspected appendicities because you're afraid of masking abdominal pathology. I'm sure we're also all in agreement that releif of pain with NTG is virtually diagnostic for cardiac ischemia? LOL. Thanks for the irony.



-Push (in the morphine)

The morphine is a class I (definitely helpful) category C (expert opinion) recommendation, so it doesn't have randomized clinical trials (big or small) behind it. Due to this conundrum, I did email the author, and am awaiting a response.

Although we may all be in agreement, there are no (to my knowledge) acknowledged experts on SDN.

As far as no morphine for abd pain, because the analgesia may mask the clinical exam, that has been shown (J Am Coll Surg. 2003 Jan;196(1):18-31.) to be clinically wrong - you can give anagesia and not blunt the exam.

Effects of morphine analgesia on diagnostic accuracy in Emergency Department patients with abdominal pain: a prospective, randomized trial.

Thomas SH, Silen W, Cheema F, Reisner A, Aman S, Goldstein JN, Kumar AM, Stair TO.

Division of Emergency Medicine, Department of Emergency Services, Massachusetts General Hospital, Boston, MA 02114-2696, USA.

BACKGROUND: Because of concerns about masking important physical findings, there is controversy surrounding whether it is safe to provide analgesia to patients with undifferentiated abdominal pain. The purpose of this study was to address the effects of analgesia on the physical examination and diagnostic accuracy for patients with abdominal pain. STUDY DESIGN: The study was a prospective, double-blind clinical trial in which adult Emergency Department (ED) patients with undifferentiated abdominal pain were randomized to receive placebo (control group, n = 36) or morphine sulphate (MS group, n = 38). Diagnostic and physical examination assessments were recorded before and after a 60-minute period during which study medication was titrated. Diagnostic accuracy and physical examination changes were compared between groups using univariate statistical analyses. RESULTS: There were no differences between control and MS groups with respect to changes in physical or diagnostic accuracy. The overall likelihood of change in severity of tenderness was similar in MS (37.7%) as compared with control (35.3%) patients (risk ratio [RR] 1.07, 95% confidence interval [CI] 0.64-1.78). MS patients were no more likely than controls to have a change in pain location (34.0% versus 41.2%, RR 0.82, 95% CI 0.50-1.36). Diagnostic accuracy did not differ between MS and control groups (64.2% versus 66.7%, RR 0.96, 95% CI 0.73-1.27). There were no differences between groups with respect to likelihood of any change occurring in the diagnostic list (37.7% versus 31.4%, RR 1.20, 95% CI 0.71-2.05). Correlation with clinical course and final diagnosis revealed no instance of masking of physical examination findings. CONCLUSIONS: Results of this study support a practice of early provision of analgesia to patients with undifferentiated abdominal pain. Copyright 2003 by the American College of Surgeons

Publication Types:

* Clinical Trial
* Randomized Controlled Trial


PMID: 12517545 [PubMed - indexed for MEDLINE]

 

[Apollyon]

I just got an email back from the cardiologist, and he says there's data coming out for unstable angina/NSTEMI where morphine use is consistently associated with increased mortality.

My advice? The tide will change (somewhat) with this new article, so go with your protocols, but be liberal in calling for medical direction (man - being a paramedic, and now being an EM doc - I LOVE giving direction) asking for more NTG instead of plowing the pt with morphine.