Paramedic-Delivered Fibrinolysis in the Treatment of ST-Elevation Myocardial Infarction: Comparison of a Physician-Authorized versus Autonomous Paramedic Approach.

Paramedic-Delivered Fibrinolysis in the Treatment of ST-Elevation Myocardial Infarction: Comparison of a Physician-Authorized versus Autonomous Paramedic Approach. Prehosp Emerg Care. 2019 Nov 13;:1-8 Authors: Davis P, Howie GJ, Dicker B, Garrett NK Abstract Background: For those patients who receive fibrinolysis in the treatment of ST-elevation myocardial infarction (STEMI), early treatment, i.e., within 2 hours of symptom onset, confers the greatest clinical benefit. This rationale underpins paramedic-delivered fibrinolysis in the prehospital setting. However, the current New Zealand approach requiring paramedics to first gain physician authorization, has proved inefficient and time consuming, particularly due to technological failings. Therefore, this study aimed to trial a new autonomous paramedic-delivered fibrinolysis model, examining the impact on time-to-treatment, paramedic diagnostic accuracy and patient outcomes. Methods: Utilizing a prospective observational approach, over a 24-month period, paramedics identified patients with a clinical presentation and electrocardiogram features consistent with STEMI, and initiated fibrinolysis. These patients were compared to a historic cohort who received fibrinolysis by paramedics within the same regions but following physician authorization. The main outcome measures were pain-to-needle (PTN) time and accuracy of paramedic diagnosis. A secondary end-point was 30-day and 6-month mortality and hospi...
Source: Prehospital Emergency Care - Category: Endocrinology Tags: Prehosp Emerg Care Source Type: research

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Conclusion: This represents the largest study of patients with VPR and angiographically-proven ACO. The MSC were highly sensitive and specific for the diagnosis of ACO in patients presenting to the ED with VPR and symptoms of acute coronary syndrome.===================================MY Comment by KEN GRAUER, MD (10/4/2020):===================================Today ’s case provides a superb example of how acute OMI can sometimes be definitively recognized even in the presence ofpacing. Unfortunately, this was not recognized by the cardiology team despite...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs
We report a case of a 49‐year‐old man with a history of smoking who presented to the emergency department with a 1 day history of chest pain that was exacerbated 5 h prior to presentation. Detailed clinical investigations and coronary angiogr aphic characteristics were recorded. The first ECG of the patient was consistent with de Winter syndrome. Acute coronary artery angiography showed that the proximal left anterior descending coronary artery was completely occluded after the first diagonal branch artery was given off. A percutaneous c oronary intervention was immediately performed. Our case indicates that ...
Source: ESC Heart Failure - Category: Cardiology Authors: Tags: Case Report Source Type: research
CONCLUSION: This case highlights a unique etiology of acute myocardial infarction in a patient with SAH leading to ST elevations, diffuse triple vessel CAV and apical scar. PMID: 33014294 [PubMed]
Source: World Journal of Cardiology - Category: Cardiology Authors: Tags: World J Cardiol Source Type: research
A ~40 year old woman started having chest discomfort.  She called 911 after an uncertain amount of time.  EMS arrived and recorded thisprehospital ECG:Obvious Anterior and Inferior STEMI, consistent with LAD occlusionAfter recording this ECG, the patient went intoventricular fibrillation.She was rapidly defibrillated.The cath lab was activated by the paramedics.She arrived complaining of chest pain, with a BP of 110/70.An ED ECG was recorded:It looks worse stillAside: Should the patient receive antidysrhythmics to prevent recurrent VT/VF?  See discussion below on both beta blockers and other anti-dysrhythmic...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs
CONCLUSION to the Case: The interventionalist finally took the patient to the cath lab. There was 100% occlusion of the RCA, which was stented.================NOTE: My sincere THANKS to Emmanuel Reisman (New York) for sharing the tracings and this case with us!================SmithQuickComments:Ken,Great case and great discussion!The modified Sgarbossa criteria are only 84% sensitive (if you use 20%) in our studies (Meyers Validation study), and if used on a consecutive group of chest pain patients with LBBB, it would probably be lower.  So indeed we need to look beyond these criteria in order to NOT mi...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs
A 58 yo male was out working in the hot sun for 2-3 hours. He stated he almost passed out, and bystanders called 911. They give him water with salt, as he thought he was dehydrated.When medics arrived, he was alert, sweating, and felt weak.  He walked to the ambulance for evaluation.  He denied headache, chest pain, nausea / vomiting and dyspnea. He had no cardiac history, meds, or risk factors. Vitals were obtained, and placed on cardiac monitor, including this 12 lead prehospital ECG: QTc =  320 ms; (QTc = 374 ms)The computer measures the ST Elevation at the J-point for you.Here it is 4.08 mm in ...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs
CONCLUSIONS: Of the subjects discharged on the HEART Pathway, 67.6% followed up. Of those subjects that followed up, 18% did so at the HEART Clinic. PMID: 32871008 [PubMed - as supplied by publisher]
Source: Military Medicine - Category: International Medicine & Public Health Tags: Mil Med Source Type: research
Discussion:The management in this case is unfortunately common practice at many places around the world where we receive cases. Why would an interventionalist violate multiple recommendations from their own guidelines and watch at 10am while an LAD occlusion plays out in front of them? What could explain why some providers do not seem interested in the fact that LAD occlusion can be identified by something other than STEMI criteria? Or why the wall motion abnormality matching the distribution of concern is ignored? The only plausible explanation is that they have been taught that this is standard practice. Under the STEMI ...
Source: Dr. Smith's ECG Blog - Category: Cardiology Authors: Source Type: blogs
Chest pain is one of the most common complaints at the emergency department (ED), and it is commonly the perceived likelihood of acute coronary syndrome (ACS) that drives management. Guidelines from the European Society of Cardiology (ESC) recommend the use of a 0-/1-h high-sensitivity cardiac troponin T (hs-cTnT) protocol to rule out or in ACS, but this is mostly based on observational studies. The aim of the ESC-TROP trial is to determine the safety and effectiveness of the ESC 0-/1-h hs-cTnT protocol when implemented in routine care. Adult chest pain patients at 5 EDs in the Sk åne Region, Sweden, are included in ...
Source: Cardiology - Category: Cardiology Source Type: research
Left ventricular free wall rupture (LVFWR) is a rare and fatal mechanical complication following an acute myocardial infarction (AMI). Cases of survival after LVFWR due to ST-segment elevation myocardial infarction (STEMI) treated with a conservative treatment strategy are extremely rare. In this case, a 55-year-old male patient with several cardiovascular risk factors presented to the emergency department with symptoms of ongoing chest pain and syncope. The patient's electrocardiogram was in sinus rhythm with ST-elevation on I, aVL, and V4 –6 leads.
Source: The American Journal of Emergency Medicine - Category: Emergency Medicine Authors: Source Type: research
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