Pre-hospital Cardiac Care Donna Venezia MD FACEP

Patient Scenario 1 4:00 PM: You are visiting a friend when she gets a call from her mother that her father has been having chest pain, nausea and weakness on and off all day. She knows you are a doctor and asks you to go over to see him. What would you do?

Patient Scenario 1 4:30 PM: You go immediately to his home by motor bike. You arrive at 4:30 because of traffic. 4:45 PM: While you are getting a better history of his symptoms, you note that he is cool and sweaty. You tell him that he might be having a heart attack and needs to go to the hospital.

Patient Scenario 1 5:00 PM: Your friend’s father is too weak to sit up on a motorbike. At the insistence of your friend’s mother, you call a neighbor and borrow a car to take him to the hospital

Patient Scenario 1 5:20 PM: You begin driving across town – in heavy traffic – to the cardiac hospital. Suddenly your friend screams that her father is unresponsive. You are passing a medical clinic.

Patient Scenario 1 5:30 PM: You and your friend carry her father into the medical clinic. Minutes go by before someone finds him a bed. 5:45 PM: You discover that he has no pulse, so you start CPR. One of the doctors finds an old defibrillator in a closet.

Patient Scenario 1 5:50 PM: Now what? Your diagnosis and treatment?

Patient Scenario 1 6:00 PM: You diagnose ventricular fibrillation and want the doctors to defibrillate your friend’s father. They tell you that they are just a small clinic and the defibrillator is old, broken and they have never used it. You now see this rhythm…..

Patient Scenario 1 6:05: The clinic has no ACLS medications You are still 30 minutes from hospital You agree with the other doctors to stop CPR You tell your friend her father is dead

Patient Scenario 1 Could the outcome have been different with a trained pre-hospital team transporting this patient?

In Vietnam According to a 2008 study from Hanoi, cardiovascular disease – both stroke and ischemic heart disease – is the leading cause of death for both men and woman in Vietnam Nguyen Thi Trang Nhung, et al. Vietnam Burden of Disease and Injury Study 2008. Hanoi School of Public Health and Univ. of Queensland, Medical Publishing House 2011.

Timing of “Sudden Death” Up to 65% of deaths related to myocardial infarction occur in the 1st hour  ventricular fibrillation 1 of 300 patients with chest pain transported by car will go into cardiac arrest en route!

Timing of “Sudden Death” Many deaths preventable with simple, rapid defibrillation – available on ambulances…not in cars or taxis! www.emedicine.com/article/155919-treatment#aw2aab6b6b2

Time to Thrombolytic and PCA PCA – Percutaneous Coronary Angioplasty American Heart Association: treat ST Elevation Myocardial Infarction (STEMI) with a thrombolytic or PCA within 12 hours of symptom onset PCA preferred over thrombolytic Saif R, et al. Association of door-to-balloon time and mortality in patients admitted to the hospital with ST elevation myocardial infarction: national cohort study, BMJ.2009;338:b1807.

Time to Thrombolytic and PCA The sooner a patient with an acute MI reaches the hospital for definitive therapy, the lower the mortality rate. Saif R, et al. Association of door-to-balloon time and mortality in patients admitted to the hospital with ST elevation myocardial infarction: national cohort study, BMJ.2009;338:b1807.

The Pre-Hospital Goal The goal of prehospital transfer… minimize the time it takes to get a cardiac patient to an appropriate hospital … in a safe manner

For EMS System to Work Patients must be knowledgeable Patients must recognize symptoms for which EMS transport is appropriate and beneficial Patients must know how to access the pre-hospital system

Local Population Education Can the patient or family recognize the symptoms of heart attack? Do they know the importance of quickly bringing him to a hospital capable of caring for a cardiac patient?

Local Population Education Is there a phone number to call to get help and an ambulance? Do people know that number?

The 911 Emergency Phone Call In US: call 911  immediately connected to a trained operator The operator activates the prehospital system by sending an appropriate level ambulance to the site of the call

The 911 Emergency Phone Call The operator advises the caller on basic life saving techniques Direct pressure to stop bleeding Start basic CPR

American Heart Association Since the 1980’s the American Heart Association (AHA) has publicized the importance of early recognition of heart attack symptoms… …and the importance of rapid transport to an appropriate cardiac center by trained pre-hospital personnel

Signs of a Heart Attack Chest discomfort: sometimes comes and goes, may be mild, feels like pressure, squeezing or fullness pain Discomfort in arms, shoulder, back, neck, jaw or stomach Shortness of breath – with or without chest discomfort Cold sweat, nausea, lightheaded

Signs of a Heart Attack “Minutes matter! Fast action can save lives… Don’t wait more than 5 minutes to call 911.” www.heart.org/HEARTORG/General/Heart-Attack-Stroke-and-Cardiac-Arrest-Signs_UCM_303977_SubHomePage.jsp

Benefit from EMS transport? Acute myocardial infarction/ischemia Cardiac Dysrhythmias: both tachycardias and bradycardias Cardiac Arrest Acute Pulmonary Edema Cardiovascular conditions associated with hypotension

Equipment on ALS Vehicles May contain: Telemetry monitoring with rhythm strip or EKG transmission Intubation and ventilation equipment, including CPAP Oxygen tank, tubing and masks

Equipment on ALS Vehicles May contain: IV tubing and needles Cardiac monitor / defibrillator / pacemaker or AED Communication equipment

Medications on ALS Vehicles New York City paramedics carry: Cardiac arrest medicine: adrenaline Acute MI medicines: aspirin, nitroglycerin, morphine Dysrhythmia medicines: atropine, adenosine, diltiazem, amiodarone, magnesium Prehospital Advanced Life Support protocols July 2012 www.nycremsco.org/images/.../ALS_Protocols_July%202012_v07012012.pdf

Medications on ALS Vehicles New York City paramedics carry: Pulmonary edema medicines: nitroglycerin, furosemide Hypotensive treatments: normal saline, dopamine Prehospital Advanced Life Support protocols July 2012 www.nycremsco.org/images/.../ALS_Protocols_July%202012_v07012012.pdf

EMS Standing Protocols In the U.S., “standing protocols” are used by medics for basic conditions without the need to call a doctor New York City Heart Attack protocol allows paramedics to start an IV, give oxygen, aspirin and nitroglcerin to anyone with suspected MI

EMS Standing Protocols If the medical condition is not clear or there are questions, medics call “Medical Control” to consult

EMS Medical Control When a medic has a critical patient whose management is difficult, “Medical Control” is contacted. “Medical Control” is frequently a senior paramedic with an emergency doctor available as back up for advise

Telemetry Transmission Before medics cardiovert a patient with an unstable rhythm, they will call medical control. They electronically transmit either an EKG or rhythm strip for review by the emergency doctor

Scenario 2 50 year old man with a history of 2 episodes of syncope and a probable MI is being transfer from a rural town by ambulance. He suddenly develops severe shortness of breath, chest pain, confusion and becomes lethargic

Scenario 2 The medics are an hour away from the hospital The patient’s vital signs: BP=75/50 mmHg; heart rate = 240 beats per minute; respiratory rate = 32 per minute; pulse oximetry = 83% on 100% facemask

Scenario 2 The medics transmit this rhythm strip to you, the medical control doctor What do you recommend?

You tells the prehospital people to cardiovert the patient Scenario 2 The rhythm strip shows rapid regular rhythm and the patient is unstable You tells the prehospital people to cardiovert the patient He is unlikely to survive the long trip without this life-saving procedure

Scenario 2 New York City paramedics have a protocol for this They would cardiovert the patient after medical control confirmation

Why Prehospital for Cardiac? Faster transportation to appropriate cardiac center Able to monitor and treat patients with life-threatening dysrhythmias at the scene and during transport Able to manage critical patients with pulmonary edema, myocardial infarction and hypotension

Questions??