Fibrinolytics/Thrombolytics

[Ace844]

not all bleeds present the same way, even neuro docs don't cancel out bleeds without scanning the dome.

Yes we can usually have a good idea if it's ischemic or a bleed, but we can never r/o a bleed. There is always the possibility.

With that arguement one could also cite the multiple instances in the literature whereby even after having a 'negative' Head CT, the pt recieved thrombolyitics, and bled out anyway....

ACE

[FL_Medic]

With that arguement one could also cite the multiple instances in the literature whereby even after having a 'negative' Head CT, the pt recieved thrombolyitics, and bled out anyway....

ACE

yea, I'm just saying that we can't r/o head bleeds in the field... misdiagnosis is another thing.

[Ridryder 911]

A underlying current bleed (albeit it may be small) cannot always be caught in the field, even with a damn good physical and history. Even with such one should not be delaying care and transport for these individuals. Until, we can have a portable CT with confirmed readings from a Neuroradiologist .. heck NO! This is way to dangerous of a procedure. I have seen missed active bleeds from great Doc's with a great H & P as well as radiology clearing the CT, and them have an active bleed.... cancel Christmas. Now, most prefer intra arterial, in lieu of peripheral thrombolytics. Faster, more effective and less complications.

For the AMI, for rural areas greater than 60 minutes to a cath lab ... potentially yes, especially those with increasing ischemia and ECG changes continuously changing. Chances are they will not be able to CABG them for at least > 1 1/2 -2 hours... better open the vessels or these patients will die. Yes, it is a bummer for the chest team later, but it is better than the latter.

R/r 911

[AZCEP]

not all bleeds present the same way, even neuro docs don't cancel out bleeds without scanning the dome.

Yes we can usually have a good idea if it's ischemic or a bleed, but we can never r/o a bleed. There is always the possibility.

The risk is there, and should not be minimized. The benefit, however, is often greater than the associated risk. This is what makes the decision making necessary. No one, not even CT/MRI/PET scanned provided neuroradiologists, can definitely rule out the possibility of a hemorrhage based on the image given.

So if the physicians can't be 100% sure, and we can do a similar level of risk assessment, why couldn't we use the same tools to do the same job. Before the medication is used, the family has to consent to it as well. They base their decision on what information we provide them. If they decide yes, then why not have it available? If they decide no, why would we be willing to argue?

Use for Acute Coronary Syndromes can wait due to the longer treatment window. Use for CVA's, without intraarterial administration can't wait. It is these patients that it could make a huge difference in. The recommendations for use are very clear on when they could be used for CVA. If we can notify a receiving facility of a possible candidate, the next step is, in fact, our being able to use the medication to fix the problem.

[FL_Medic]

The risk is there, and should not be minimized. The benefit, however, is often greater than the associated risk. This is what makes the decision making necessary. No one, not even CT/MRI/PET scanned provided neuroradiologists, can definitely rule out the possibility of a hemorrhage based on the image given.

So if the physicians can't be 100% sure, and we can do a similar level of risk assessment, why couldn't we use the same tools to do the same job. Before the medication is used, the family has to consent to it as well. They base their decision on what information we provide them. If they decide yes, then why not have it available? If they decide no, why would we be willing to argue?

Use for Acute Coronary Syndromes can wait due to the longer treatment window. Use for CVA's, without intraarterial administration can't wait. It is these patients that it could make a huge difference in. The recommendations for use are very clear on when they could be used for CVA. If we can notify a receiving facility of a possible candidate, the next step is, in fact, our being able to use the medication to fix the problem.

I appreciate your response AZCEP, thanks.

[ukcanuck]

I find the debate as to whether to use pre hospital thrombolytics interesting.

It is considered standard of care even if you are less than 10 mins from the ER over here. The papers, which I don't have at hand but if you want them I will dig them out, showed that for every min delay in re establishing flow cost the patient 11 days of life. It also increased the incidence of LVF/CCF which has a worse life expectancy than cancer over here.

This was put into place after many studies and many high level conferences. It may have had something to do with the fact that in my area we serve probably the best part of 1.5 million and there are two cath labs about 1.5 to 2 hours apart. Neither are really set up for emergency admits for acute MI.

Using PHT means the patient gets care faster as getting the pt to the cath lab would be hard within rec time frames.

They are only just starting to use thrombolytics/fibrinolytics for CVAs at one hospital out of eight and that is the local neuro centre.

I would be very wary about using it pre hosp for CVA as it is best practice to completely r/o a bleed.

PHT is widely used throughout europe all with good results - so apart from the fact that you would be able to get the patient to a PCI suite faster than us why wouldn't you do it? It is solving the patients problem.

[FL_Medic]

I find the debate as to whether to use pre hospital thrombolytics interesting.

It is considered standard of care even if you are less than 10 mins from the ER over here. The papers, which I don't have at hand but if you want them I will dig them out, showed that for every min delay in re establishing flow cost the patient 11 days of life. It also increased the incidence of LVF/CCF which has a worse life expectancy than cancer over here.

This was put into place after many studies and many high level conferences. It may have had something to do with the fact that in my area we serve probably the best part of 1.5 million and there are two cath labs about 1.5 to 2 hours apart. Neither are really set up for emergency admits for acute MI.

Using PHT means the patient gets care faster as getting the pt to the cath lab would be hard within rec time frames.

They are only just starting to use thrombolytics/fibrinolytics for CVAs at one hospital out of eight and that is the local neuro centre.

I would be very wary about using it pre hosp for CVA as it is best practice to completely r/o a bleed.

PHT is widely used throughout europe all with good results - so apart from the fact that you would be able to get the patient to a PCI suite faster than us why wouldn't you do it? It is solving the patients problem.

What types of turnouts have you had with its use.

[ukcanuck]

Do you mean results, numbers of patients, or personel experience? I know that my service has done 50 this month and we limit to STEMI within a set guidelines. I have done several with only one adverse during which the pt died but the PM showed he would have died anyway due to the extent of MI and heart disease

[FL_Medic]

Do you mean results, numbers of patients, or personel experience? I know that my service has done 50 this month and we limit to STEMI within a set guidelines. I have done several with only one adverse during which the pt died but the PM showed he would have died anyway due to the extent of MI and heart disease

What was the cause of death though...

[Ace844]

What was the cause of death though...

DWPA: Dead With Paramedic Assistance.. :wink: :shock: 8) hahahahaha,..... just kidding