Pre-Hospital ALS and protocol developement

[director1387]

:?: Is anyone in EMS land using Glycoprotein inhibitors such as ReoPro or Integrilin. I have searched the internet looking for a protocol to no avail. I would appreciate some feed back or if you have a protocol you would like to share. We currently have a very basic C/P protocol but would like to be more aggressive, we have 2 cath labs available within 20 minutes and currently do not have to ask permission to transport there, studies suggest that concommittent use of unfractionated Heparin and ASA with an inhibitor lessons mortality by about 7-9%. Any opinions out there?

[OVeractiveBrain]

Not a prehospital intervention. The risk of cranking up their INRO is too great prehospitally, ESPECIALLY when you have cath labs some close. TO be honest, if youre following a standard chest pain algorithm (i.e. ASA, NTGx3, Morphine x2, BetaBlocker x2) each with about 3-5 minutes between intervention to reasses, youre already looking at a 24-40 minute protocol length. Not to mention that you have to gain access, get a 12 lead and prep for admission to the er or cath lab.

As far as ACS goes, I think paramedics have sufficient treatment options and diagnostic tools to keep them busy. Whenever I post against adding a protocol to paramedic repitoire, I always state that we cannot cater to the best medics, but must succumb to the average or below. Jumping to more advanced treatments without first considering more benign ones is one risk, inappropriately administering a risky drug is another,and finally, stressing a protocol load will just make some medics confused. Thusly, I am strongly against the use of any "blood thinners" initiated prehospitally.

When active in a critical care transport from a satellite hospital to one with catherization available, simply taking orders from the M.D. dispatching would suffice. Since they have often already received their bolus, the maintenance drip is usually specified by the MD within certain parameters. You dont have to be a CCT medic to transfer these patients in my services in connecticut. I just always make sure to ask for orders for adjustment, pain management or additional intervention from the doctor. Even if they are standing order for new onset acute chest pain when we get them, I would rather pass the buck to the MD dispatching, since he/she has already initiated a more advanced procedure than is in our own protocols.

[Ridryder 911]

I agree, not knowing the baseline of INR, as well as creatinine, etc. on some medications can be risky, as well as the costs involved. Remember, most EMS will only receive one payment structure for ACLS II payment, etc..

If one is looking for a lower risks of clot inhibitor, after ASA, I would suggest Loveknox route, some EMS are administering SQ and IV route. One needs to really investigate in depth before making such changes, especially the receiving hospitals with cath labs. Many prefer not to cath with certain pre-meds...

R/r 911

[flight-lp]

About two years ago, a service I was with utilized Aggrastat pre-hospital. While I could see the benefit, unfortunately it wasn't cost effective, wasn't truly understood or appreciated by many medics, and received frowns by several cardiologists who preferred ReoPro or Integrilin. Currently we use O2, NTG, ASA, Morphine / Fentanyl, Lovenox, and Heparin. Seems to work well and is cath lab compatible............

[director1387]

I appreciate the in-put. I posted this question after meeting with my medical director and he suggested we look at developing a protocol for an inhibitor. Doing research on ReoPro and Integrilin suggest that it has been given in several studies pre-hospital but there is not a lot of info out there on what the parameters are for administration. We currently do not give beta blockers and it sounds as if this might be the logical next step for our small service. Thanks again.

[rgpemt]

Maine EMS has INtegrelin listed as a Paramedic Interfacility Transfer med. We however do not have it strictly pre-hospital in our protocols. We are some would say behind the times in regards to our Protocols. Hope its a help...The New Guy