Florida Today is reporting that Brevard County Fire-Rescue has received a substantial grant from the Florida Department of Health for ECG transmission.
Brevard County Fire-Rescue is implementing Bluetooth technology to transmit electrocardiogram readings from cardiac patients in the field to hospitals so doctors are better prepared to treat them.
In about three or four months, more than 93 units, including 40 fire-rescue ambulances, will be equipped with the new technology for rapid transmission of EKG readings. Melbourne and Palm Bay are among seven other fire departments that will benefit from the technology.
It will cost about $155,000 to equip ambulances for the new technology, and the entire cost is funded by a Florida Department of Health grant, including server and modem costs for the next five years. Hospitals will set up receiving centers to receive the EKG readings.
Heartwire is reporting a review of Olasveengen TM, Sunde K, Brunborg C, et al. Intravenous drug administration during out-of-hospital cardiac arrest: a randomized trial.JAMA 2009; 302:2222-2229.
Some highlights:
“[A] large randomized trial found that giving IV drugs like epinephrine and atropine in the setting of out-of-hospital cardiac arrest made it more likely that patients would be admitted to the hospital but little difference in whether they survived to discharge.
“That outcome was in spite of their undergoing resuscitation longer and receiving more defibrillations, and more often reattaining a spontaneous circulation, compared with another group that didn’t receive IV drugs during arrest.
“The trial is only the latest of several in recent years to reappraise the efficacy of major elements of conventional cardiopulmonary resuscitation.”
“The message for emergency providers is that, for now, the cornerstones of optimal cardiac resuscitation include high-quality cardiopulmonary resuscitation with minimal interruptions for anything, including any drug administration, and early defibrillation (emphasis added).”
“The quality of delivered cardiopulmonary resuscitation (including chest-compression rate, ventilation rate, and other factors), a prospectively defined secondary end point, was within guidelines and comparable in the two groups [...] So was the prevalence of therapeutic hypothermia as part of management, which exceeded 70%. (emphasis added).”
The South Carolina Hospital Association is reporting that according to the Hospital Compare website, South Carolina ranks #3 in the nation for the percentage of heart attack patients who receive PCI within 90 minutes of arrival.
This is an incredible achievement considering the relatively short period of time the SC Chapter of AHA Mission: Lifeline has been actively working toward making regionalized STEMI care a reality in South Carolina!
“A specific procedure helped save Tiralosi’s life. Special cooling pads, not available in all emergency rooms, lowered his body temperature to 91 degrees, essential in preventing long-term neurological damage and preserving brain function. Placed in a medically induced coma, incredibly, he began to wake up three days later — without brain damage.”
Here are some links to an excellent webcast from the D2B Alliance website. It’s the “D2B Sustain the Gain” October seminar entitled “How to Establish a Multi Hospital STEMI Transfer System”.
I found one part of the webcast to be particularly interesting. This is Dr. Greg Mishkel from the Prairie Heart Institute discussing the STEMI system in Central Illinois.
“Although the door-to-balloon times in Springfield have not achieved less than 90 minutes door-to-balloon time in the majority of patients because of the geography, we have effectively achieved a very high rate of less than 120 minutes door-to-balloon time for our transport program.”
“But as I say, the proof is in the pudding, and this is a nice example where you’re looking at pre-transfer and transfer outcomes and if you just look at the composite on the far right, you see that we have half the adverse event rates associated with the treatment of STEMI using this program. And if we look at composite event rates at the Springfield program, which is in the light blue, and the Southern Illinois program in the green, and the NRMI database in the red, you can see that we are well below the national average in terms of the adverse event rates.”
EMS is called to a tennis club to assess a 39 year old male who experienced a syncopal episode while playing tennis.
On arrival, the patient is lying down on the ground next to a bench. He appears lethargic and pale. Bystanders are laying ice cold towels around his head and chest and tell you they think he’s suffering from heat exhaustion.
Radial pulses are slow and barely palpable.
The patient is transferred to the gurney and the patient is relocated to the back of the ambulance.
The patient is oriented to person, place, and time. He does not remember fainting but understands that it occurred.
He admits to mild chest discomfort and nausea.
Past medical history is significant for Hodgkin’s Lymphoma.
Vital signs are assessed.
Resp: 16
Pulse: 30
BP: 74/46
SpO2: 100 on RA
The cardiac monitor is attached.
A 12-lead ECG is captured.
A rhythm change is noted on the monitor.
With the rhythm change the vital signs are reassessed.
EMS is called to the residence of a 82 year old female complaining of “flu-like” symptoms, including vomiting x 4-5 hours.
On arrival, the patient is found sitting on her bed alert and oriented to person, place, time, and event.
The patient’s skin is pale but warm and dry.
Past medical history: Breast CA, double mastectomy, HTN, hyperlipidemia
Meds: Unknown antihypertensives
The cardiac monitor is attached.
The patient is relocated to the ambulance.
Upon questioning the patient admits to chest discomfort and mild dyspnea.
Onset: 4-5 hours ago Provoke: Nothing makes the pain better or worse Quality: Described as “discomfort” and “rock-like” Radiate: The pain does not radiate Severity: Patient gives the pain a 8/10 Time: No previous similar episodes
A 12-lead ECG is captured.
An additional ECG is captured en route to the hospital.
The ACC/AHA focused update of guidelines for STEMI and PCI have been released. They offer new insight into which patients should be given thrombolytics prior to transfer for PCI. They also give a “shout out” to Mission: Lifeline!
Here are some highlights (with emphasis added in some key areas):
STEMI Patients Who Are Candidates for Reperfusion
The 2007 STEMI Focused Update describes several strategies for reperfusion, among them facilitated PCI and rescue PCI. These terms are no longer used for the recommendations in this update so that the contemporary therapeutic choices that lead to reperfusion as part of the treatment of patients presenting with STEMI can be described without these potentially misleading labels.
Very interesting indeed!
A detailed discussion about facilitated PCI and rescue PCI follows (including the ASSENT-4, FINESSE, REACT, CARESS, and TRANSFER-AMI trials). And then:
[A] pathway has been suggested for the care of STEMI patients that has been divided into those patients presenting to a PCI-capable facility and those presenting to a non–PCI-capable facility. Those seen at a PCI-capable facility should be moved expeditiously to the catheterization laboratory, with appropriate antithrombotic therapy for catheterization and PCI if appropriate. There has been discussion about whether the recommended door-to-balloon time (or first medical contact–to-balloon time) should be greater than 90 minutes, with the recognition that in certain patients, the mortality advantage of primary PCI compared with fibrinolytic therapy is maintained with more prolonged door-to-balloon times. However, the writing groups continue to believe that the focus should be on developing systems of care to increase the number of patients with timely access to primary PCI rather than extending the acceptable window for door-to-balloon time.
The update continues:
Those patients presenting to a non–PCI-capable facility should be triaged to fibrinolytic therapy or immediate transfer for PCI. This decision will depend on multiple clinical observations that allow judgment of the mortality risk of the STEMI, the risk of fibrinolytic therapy, the duration of the symptoms when first seen, and the time required for transport to a PCI-capable facility. If primary PCI is chosen, the patient will be transferred for PCI. If fibrinolytic therapy is chosen, the patient will receive the agent(s), and a judgment as to whether the patient is high risk or not will be made. If high risk, the patient should receive appropriate antithrombotic therapy and be moved immediately to a PCI-capable facility for diagnostic catheterization and consideration of PCI. If not high risk, the patient may be moved to a PCI-capable facility after receiving antithrombotic therapy or may be observed in the initial facility.
Patients best suited for transfer for PCI are those STEMI patients who present with high-risk features, those with high bleeding risk from fibrinolytic therapy, and patients presenting late, that is, more than 4 hours after onset of symptoms. The decision to transfer is a judgment made after consideration of the time required for transport and the capabilities of the receiving hospital. Patients best suited for fibrinolytic therapy are those who present early after symptom onset with low bleeding risk. After fibrinolytic therapy, if the patient is not at high risk, transfer to a PCI-capable facility may be considered, especially if symptoms persist and failure to reperfuse is suspected.
The duration of symptoms should continue to serve as a modulating factor in selecting a reperfusion strategy for STEMI patients. Although patients at high risk (e.g., those with congestive heart failure, shock, and contraindications to fibrinolytic therapy) are best served with timely PCI, “inordinate delays between the time from symptom onset and effective reperfusion with PCI may prove deleterious, especially among the majority of STEMI patients at relatively low risk”. Accordingly, each community and each facility in that community should have an agreed-upon plan for how STEMI patients are to be treated. This includes which hospitals should receive STEMI patients from emergency medical services units capable of obtaining diagnostic ECGs, management at the initial receiving hospital, and written criteria and agreements for expeditious transfer of patients from non–PCI-capable to PCI-capable facilities.
The development of regional systems of STEMI care is a matter of utmost importance.This includes encouraging the participation of key stakeholders in collaborative efforts to evaluate care using standardized performance and quality improvement measures, such as those endorsed by the ACC and the AHA for ACS. Standardized quality-of-care data registries designed to track and measure outcomes, complications, and adherence to evidence-based processes of care for ACS are also critical: programs such as the National Cardiovascular Data Registry ACTION Registry, the AHA’s “Get With The Guidelines” quality improvement program, and those performance-measurement systems required by the Joint Commission and the Centers for Medicare and Medicaid Services. More recently, the AHA has promoted its “Mission: Lifeline” initiative, which was developed to encourage closer cooperation and trust among prehospital emergency services, and cardiac care professionals. The evaluation of STEMI care delivery across traditional care-delivery boundaries with these tools and other resources is imperative to identify systems problems and to enable the application of modern quality improvement methods, such as Six Sigma, to make necessary improvements.
Let’s hear it for Mission: Lifeline!
*** Update 12/13/09 ***
You can download a slide set from the American Heart Association HERE (PDF).
Since the Veteran’s Day activities at Shelter Cove Community Park scheduled for today have been canceled due to inclement weather, I’d thought I’d repeat last year’s dedication to America’s veterans.
Happy Veteran’s Day!
11/11/08
To all the brave veterans of America’s wars, the Prehospital 12 Lead ECG blog says “Thank you for your service to our country!”
Today Engine 6, Medic 6, and Truck 6 had the honor of attending the Veteran’s Day Memorial service at Shelter Cove Community Park.
The keynote speaker was Medal of Honor recipient Major General James E. Livingston – Retired. To my knowledge, this is the first time I’ve seen a Medal of Honor recipient in real life. Like all Medal of Honor recipients, the citation for his medal is amazing (see link).
Remembering the sacrifice of America’s heroes gave me pause to consider the sacrifices that I haven’t made in the service of my country.
I remember the quote from the 2002 adaptation of The Four Feathers. “Dr. Johnson once said, ‘Every man feels meanly about himself for not having been a soldier.’ Well, that’s something no one here tonight need fear.”
I do feel meanly about myself for not having been a soldier. I often wish I would have joined the military right out of high school. I serve my community as a firefighter and a paramedic, and while the job can be dangerous, no one’s shooting at me (at least not yet).
In WWII, every man, woman, and child sacrificed. My father once told me a story that illustrates this point. The year was 1942 or 1943 and my father was in the 1st or 2nd grade at St. Gabriel Elementary School in Detroit, Michigan (near Dearborn). The school was run by the Dominican nuns of Adrian. During WWII, scrap metal drives were common, so in the front yard of the rectory, there was a pile of scrap metal. One day when the pile was big enough, a truck came by to pick it up. Before it was taken away, the nun who was the principal of the school (my dad thinks her name was Sister Alphonse) threw the school bell on top of the pile.
Are you listening, Steven Spielberg?
My father went on to mention ration cards. When I asked what they were, he explained they “allowed you to buy things that were hard to get.” You know. Things like butter.
The most I’ve sacrificed in the war on terror is longer lines at the airport and perhaps higher fuel prices.
There’s something wrong with that.
My dad went on to serve his country in the U.S. Army. Fortunately for him (and perhaps for me), the Korean War ended while he was in boot camp. He was stationed in Fort Richardson, Alaska.
My heartfelt gratitude goes to all who served, and all who still serve; especially those who were killed, those who were wounded, and those who were left behind.
Is there anything about this ECG (other than the poor data quality) that interests you?
The patient was a 90 year old male, fall with injury. Also complaining of pain between the shoulder blades.
*** UPDATE ***
This ECG caught my eye because it satisfies one of Sgarbossa’s criteria for the identification of AMI in the presence of LBBB. Specifically, the concordant ST-segment depression in lead V3 is a highly suspicious finding.
As a stand-alone finding, concordant ST-segment depression in a right precordial lead gives this ECG a score of 3 out of 10 (probability of AMI 66%).
I personally don’t think it’s necessary to score the ECG. As far as I’m concerned, an ECG that meets any of the criteria should be considered equivalent to an ECG showing acute STEMI, especially when you consider the depth of the S-wave in leads showing discordant ST-elevation (see previous posts on this issue).
So was this patient experiencing an acute STEMI? Here’s what I found out.
Patient (90 y.o.) arrived via EMS from XXXXXXXX after falling; there was no LOC, but did complain of back pain between the shoulder blades and diffuse abdominal pain. Extensive PMH: AAA, non-operable, HTN, CAD, CABG, LBBB, anemia, cardiomyopathy and dementia. The ED physician spoke to the daughter extensively who did not want her father worked up, but did consent to a thoracic x-ray and stated she only wanted him to receive pain medication and return transport to the XXXXXXXX and did not want any further diagnostics noting that his dementia worsens when he is out of his environment. He has a living will /advanced directive on file and with him a DNR order.
He was given pain medication in the ED, the thoracic film showed no acute injury and a prescription for Lortab was written and he was sent back to the nursing home. He did not have an EKG performed on this visit or any other diagnostics. The patient was here for an admission in 6/2009 and it appears that the EKGs are very similar.
Interesting!
When designing a STEMI program you have to make difficult choices when it comes to exclusion criteria like age, DNR status, and neurological status. Was this patient experiencing an acute thrombotic event in an epicardial coronary artery? I guess we’ll never know.
It’s possible this ECG finding was old and it’s possible it was secondary to aortic dissection or aneurysm.
Photo credit: flickr
Follow the Prehospital 12-Lead ECG blog