Performance of prehospital fibrinolysis
- Henderson McGinnis, MD
Henderson McGinnis, MD
- Associate Professor of Emergency Medicine
- Wake Forest University Health Sciences
- Section Editors
- James Hoekstra, MD
James Hoekstra, MD
- Section Editor — Adult Cardiology Emergencies
- Professor and Fredrick Glass Chair
- Wake Forest University
- Freek Verheugt, MD, FACC, FESC
Freek Verheugt, MD, FACC, FESC
- Section Editor — Coronary Heart Disease
- Onze Lieve Vrouwe Gasthuis, Netherlands
Fibrinolytics are an effective reperfusion therapy for many patients with ST elevation myocardial infarction (STEMI), but they must be administered within a tight time frame [1,2]. For each 30 minute delay to reperfusion, there is approximately a 10 percent relative increase in mortality in patients with STEMI.
Many factors may contribute to delays in therapy, including patient education and systems issues. Patients who present with STEMI in rural locations may live far from emergency departments or catheterization laboratory facilities. In these settings, prehospital fibrinolytic therapy, administered by paramedics or other prehospital personnel prior to arrival in the emergency department, may decrease the time to reperfusion [2-17].
This topic describes the training, treatment protocols, and quality assurance programs needed to ensure a safe and effective prehospital fibrinolysis program. Detailed information about the medications, including fibrinolytics, used to treat STEMI, data supporting the effectiveness of prehospital fibrinolysis, and general information about the diagnosis and management of acute coronary syndrome and STEMI are presented separately. (See "Fibrinolysis for acute ST elevation myocardial infarction: Initiation of therapy" and "Overview of the acute management of ST elevation myocardial infarction" and "Initial evaluation and management of suspected acute coronary syndrome (myocardial infarction, unstable angina) in the emergency department" and "Fibrinolysis for acute ST elevation myocardial infarction: Initiation of therapy", section on 'Prehospital fibrinolysis'.)
APPLICABILITY OF PREHOSPITAL FIBRINOLYSIS TO COMMUNITY EMS PRACTICE
Achieving myocardial reperfusion as rapidly as possible is the key to improving survival and decreasing morbidity in patients with acute myocardial infarction. There are several treatment options for these patients who are found to have ST segment elevation myocardial infarction (STEMI). Multiple studies have demonstrated the effectiveness of prehospital fibrinolysis in reducing the time to treatment for patients with STEMI and improving outcomes. These studies are described separately. (See "Fibrinolysis for acute ST elevation myocardial infarction: Initiation of therapy", section on 'Prehospital fibrinolysis'.)
The practicability of using general community emergency medical services (EMS) to perform fibrinolysis has been demonstrated in several studies [14,18-22]. The ER-TIMI 19 trial included 20 EMS systems in urban, semi-urban, and rural areas in the United States and Canada [18,23]. A straightforward training program permitted paramedical personnel working with a remote medical control physician to screen patients with suspected MI by history, physical examination, and electrocardiogram (ECG). Patients with an STEMI received fibrinolytic therapy within a median of 31 minutes after arrival of paramedical personnel in comparison to 63 minutes for in-hospital fibrinolysis in a control group.
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