In message <001b01bfed26$0deae020$12458cd4@default>, Jeremy Mayhew
<[log in to unmask]> writes
1)999 call to ambulance arrival 8 minutes.
>Chest pain, good history, usual packing, into ambulance 10 minutes max.
>Cannula en-route, arrive at A&E having pre-warned them say after further
10
>minutes. Door to needle time .....20 minutes in efficient units. Say
caller
>had chest pain for 30 minutes playing with GTN spray first.
>
>Pain to needle time at very best 80 minutes or so....
>
>2)999 call to ambulance arrival 8 minutes.
>Chest pain, good history, usual packing, ecg and into ambulance 10-12
>minutes maximum - radio/ telephone ahead with diagnosis of acute MI so
strep
>is in A&E ready to be drawn up. A&E check exclusion criteria, confirm
>suspected diagnosis and setup strep inside 10 minutes of arrival
>
>Pain to needle time improved to say 60- 70 minutes....
>
>3)as above but time on scene delayed for pre-hospital thrombolysis, 10
>minutes to pack into ambulance, 1-2 minutes ecg, 1-2 minutes cannula, 5
>minutes setting up strep and excluding contra-indications and running with
>strep started
>
>Improves to about 45-50 minutes.
Have no problem with scenario 2: this happens in real life round our
way. I still have some doubts about the speed of doing a reliable
12-lead in someone's home, or in the back of the bus. If there is kit
availbale in ambos that really can do a reliabel ECG in 2 minutes, then
fine. Better still, the crew let us know if they've got a CLINICALLY
suspicious MI in the back (they are very good at this and doen't slow
down their transport time at all), so we have everything ready as
described in 2 above, but WE do the 120-lead (our gadgets take seconds).
In transit, crew start treatment with aspirin, GTN, oxygen, line.
Scenario 3 runs the risk of hypotension and reperfusion arrhythmias in
the back of the ambo en route. Crews CAN cope with this, but may have
to stop to stabilize / defib / tube etc. Is this a justified risk if
gain is ~10 minutes to needle? These sort of side-effects are common
enough that we have a policy that anyone started on lysis in A&E stays
in A&E until finished, rather than be transported 100 yards to CCU with
strep running. Maybe over-cautious, but I would be worried about the
potential problems occuring if lysing en route. If long way to A&E, then
scenario 3 justified.
>Was there not some recent concerns muted about accuracy of pre-hosp ecg's
>magically returning to normal? Are the machines reliable?
Check the archives. Helpful Hewlett-Packard staff explained problem to
do with frequency response. In a nutshell: Ambulance monitors
traditionally set to best frequency response to look at rhythm
disturbance, which can give spurious ST elevation. Hospital 12-lead
machines set up to different frequency response which gives reliable ST
changes. I'm sure this is an easily-solved problem to do with set-up of
the kit on ambos. May already have been addressed (Mike Bjorky please
advise).
Dr G Ray
Staff Grade
A&E
Sussex
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