I hear that AHA is behind a blind study for field TPA adminstration in the field for stemi pt's whiile they are being tight lip about the results to be relased later this year what do you guys think about it. what are your predictions ? do you think this will be the next step in EMS stemi care ? feel free to give your thoughts , I know what i think but want to see what other medics think.

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Have I missed something....thrombolytics have been used in the field for stemi's by paramedics for a while. I've done 3. Evidence has moved to suggest that pci is the first line intervention. EMS role is about reducing the door to balloon time by minimising on scene times ect

Could be good for rural places with long E2B times, but probably worthless in places where you can hit a center with a 24-hr cath lab within 15 minutes' drive.

Are you sure they're using alteplase? It's hard to administer. Reteplase is easier (was used in ER-TIMI-19) but most EMS systems use tenecteplase (TNK) now due to ease of administration. There have been many studies of prehospital fibrinolysis so as Neil indicates this is nothing new. Prompt, expertly performed primary PCI has emerged as the preferred reperfusion strategy but most transfer and rural patients are not receiving PCI in a timely manner.

I would imagine that this study is PATCAR (http://clinicaltrials.gov/ct2/show/NCT00178620), which was done in Houston, as I believe it has been completed as the HFD protocols no longer contain the study protocol. They were giving 10U of retevase and transporting directly to a cath lab for STEMIs.  I know the preliminary results were promising, however it was not randomized or blinded.  Considering that it undertaken in an urban setting, I could see it potentially changing practices if there was a clear benefit in terms of survival and quality of life.  I suppose there have been another study of prehospital thrombolytics that was randomized and blinded, but I would guess that it would have been done in Europe, which would likely make it difficult to apply any positive findings to US EMS systems.

There appears to be a sort of pendulum swing in the minds of some people. An editorial favoring prehospital lysis has just appeared in Archives of Internal Medicine!

Rapid reperfusion can also be accomplished by using a prehospital thrombolytic strategy with ambulance transmission of electrocardiograms to physicians and administration of lytic agents in the ambulance or on immediate arrival at the emergency department.10 Prehospital thrombolytics have been used successfully, mostly outside of the United States.11 Importantly, recent data have shown the gap is narrowing between benefit of a pPCI and thrombolytic therapy strategy....  Putting these findings together, the studies summarized herein and those in this issue make a powerful argument that the reperfusion strategy that will save the most lives is thrombolytic therapy (in the ambulance) for patients who cannot be immediately and directly taken to a hospital with pPCI capability. Similarly, patients who present to a hospital without pPCI capability should receive thrombolytics. ... Besides being markedly faster, thrombolytics have other advantages over transfer. ...  In addition, the transfers themselves, particularly by an ambulance, are expensive and there are increasing reports of air ambulance crashes with loss of lives of patients and transport personnel.

Keep in mind that this is an internal med doc writing this, and they tend to be pretty conservative about treatment strategy. I love this topic - I used the Wilkes EMS experience with paramedic fibrinolysis as the subject for my initial research review at my blog.

I wonder what were the percentages. It seems promising except for the bleeding concerns. I hope to hear results soon... I am excited about this study... Thanks so much for the information....


Scott RB said:

I would imagine that this study is PATCAR (http://clinicaltrials.gov/ct2/show/NCT00178620), which was done in Houston, as I believe it has been completed as the HFD protocols no longer contain the study protocol. They were giving 10U of retevase and transporting directly to a cath lab for STEMIs.  I know the preliminary results were promising, however it was not randomized or blinded.  Considering that it undertaken in an urban setting, I could see it potentially changing practices if there was a clear benefit in terms of survival and quality of life.  I suppose there have been another study of prehospital thrombolytics that was randomized and blinded, but I would guess that it would have been done in Europe, which would likely make it difficult to apply any positive findings to US EMS systems.

Obviously, there are many systems that do not use TPA for ACS. IF your system allows TPA or Heparin/NTG IV administration in the Pre-hospital setting; please provide links to your protocols and any associated data. As the original poster is inquiring; I am inquiring also... In NYC, we give ASA and nitro them SL: they took out MSO4...

http://nycremsco.org/images/articlesserver/ALS_Protocols_August_201...

Pages 13-14

http://nycremsco.org/images/articlesserver/General_Operating_Proced...

Page 8

Thanks..



Neil White said:

Have I missed something....thrombolytics have been used in the field for stemi's by paramedics for a while. I've done 3. Evidence has moved to suggest that pci is the first line intervention. EMS role is about reducing the door to balloon time by minimising on scene times ect

When they published their preliminary findings, there wasn't any significant difference in bleeding, if I recall.  You should be able to find the abstract on pubmed.

Alexander Woo said:

I wonder what were the percentages. It seems promising except for the bleeding concerns. I hope to hear results soon... I am excited about this study... Thanks so much for the information....


Scott RB said:

I would imagine that this study is PATCAR (http://clinicaltrials.gov/ct2/show/NCT00178620), which was done in Houston, as I believe it has been completed as the HFD protocols no longer contain the study protocol. They were giving 10U of retevase and transporting directly to a cath lab for STEMIs.  I know the preliminary results were promising, however it was not randomized or blinded.  Considering that it undertaken in an urban setting, I could see it potentially changing practices if there was a clear benefit in terms of survival and quality of life.  I suppose there have been another study of prehospital thrombolytics that was randomized and blinded, but I would guess that it would have been done in Europe, which would likely make it difficult to apply any positive findings to US EMS systems.

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