CEU Review Form Advanced Clinical Insights & Practice: Acute Coronary Syndrome (PDF) Valid until September 5, 2008
Advanced Clinical Insights & Practice is an ongoing series designed to provide continuing education to an ever-expanding realm of paramedicine that needs more of it: the critical care transport paramedic. Second, and equally important, are the benefits that can be reaped by other certification levels reading this feature. For EMT-Basics and Intermediates, it will provide a great enhancement to your core knowledge, although most of the interventions discussed will be beyond your traditional scope. For paramedics, it will augment both your pathophysiological understanding and clinical assessment/management skills of diseases and injuries discussed. Ultimately, it is hoped that anyone who reads these articles will become a better clinician. The next article will appear in the October issue.
This article provides the critical care paramedic with a review of the ongoing management of a patient with an acute coronary syndrome (ACS). In the March issue, we focused on the management and critical care transport of an unstable ACS patient from a small outlying community hospital back to the cath lab. In this article, we focus on the same patient as she progresses through the catheterization lab with complications. It is important to remember that, due to the instability of the precipitating condition, not all patients have a successful outcome with catheterization, and the critical care transport crew may be summoned again for transport.
CASE STUDY, PART I
It's around 0930 hours, and you and your partner have arrived at your program's sister hospital where you are to transfer a "stable cardiac patient" back to the main campus for ongoing definitive treatment after she received emergent cardiac catheterization. Upon arrival, you find the patient still in cath lab #3 and immediately detect distress in everyone present. From your vantage point behind the lead wall and viewing glass, you can see the patient lying supine on the table, where the cardiologist is frantically working with catheters in her groin, another care provider is assisting the patient's ventilations with a bag-valve mask, and two nurses are regulating IV drips and administering medications. Your RN partner turns to you and says, "I thought this was supposed to be a routine transport." "Me too," you whisper back quietly, as you watch the situation unfolding before your eyes. In the following article, we will return to this case study to provide additional information as it pertains to the discussion.
ACTIVATING THE CATH LAB
In many of today's EMS systems, advancements have been made that allow EMS providers to identify patients at risk for acute coronary syndromes or an AMI event through a thorough history and physical examination, and by obtaining and transmitting a 12-lead ECG to the hospital. This information allows the emergency department physician or a cardiologist to activate the cardiac catheterization team. With this ability, some EMS systems have developed a protocol to allow prehospital providers to bypass the ED and proceed directly to definitive treatment in the cath lab. In fact, there is ongoing research into a combination of therapies, where prehospital providers administer low-dose fibrinolytics to STEMI patients and then deliver them to the cath laboratory.
It is important to note that treatment rendered by the prehospital and ED providers is not ineffective. It's just that many interventions done in the emergency setting (both prehospital and ED) are geared to minimize or halt the active infarction and deal with other cardiovascular complications, but they do not provide true repair to the damaged blood vessel. It's with this mind-set the critical care provider must remember the old saying that "time is muscle."