STEMI Destinations; Airway Types and CPR; Child Maltreatment

Transport of STEMI Patients Directly to PCI Centers
     Le May MR, Davies RF, Dionne R, et al. Comparison of early mortality of paramedic-diagnosed ST-segment elevation myocardial infarction with immediate transport to a designated primary percutaneous coronary intervention center to that of similar patients transported to the nearest hospital. Am J Cardiol 98(10):1,329-33, Nov. 15, 2006.

     Abstract: Speed of reperfusion is critical in ST-segment elevation myocardial infarction (STEMI). [Authors] assessed the safety and feasibility of an integrated metropolitan approach in which advanced-care paramedics interpret the prehospital electrocardiogram and independently refer patients with STEMI to a designated center for primary percutaneous coronary intervention (PCI). [Authors] developed and implemented a protocol in which paramedics trained in electrocardiographic interpretation bypassed the nearest emergency room and referred patients with suspected STEMI directly to a designated primary PCI center (paramedic-referred primary PCI). Outcomes of these patients were compared with those of a retrospective cohort of 225 consecutive patients with STEMI transported by ambulance to the nearest hospital emergency department. [Authors] treated 108 consecutive patients with STEMI using ambulance services according to the paramedic-referred primary PCI protocol. Primary PCI was performed in 93.5%, versus 8.9% in the control group, and the median door-to-balloon time was 63 minutes, versus 125 in the control group (p

     Comment: It is well established that primary PCI (balloon angioplasty) to open the blocked coronary artery is the preferred treatment for STEMI, and that shortening the time interval between onset of pain (blockage of the artery) and inflating the balloon (reopening the artery) helps preserve heart muscle and improve patient outcomes. One effective way to shorten times to PCI is for EMS to identify patients with STEMIs by performing 12-lead ECGs and then transporting them directly to PCI-capable hospitals. This avoids the often-long delays in identifying the STEMI in the emergency department and arranging for a transfer to a PCI hospital. These researchers found that this resulted in a substantial decrease in time to PCI (over an hour) and reduction in mortality. This is further evidence that a regional approach using PCI-capable hospitals as STEMI receiving centers provides good care to heart attack patients. EMS systems should look at taking the lead in developing them in their communities.

Airway Types and Other CPR Tasks
     Abo BN, Hostler D, Wang HE. Does the type of out-of-hospital airway interfere with other cardiopulmonary resuscitation tasks? Resuscitation, Nov. 23, 2006 [Epub ahead of print].

     Abstract: Out-of-hospital rescuers often perform tracheal intubation (TI) prior to other cardiopulmonary resuscitation (CPR) interventions. TI is a complex and error-prone procedure that may interfere with other key resuscitation tasks. [Authors] compared the effects of TI versus esophageal tracheal Combitube (ETC) insertion on the accomplishment of other interventions during simulated cardiopulmonary resuscitation. Methods-In this prospective trial using a human simulator, two-paramedic teams simulated resuscitation of a ventricular fibrillation cardiopulmonary arrest using standard Advanced Cardiac Life Support guidelines. In each of two trials, teams used either TI or ETC as the primary airway device. Following delivery of three rescue shocks, [authors] measured time intervals to successful airway placement, intravenous (IV) line insertion, drug administration, delivery of fourth rescue shock and completion of all four tasks. [Authors] also measured the total time without chest compressions. [They] compared task completion times using non-parametric statistics (Wilcoxon signed-ranks test) with a Bonferroni-adjusted p-value of 0.008. Results-Twenty teams each completed two scenarios. Participants required a median of 172.5 seconds (IQR: 146.5-225.5) to accomplish all four tasks. Elapsed time to airway placement was significantly less for ETC than TI (median difference 26.5 seconds [IQR 13-44.5], p = 0.002). Time without chest compressions was less for ETC than TI (median difference 8.5 seconds [IQR 2.5-23.5], p = 0.005). There were no differences between ETC and TI in times to IV placement (median difference 23.5 seconds [IQR (-20)-61], p = 0.11), drug delivery (39.5 seconds [IQR (-18)-63], p = 0.07), delivery of fourth rescue shock (39.5 seconds [IQR (-21.5)-87.5], p = 0.07) or completion of all four tasks (33 seconds [IQR (-11)-74.5], p = 0.08).