Thanks to everybody who chimed in on our last "Flight"! We had a great discussion on the management of the STEMI transfer patient. These aren't just "milk runs" as pointed out by Dr. Hinckley. The highlights of the discussion are below with additional commentary on the case by Dr. Bill Hinckley and Air Care Resident Assistant Medical Director Dr. Matt Chinn. Out final flight will be lifting off June 1 and it's a doozy - looking forward to the discussion!
Q1 - What can you do to help facilitate the movement of the patient from the outside hospital to the cot (what responsibilities are yours and what are the nurses, do you have assigned roles)? What times are you responsible for knowing and documenting in Golden Hour?
Several responded to this question, speaking to the need for excellent communication between flight nurse and flight doc/NP. Flight Nurse Rick Jamie chimed in first laying out clearly how he approaches this part of the transfer of care.
“The FN will start transferring any drips we may NEED to take otherwise, taking down and securing IV access will occur. At the same time, or just after getting report from the sending Physician (if present) the FMD will start placing the patient on the monitor. Once secured on monitor, movement to cot will occur.”
He also notes the importance of both crew members assisting with moving the cot. In tight corners, down ramps, and in a rush, some cots can become top heavy, making them prone to tip. Thus, it’s extremely important to have control of the cot at all times. In the words of John Wooden “Be quick, but don’t hurry.”
Ryan Ziegler and flight doc Rob Thompson also responded with similar thoughts to Rick Jamie, stating that they would perform a quick exam and then get to work transferring the patient to the monitors and placed on the pads.
Q2 - As you move the patient to the cot he has a ventricular fibrillation arrest. What are your priorities for management of the patient? What if he arrests in the helicopter, what interventions do you need to perform and who performs them?
As pointed out by Rick Jamie this is indeed an all too common occurrence. Ryan Ziegler points out one of the best courses of action initially (if the rest occurs immediately) is to slide the patient back onto the ED stretcher and run the code using all of the resources of the ED staff. Being prepared for this eventuality is perhaps one of the most significant learning points of the discussion and the case. Rightly, Rick Jamie notes that putting pads on the patient prior to transferring them to the new stretcher is, and should be, standard operating procedure.
If (and when) a patient codes in the back of the helicopter (or MICU truck), things get a whole lot more complicated. Take a look at this post and video from last spring (http://www.tamingthesru.com/blog/acmc/running-a-code-in-tight-quarters) for an idea of just how chaotic it is. The greatest challenges you will face in that environment are effective CPR and a lack of hands to accomplish all the needed tasks. You need to perform CPR with minimal interruptions, provide adequate ventilations at a rate of 10/min, shock if defib is needed, and administer meds.
You have 2 people and 4 hands to do all that, and, you’re traveling at 150 mph.
As Ryan Ziegler points out, one of the first thing you will need to do is let the pilot know that you are going to be out of your seat belts because of the change in the patient’s condition. From there, you need to prioritize your actions and clearly communicate with your crew-mate. Airway can be managed by BVM ventilation as pointed out by Rick Jamie. But, it is extremely challenging to perform single-operator BVM ventliation with excellent technique. A better approach outlined by several would be to place an EGD or to attempt to intubate the patient either with DL or VL. EGD has the significant advantage of being fast and simple to place. Placing the patient on the vent also seems to be an option, but (as pointed out by Michael Perlmutter) you will need to make sure that the ventilator will continue to operate with the high intra-thoracic pressures encountered in CPR. From there, trading off in CPR duties as able, helping draw up meds, and defibrillating the patient when indicated are the actions of most import.
Q3 - You have performed good quality ACLS at the outside hospital. The patient is still in cardiac arrest. What other resources do you have at the hospital to try to save this patients life beyond ACLS?
As pointed out by many, the administration of thrombolytics is an option in this patient. The use of thrombolytics during cardiac arrest is somewhat controversial. Studies where thrombolytic medications were administered in undifferentiated cardiac arrest have not shown any improvement in mortality. There is some thought, however, that when the cause of the arrest is known and when that cause is treatable with thrombolytic medications, it may be reasonable and potentially beneficial to give a thrombolytic medication. In the case of the patient arresting from a pulmonary embolism, alteplase is the medication of choice (administered in a bolus of 50-100 mg with CPR continued for at least 15 min post administration). See this post on Academic Life in EM for more info (http://www.aliem.com/whats-the-code-dose-of-tpa/). In the case of STEMI, tenecteplase is also an option and has theoretic benefit over alteplase in that it has greater specificity for fibrin binding sites and may also impair platelet aggregation. These benefits have not been accompanied by improvements in mortality in studies of patient with AMI.
Q4 - What do you do if you have ROSC but the patient’s blood pressure is 60/30 and the referring facility wants you to leave immediately?
As might be expected, most everybody was reticent to leave the hospital until the patient was more stabilized. Most everybody was wanting to reach for a pressor +/- an inotrope in this patient. Getting those meds on board prior to departure would certainly give you a bit more comfort for the flight. Flight doc Christian Renne rightly brought up that a push dose pressor could be used to bridge the patient to the pressor gtt. Levophed seems to be the pressor that most would reach to first. As for the inotrope, Zaf Qasim had some excellent points on the use of Milrinone vs Dobutamine.
“A quick comment if I may about milrinone use - the phosphodiesterase inhibitors have been useful in the chronic heart failure population as well as in some post-op cardiac surgery patients. However, its use in the setting of cardiogenic shock is more tricky not only because it acts as a direct vasodilator, but also importantly because it can precipitate tachydysrhythmias. Dobutamine has less of a tendency to do the latter, so in this setting would be a much better choice if you need an inotrope in conjunction with the norepinephrine for its peripheral vasoconstrictor effect.”
Perrot, J., Henneberry, R., & Zed, P. (2010) Thrombolytics for cardiac arrest: case report and systematic review of controlled trials. Annals of Pharmacotherapy. Dec;44(12):2007-13. doi: 10.1345/aph.1P364. Epub 2010 Nov 30.
Hayes, B. What's the Code Dose of tPA. Academic Life in EM. pub. 3/14/13.
Melandri, G., Vagnarelli, F., Calabrese, D., Semprini, F., Nanni, S., & Branzi, A. (2009). Review of tenecteplase (TNKase) in the treatment of acute myocardial infarction. Vascular Health and Risk Management, 5, 249–256.
Dundar, Y., Hill, R., Dickson, R., & Walley, T. (2003) Comparative efficacy of thrombolytics in acute myocardial infarction: a systematic review. QJ Med. 96(2):103-13. PMID: 12589008. http://dx.doi.org/10.1093/qjmed/hcg016