It’s true that sometimes critical care transport missions to transport STEMI patients to PCI are fairly uneventful. But if we allow ourselves to get lulled into a “Milk Run” mindset, it will most definitely come back to bite us. The jovial, normotensive, fairly comfortable-appearing STEMI patient may be only a couple of minutes away from V Fib arrest or florid cardiogenic shock. When that occurs, if we have expected and prepared for such a complication, it’s likely that we’ll be able to manage it successfully.
About 6 years ago, we at UC Health Air Care & Mobile Care recognized that despite the use of our helicopter, our interhospital transfer STEMI patients were often not achieving the door (at the referring hospital) to balloon times that we wanted. In a very detailed fashion, we broke down every interval of an interhospital STEMI transfer and brainstormed ways in which we could safely minimize those intervals. This led to the creation of our Code STEMI protocol, which went live in May 2011. That same year, Wang et al published their landmark DIDO paper (DIDO = Door In to Door Out time) showing that STEMI patients requiring interhospital transfer for PCI die less often the quicker they leave the referring ED. The ACMC Code STEMI protocol is perfectly designed to minimize DIDO.
There are essentially three components of Code STEMI. First, the referring hospital can request activation of ACMC (for air or ground response) prior to securing an accepting hospital, bed, and interventional cardiologist (which can be time-intensive), allowing these processes to simultaneously occur in parallel as opposed to in series. This is enabled by the always-available default autoacceptance of any STEMI patient at UCMC’s cardiac cath lab by UC cardiology, in the event that the primary referral plan falls through. Secondly, ACMC no longer continues heparin, GP2B3A inhibitor, or nitroglycerin IV drips during transport for STEMI patients. Switching these drips over from referring hospital pumps to our transport pumps was time-intensive and unnecessary, as they’d just be discontinued upon cath lab arrival anyway. Thirdly, we encourage (but never mandate) STEMI hot (rotors turning) loads and offloads, when the flight crew feels that it’s safe to do so. Code STEMI has allowed ACMC to shave 15 minutes off our patients’ DIDO times, which is data that we’re in the process of publishing now. That’s a lot cardiac myocytes.
Take a listen to our recap podcast of our most recent "Flights" case with Bill Hinckley and Andrew Latimer sharing their thoughts on the management of this patient and similar patients…
WHAT ARE YOUR THOUGHTS AT THE BEGINNING OF THIS PATIENT ENCOUNTER AND WHAT ARE YOUR FIRST ACTIONS AT THE BEDSIDE OF THIS PATIENT? WHAT CAN YOU DO TO HELP MORE RAPIDLY FACILITATE THE MOVEMENT OF THE PATIENT TO YOUR COT AND INTO THE AIRCRAFT? 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?
The initial assessment of these patient’s should focus on a time-efficient history and physical, data collection, and transfer to the helicopter. As pointed out by many, the initial steps at the bedside involve having the nurse focus on the IV drips (if any of these are to be continued), while you gather the critical aspects of the history and physical and place the patient on the monitor and apply the defib pads. In this hypotensive patient with an inferior STEMI, stopping the nitro gtt, dopamine gtt, and starting a bolus of IVF is a good next step. Not pointed out by many, there are some crucial times to gather as you are initially sorting through the patient’s presentation. You’ll want to document time of arrival to the ED and the time of initial diagnostic EKG.
JUST AFTER TAKEOFF, THE PATIENT TURNS TO YOUR PARTNER AND SAYS “I DON’T FEEL SO WELL…” AND PROMPTLY GOES INTO A VENTRICULAR FIBRILLATION ARREST. WHAT ARE YOUR PRIORITIES FOR THE MANAGEMENT OF THE PATIENT? WHAT INTERVENTIONS DO YOU NEED TO PERFORM AND WHO PERFORMS THEM? AND, HOW DOES THIS DIFFER INSIDE THE BACK OF THE HELICOPTER WHEN COMPARED WITH A CODE IN THE ED?
This is where things get tricky - the in-flight code. Running a code in-flight is exceptionally challenging, take a look at this post to see first hand just how difficult it can be. As Dr. Sabedra points out, early defibrillation is key as the patient has a shockable rhythm (thus the importance of having defib pads already applied to the patient). She also points out that the 2 top priorities of the management of this code should be on shocks and high quality CPR. Airway management should focus on minimal effort interventions. Early defib may result in early ROSC and obviate the need for any airway intervention. If you do need to intervene, an iGel or other such extraglottic device is a quick way to ensure delivery of effective ventilation and oxygenation. What about epi though? Drugs are certainly nice to have but take a back seat in the management of these patients. If you have the time to help pull up and administer drugs while the nurse delivers compressions, great. If not, focus on the things that matter the most, electricity, CPR, and appropriate oxygenation/ventilation.
THE PATIENT IS STILL IN CARDIAC ARREST AS YOU ARE LANDING AT THE RECEIVING CATH-CAPABLE HOSPITAL HELIPAD AND YOU AND YOUR PARTNER ARE STILL VALIANTLY TRYING TO RESUSCITATE THE PATIENT. WHAT ARE YOUR NEXT STEPS? IS THERE ANYONE THAT YOU WOULD CONSIDER CALLING? DO YOUR DESTINATION PLANS CHANGE AT ALL?
There are 2 critical aspects to this question as pointed out by Dr. Shaw. First, the Air Crew is going to be a bit fatigued after running this code. Having additional staff on hand to help with continued CPR is going to be huge. Second, this patient’s cardiac arrest is ultimately secondary to ischemia and blockage of a coronary artery. Coordinating with the receiving hospital and the cardiac cath lab is also going to be important. Some facilities will divert you to the ED where you can run the code further (and in this case it may be that you consider pushing lytics if all other options are exhausted). Some centers may be comfortable with taking the arresting patient to the cath lab, though this is still relatively uncommon.
NOW, INSTEAD OF MAKING IT TO THE AIRCRAFT, THE PATIENT ARRESTS AS YOU ARE MOVING HIM ONTO YOUR COT WHILE STILL AT THE REFERRING HOSPITAL. YOU PERFORM GOOD QUALITY CPR AND ACLS AT THE OUTSIDE HOSPITAL FOR ~10 MINUTES, BUT THE PATIENT IS STILL IN CARDIAC ARREST. WHAT OTHER INTERVENTIONS COULD YOU CONSIDER? WOULD YOU CONSIDER STILL TRANSPORTING THE PATIENT IN THIS STATE?
As pointed out by Dr. Merriam, loading the patient in the helicopter while they are coding is not a good idea. If you are still in the ED of the referring facility, running the code further while you are there is going to be best for the patient and for the crew. For the refractory V fib or Vtac patient there are a number of ‘hail mary’ options available: double sequential defibrillation, pushing thrombolytics, and esmolol are all considerations in this scenario.
Wang TY, Nallamothu BK, Krumholz HM, Li S, Roe MT, Jollis JG, Jacobs AK, Holmes DR, Peterson ED, Ting HH. Association of door-in to door-out time with reperfusion delays and outcomes among patients transferred for primary percutaneous coronary intervention. JAMA. 2011 Jun 22;305(24):2540-7.
Written and Edited by William Hinckley, MD and Jeffery Hill, MD MEd