- Email: [email protected]
Thrombolysis and aeromedical evacuation
Clinical CaUseStudy
Thrombolysis and Aeromedical Evacuation by Randy Hunt, R.N., NREMT-P
Central Air and hospital personnel wheel a cardiac patient the short distance from the helipad to the hospital.
It is a S e p t e m b e r evening in rural w e s t e r n Arkansas. At 2130 h o u r s a thirty seven year-old male walks into the e m e r g e n c y d e p a r t m e n t of the small rural c o m m u n i t y hospital complaining of chest pain radiating to his left shoulder. He is nauseated, diaphoretic and complaining of s h o r t n e s s of breath. An e m e r g e n c y r o o m physician makes the diagnosis of an acute myocardial infarction. Because of the patient's age, condition a n d the absence of a history of p r e v i o u s cardiac problems, this physician contacts the St. John Medical Center, Cardiovascular Institute o n the possibility of p e r f o r m i n g thrombolysis. Problem: The hospital in Arkansas is one h u n d r e d and t w e n t y miles from Tulsa a n d transport by g r o u n d a m b u l a n c e is at least a three h o u r trip. The effectiveness of the thrornbolysis p r o c e d u r e is greatest w h e n i m p l e m e n t e d within three h o u r s of the onset of chest pain. Solution: Alert the aeromedical critical care team at St. John's flight operations center o p e r a t e d b y Central Air Ambulance, n i c k - n a m e d "Central S e v e n " b y the staff and flight crew. Since the time factor is highly critical, the decision is m a d e to use the D a u p h i n turbine p o w e r e d helicopter 8 HOSPITALAVlATION, MAY 1985
b a s e d at St. John's heliport in Tulsa. Transferring the patient from the hospital to Tulsa via the D a u p h i n helicopter can be accomplished in less t h a n one h o u r a n d fifteen minutes. Five minutes after notifying the Central Air dispatcher, the red a n d white D a u p h i n helicopter is lifting off the helipad with a pilot-medic, a critical care registered n u r s e - p a r a m e d i c and a p a r a m e d i c - c o m m u n i c a t i o n s specialist o n board. Patient information is transmitted via special c o m m u n i c a t i o n e q u i p m e n t to insure patient confidentiality a n d to alert the flight crew to the patient's current status. Prior to the arrival of the Central S e v e n flight crew, the attending physician i m p l e m e n t s the following treatment: (1) O x y g e n per nasal cannula, (2) IV D5W in the left arm at a KVO rate, (3) Nitroglycerin, sublingual, (4) M o r p h i n e sulfate IV if no relief with Nitroglycerin and (5) base line data including an ECG, cardiac e n z y m e s and other routine lab work. Within thirty minutes of the call, Central Seven arrives in the small rural c o m m u n i t y . A review of the clinical data and a complete pre-flight assessment is carried out b y the n u r s e
to establish a data base. The patient records are packaged, and the patient is placed on the helicopter's portable monitoring e q u i p m e n t and o x y g e n system. Ten minutes later, the patient along with his wife, is on b o a r d the helicopter e n r o u t e to St. John Medical Center, Cardiovascular Institute. In flight the registered n u r s e - p a r a m e d i c and the p a r a m e d i c i m p l e m e n t the following protocol to prepare the patient for the p e n d i n g procedure.
1. Administration of o x y g e n per mask at eight liters per minute to increase their F102. 2. I m p l e m e n t a t i o n of a second IV with D5W at a KVO rate. 3. The administration of prophylactic lidocaine, a one m g per kilogram bolus followed by a c o n t i n u o u s infusion of two to four rags per minute. 4. The drawing of blood for bleeding studies, repeat cardiac e n z y m e s and SMA6 and other tests for admission. 5. C o n t i n u o u s cardiac monitoring. 6. Vital signs every ten minutes. 7. Insertion of a foley catheter to gravity drainage. 8. M o r p h i n e sulfate IV in two m g
Clinical Case increments not to exceed ten rngs. 9. Shave and prep both femoral areas. 10. Place the patient in a position of comfort. One h o u r and ten minutes after the onset of his chest pain, the patient arrives at St. John Medical Center. He is taken directly to the emergency department where the cardiac cath team along with the emergency department staff meet the patient. The data base is reviewed. A second ECG, repeat cardiac enzymes, bleeding times, routine admission lab and chest x-ray are ordered. An history, complete cardiovascular assessment, and a consent for the emergency thrombolysis procedure is obtained. This data confirms the initial diagnosis, the patient is experiencing an acute myocardial infarction and is a candidate for the thrornbolysis procedure. The implementation of intracoronary thrombolysis requires that the patient fit the following criteria: (1) The patient must reach St. John Medical Center within three hours of the onset of chest pain. (2) The pain is not relieved by nitroglycerin. (3) ECG changes reflecting myocardial ischernia are present, elevation of the S-T segments of three millimeters or more, T-wave inversion, and reciprocal changes in leads opposite the site of infarction. Q-waves should be absent or less thaw one third the height of the QRS complex. (4) There are no contraindications to~ anticagulation therapy. The patient meets these criteria. It has been two and one half hours since the onset of chest pain. His pain is only relieved by morphine sulfate, and his ECG reveals elevated S-T segments in the lateral leads with reciprocal changes in the inferior leads. Q-waves are not significant. The decision is made to proceed with the thrombolysis procedure. The patient is moved from the emergency department to the cardiac catheterization laboratory, draped and a femoral puncture site is selected. Time is saved because the possible puncture sites were previously p r ep p ed in flight by the flight nurse. The skin and subcutaneous site over the femoral artery is infiltrated with Lidocaine, a percutaneous puncture is performed 10 HOSPITAL AVIATION, MAY 1985
Study
...
using a large bore needle, and a coronary artery catheter is inserted, using the Se|dinger technique. Under direct fluoroscopy a Judkins Amplatz or Sones catheter is inserted into the femoral artery and passed upw ard into the aorta. At the same time the patient is heparinized with a bolus of 5000 units of heparin followed by an intravenous infusion of heparin in DSW. The catheter is passed into the region of the Sinus of Valsalva and positioned at the opening (ostiurn) of the affected artery. An arteriogram is performed to confirm the presence of a clot and its size, and to determine if lysis is feasible, t h e arteries are examined for evidence and the degree of plaque formation. A thrombus is located and it is determined that the clot should respond to the lysis procedure. The catheter is advanced into the affected artery to a point two to three millimeters above the thrombus. A bolus of 25,000 units of Streptokinase is infused via the coronary catheter, followed by a continuous infusion of 2000 to 5000 units per minute. While t h e procedure continues cautiously and slowly, the patient's vital signs and ECG are constantly monitored by the cath team for any changes in the S-T segments, Q-wave development, or the occurence of ventricular dysrhythmias. After thirty minutes the clot begins to lyse and reperfusion of the distal artery and myocardium begins. This is confirmed by the intermittent infusion of a contrast medium and recurrent arteriograms. The infusion of the Streptokinase is continued for approximately one and one half hours to ensure complete clot lysis and arterial patency. It is during this period that the development of reprefusion PVC's and ventricular dysrhythrnias often occur due to the reprefusion of the irritable myocardium. In some cases, a patient having minimal arterial disease may also undergo angioplasty, a procedure in which a balloon catheter is inserted into the affected artery to the level of the plaque and the balloon is inflated to crush and smooth the plaque. The objective of the thrombolysis procedure is to decrease the size of the infarction produced by the clot and subsequent tissue ischemia. Thus what might have been an extensive infarction with massive myocardial
damage is reduced to a small infarction with minimal myocardial damage. Within thirty minutes of the onset of chest pain, some p e r m a n e n t damage occurs in the affected myocardial cells. Studies have sh o w n that without the procedure fifteen to twenty percent of the patients with the diagnosis of acute myocardial infarction died, whereas with the procedure the mortality rate was less than five percent. The incidence of cardiogenc shock is reduced with the procedure by limiting the area of myocardial death, thus decreasing the chance of left ventricular failure. For the patient with extensive multiple vessel disease, the thrornbolysis procedure may keep vessels open until coronary bypass surgery can be performed. Eighty percent of all procedures are successful and that success is attributed to two factors; the patient receiving care within three hours of the onset of pain, and the alert and assertive reactions of physicians in the rural area. Formation of the clot is not complete for eight to ten hours, however, one must remember that irrepairable damage to the cardiac cells begins within thirty minutes of the formation of a thrombus. Getting to the patient within the first three hours limits the size of the infarction, and decreases the incidence of the complications associated with acute myocardial infarction. Six hours after the onset of his pain, the patient is resting in the coronary intensive care unit at St. John Medical Center, the thrombolysis procedure having been successful. The patient tolerated the procedure without complication. Subsequent arteriograms revealed the artery to be patent and perfusioning, with no evidence of new thrombus formation and only single artery involvement. Prior to the advent of this procedure and rapid aeromedical transport, the patient would have suffered extensive myocardial damage, and would have been at high risk for incurring complications associated with the loss of an extensive area of the left ventricle (congestive failure, ventricular aneurysms and lethal dysrhythmias.) Key to the success of this procedure is getting the client into an equipped medical center before extensive myocardial necrosis occurs. This requires coordination between the transferring physician, receiving
Clinical Case Study... cardiologist and the aeromedical transport team (when the patient is located in remote areas). The aeromedical team can save precious minutes if they are familiar with the thrombolysis procedure and are trained to implement protocols that aid in preparing the patient for the procedure. The aeromedical transport team must be certified in Advanced Cardiac Life Support, must know the protocols for the management of dysrrythmias and must be prepared to implement these procedures in the event of dysrrythmias or cardiac arrest. In the event the patient has already received streptokinase, the flight team must be aware of the following complications: 1) Ventricular dysrhythmias, 2) Bleeding from puncture sites or GI tract, and 3) Junctional or brady dysrhythmias. Thus the flight team must understand these complications and be prepared to implement the appropriate protocol. The Flight Team may decrease the likelihood of ventricular dysrhythmias by administering lidocaine, 50 to 100 mg. bolus followed by a 2-4 mg/min, drip. In the event the dysrhythmia is refractory to lidocaine, medications such as procainamide or bretylium should be on hand. With juntional or brady dysrhythmias that become symptomatic, Atropine is the drug of choice. However, if the rhythm is refractory to atropine, isopeternol must be in the drug kit. Bleeding from puncture sites may be controlled by direct pressure. GI bleeding may require the insetion of an NG tube and ice saline lav~ge during transport. Severe bleeding may require plattlets or whole blood. The flight team should alert the receiving facility of any current or pending complications. The success of a thrombolysis depends on many variables. However, the care given during transport cannot be overly emphasized. Precious minutes may be saved by a flight team capable of completing procedures while airborne. Key elements of inflight care such as: maintaining adequare oxygenation, relief of pain, minimizing the anxiety and stress associated with an acute myocardial infarction, and delivering the patient within the allotted time ready for the catheterization laboratory, are critical
elements 0fsuccess. In the case discussed in this article, the patient arrived within the critical time period, the procedure successful, and the loss of an extensive amount of myocardium prevented. The patient's arteriograms revealed only single vessel disease, thus the need for coronary bypass surgery was ruled out. With appropriate follow-up, diet, exercise and medication he, like many others, may continue to lead a normal and relatively unrestricted and productive life. Without rapid aeromedical transport and highly trained transport personnel, the victim of an AMI may not reach a medical center in time to receive the benefit of the thrombolysis procedure. However with helicopters equipped with the latest in advanced cardiac life support equipment and staffed by R. N. s and paramedics well versed in ACLs and the thrombolysis procedure, the victim of the AMI may reach the facility with time to spare, ready to go into the cath lab after only a short admission period. Aeromedical transport with skilled personnel is that vital link needed in getting a critical AMI from a rural area into a major medical center if a large portion of the myocardium is to be saved. References: (1) Caroline, N.L., Emergency Care In The Streets; Third edition. (2) The American Heart Association "Text: Advanced Cardiac Life Support. (3) Dubins, Dale, Rapid Interpretation of EKG's. (4) Dr. Loft Basta, MD, Cardiologist, St. John Medical Center; an interview. (5) Luckmann and Sorensen, Medical-Surgical Nursing; Second edition. (6) Sister Julie Mantermach, RN, MSN; Assistant Vice President, St. John Medical Center, Cardiovascular Institute; an interview. (7) Drury, Doug, NREMT-A, Chief Pilot, Central Air Ambulance; An interview. (8) Photography by Theresa Thompson, Medical photographer St. John Medical Center. (9) Kloner, Robert A., Ellis, E.G., Ruediger L. and Braunwald, E.:
Studies of Experimental Coronary Artery Reperfusion. Effects on infarct size, myocardial function, biochemistry, ultrastructure and microvascular damage. Circulation, Part II: pg I-8, 1983. (10) Marder, V.J.; Pharmacology of Thrombolytic agents. Implication for therapy of coronary artery thrombosis. Circulation, Part II; pg 1-2; 1983. (11) Jennings, R. B. and Reimer, K.A., Factor involved in salvaging ischemic myocardium: Effect of Reperfusion of Arterial Blood. Circulation, Part II: pg 1-25: 1983. Randy Hunt RN, EMT-P has been employed by Central Air Ambulance since 1967. He began his career as a base EMT, and completed paramedic training in 1973. Completing his requirements for ADN in 1976, and BSN in 1984, Mr. Hunt is currently certified as an ACLS instructor, BLS inst/trainer and state EMT and EMT-P instructor. He has been chief flight nurse for Central for the past five years. Appreciation is given to the following individuals for their interviews and for sharing their experiences with the author in regards to the Thrombolysis procedure: 1) Drs. Neal, Raines, Zoller MDS, St. John Medical Center 2) Diana Ritter, RN, Cardiovascular Institute, St. John Medical Center. 3) Dr. Deleon MD; Cardiovascular Institute, St. John Medical Center.
COMMENT
Anderson et al (a Randomized Trial of Intrac0ronary Streptokinase in the Treatment of Acute Myocardial Infarction, NEJM, Vol 308, pages 1312-1318, June 1983) and Khaka et. al. (Intracoronary Fibrinolytic Therapy in Acute Myocardial Infarction: Report of a Prospective Randomized Trial, NEJM, Vol 308, pages 1305-1311, June 1983) point to the importance of early thrombolytic therapy. Alexander Jablonowski, M.D. (Helicopter Transport of Patients with Acute Myocardial Infarction for Intracoronary Streptokinase Thrombolysis and Percutaneous Transluminal Coronary Angioplasty. Abstract presented at the Third Annual Ashbeams/NFNA Conference, Jacksonville, Florida, December 1982) was one of the first to suggest the use of helicopters in providing rapid transport of patients suitable for this mode of treatment. This article reemphasizes these benefits. HOSPITAL AVIATION, MAY 1985 11
Thrombolysis and Aeromedical Evacuation by Randy Hunt, R.N., NREMT-P
Central Air and hospital personnel wheel a cardiac patient the short distance from the helipad to the hospital.
It is a S e p t e m b e r evening in rural w e s t e r n Arkansas. At 2130 h o u r s a thirty seven year-old male walks into the e m e r g e n c y d e p a r t m e n t of the small rural c o m m u n i t y hospital complaining of chest pain radiating to his left shoulder. He is nauseated, diaphoretic and complaining of s h o r t n e s s of breath. An e m e r g e n c y r o o m physician makes the diagnosis of an acute myocardial infarction. Because of the patient's age, condition a n d the absence of a history of p r e v i o u s cardiac problems, this physician contacts the St. John Medical Center, Cardiovascular Institute o n the possibility of p e r f o r m i n g thrombolysis. Problem: The hospital in Arkansas is one h u n d r e d and t w e n t y miles from Tulsa a n d transport by g r o u n d a m b u l a n c e is at least a three h o u r trip. The effectiveness of the thrornbolysis p r o c e d u r e is greatest w h e n i m p l e m e n t e d within three h o u r s of the onset of chest pain. Solution: Alert the aeromedical critical care team at St. John's flight operations center o p e r a t e d b y Central Air Ambulance, n i c k - n a m e d "Central S e v e n " b y the staff and flight crew. Since the time factor is highly critical, the decision is m a d e to use the D a u p h i n turbine p o w e r e d helicopter 8 HOSPITALAVlATION, MAY 1985
b a s e d at St. John's heliport in Tulsa. Transferring the patient from the hospital to Tulsa via the D a u p h i n helicopter can be accomplished in less t h a n one h o u r a n d fifteen minutes. Five minutes after notifying the Central Air dispatcher, the red a n d white D a u p h i n helicopter is lifting off the helipad with a pilot-medic, a critical care registered n u r s e - p a r a m e d i c and a p a r a m e d i c - c o m m u n i c a t i o n s specialist o n board. Patient information is transmitted via special c o m m u n i c a t i o n e q u i p m e n t to insure patient confidentiality a n d to alert the flight crew to the patient's current status. Prior to the arrival of the Central S e v e n flight crew, the attending physician i m p l e m e n t s the following treatment: (1) O x y g e n per nasal cannula, (2) IV D5W in the left arm at a KVO rate, (3) Nitroglycerin, sublingual, (4) M o r p h i n e sulfate IV if no relief with Nitroglycerin and (5) base line data including an ECG, cardiac e n z y m e s and other routine lab work. Within thirty minutes of the call, Central Seven arrives in the small rural c o m m u n i t y . A review of the clinical data and a complete pre-flight assessment is carried out b y the n u r s e
to establish a data base. The patient records are packaged, and the patient is placed on the helicopter's portable monitoring e q u i p m e n t and o x y g e n system. Ten minutes later, the patient along with his wife, is on b o a r d the helicopter e n r o u t e to St. John Medical Center, Cardiovascular Institute. In flight the registered n u r s e - p a r a m e d i c and the p a r a m e d i c i m p l e m e n t the following protocol to prepare the patient for the p e n d i n g procedure.
1. Administration of o x y g e n per mask at eight liters per minute to increase their F102. 2. I m p l e m e n t a t i o n of a second IV with D5W at a KVO rate. 3. The administration of prophylactic lidocaine, a one m g per kilogram bolus followed by a c o n t i n u o u s infusion of two to four rags per minute. 4. The drawing of blood for bleeding studies, repeat cardiac e n z y m e s and SMA6 and other tests for admission. 5. C o n t i n u o u s cardiac monitoring. 6. Vital signs every ten minutes. 7. Insertion of a foley catheter to gravity drainage. 8. M o r p h i n e sulfate IV in two m g
Clinical Case increments not to exceed ten rngs. 9. Shave and prep both femoral areas. 10. Place the patient in a position of comfort. One h o u r and ten minutes after the onset of his chest pain, the patient arrives at St. John Medical Center. He is taken directly to the emergency department where the cardiac cath team along with the emergency department staff meet the patient. The data base is reviewed. A second ECG, repeat cardiac enzymes, bleeding times, routine admission lab and chest x-ray are ordered. An history, complete cardiovascular assessment, and a consent for the emergency thrombolysis procedure is obtained. This data confirms the initial diagnosis, the patient is experiencing an acute myocardial infarction and is a candidate for the thrornbolysis procedure. The implementation of intracoronary thrombolysis requires that the patient fit the following criteria: (1) The patient must reach St. John Medical Center within three hours of the onset of chest pain. (2) The pain is not relieved by nitroglycerin. (3) ECG changes reflecting myocardial ischernia are present, elevation of the S-T segments of three millimeters or more, T-wave inversion, and reciprocal changes in leads opposite the site of infarction. Q-waves should be absent or less thaw one third the height of the QRS complex. (4) There are no contraindications to~ anticagulation therapy. The patient meets these criteria. It has been two and one half hours since the onset of chest pain. His pain is only relieved by morphine sulfate, and his ECG reveals elevated S-T segments in the lateral leads with reciprocal changes in the inferior leads. Q-waves are not significant. The decision is made to proceed with the thrombolysis procedure. The patient is moved from the emergency department to the cardiac catheterization laboratory, draped and a femoral puncture site is selected. Time is saved because the possible puncture sites were previously p r ep p ed in flight by the flight nurse. The skin and subcutaneous site over the femoral artery is infiltrated with Lidocaine, a percutaneous puncture is performed 10 HOSPITAL AVIATION, MAY 1985
Study
...
using a large bore needle, and a coronary artery catheter is inserted, using the Se|dinger technique. Under direct fluoroscopy a Judkins Amplatz or Sones catheter is inserted into the femoral artery and passed upw ard into the aorta. At the same time the patient is heparinized with a bolus of 5000 units of heparin followed by an intravenous infusion of heparin in DSW. The catheter is passed into the region of the Sinus of Valsalva and positioned at the opening (ostiurn) of the affected artery. An arteriogram is performed to confirm the presence of a clot and its size, and to determine if lysis is feasible, t h e arteries are examined for evidence and the degree of plaque formation. A thrombus is located and it is determined that the clot should respond to the lysis procedure. The catheter is advanced into the affected artery to a point two to three millimeters above the thrombus. A bolus of 25,000 units of Streptokinase is infused via the coronary catheter, followed by a continuous infusion of 2000 to 5000 units per minute. While t h e procedure continues cautiously and slowly, the patient's vital signs and ECG are constantly monitored by the cath team for any changes in the S-T segments, Q-wave development, or the occurence of ventricular dysrhythmias. After thirty minutes the clot begins to lyse and reperfusion of the distal artery and myocardium begins. This is confirmed by the intermittent infusion of a contrast medium and recurrent arteriograms. The infusion of the Streptokinase is continued for approximately one and one half hours to ensure complete clot lysis and arterial patency. It is during this period that the development of reprefusion PVC's and ventricular dysrhythrnias often occur due to the reprefusion of the irritable myocardium. In some cases, a patient having minimal arterial disease may also undergo angioplasty, a procedure in which a balloon catheter is inserted into the affected artery to the level of the plaque and the balloon is inflated to crush and smooth the plaque. The objective of the thrombolysis procedure is to decrease the size of the infarction produced by the clot and subsequent tissue ischemia. Thus what might have been an extensive infarction with massive myocardial
damage is reduced to a small infarction with minimal myocardial damage. Within thirty minutes of the onset of chest pain, some p e r m a n e n t damage occurs in the affected myocardial cells. Studies have sh o w n that without the procedure fifteen to twenty percent of the patients with the diagnosis of acute myocardial infarction died, whereas with the procedure the mortality rate was less than five percent. The incidence of cardiogenc shock is reduced with the procedure by limiting the area of myocardial death, thus decreasing the chance of left ventricular failure. For the patient with extensive multiple vessel disease, the thrornbolysis procedure may keep vessels open until coronary bypass surgery can be performed. Eighty percent of all procedures are successful and that success is attributed to two factors; the patient receiving care within three hours of the onset of pain, and the alert and assertive reactions of physicians in the rural area. Formation of the clot is not complete for eight to ten hours, however, one must remember that irrepairable damage to the cardiac cells begins within thirty minutes of the formation of a thrombus. Getting to the patient within the first three hours limits the size of the infarction, and decreases the incidence of the complications associated with acute myocardial infarction. Six hours after the onset of his pain, the patient is resting in the coronary intensive care unit at St. John Medical Center, the thrombolysis procedure having been successful. The patient tolerated the procedure without complication. Subsequent arteriograms revealed the artery to be patent and perfusioning, with no evidence of new thrombus formation and only single artery involvement. Prior to the advent of this procedure and rapid aeromedical transport, the patient would have suffered extensive myocardial damage, and would have been at high risk for incurring complications associated with the loss of an extensive area of the left ventricle (congestive failure, ventricular aneurysms and lethal dysrhythmias.) Key to the success of this procedure is getting the client into an equipped medical center before extensive myocardial necrosis occurs. This requires coordination between the transferring physician, receiving
Clinical Case Study... cardiologist and the aeromedical transport team (when the patient is located in remote areas). The aeromedical team can save precious minutes if they are familiar with the thrombolysis procedure and are trained to implement protocols that aid in preparing the patient for the procedure. The aeromedical transport team must be certified in Advanced Cardiac Life Support, must know the protocols for the management of dysrrythmias and must be prepared to implement these procedures in the event of dysrrythmias or cardiac arrest. In the event the patient has already received streptokinase, the flight team must be aware of the following complications: 1) Ventricular dysrhythmias, 2) Bleeding from puncture sites or GI tract, and 3) Junctional or brady dysrhythmias. Thus the flight team must understand these complications and be prepared to implement the appropriate protocol. The Flight Team may decrease the likelihood of ventricular dysrhythmias by administering lidocaine, 50 to 100 mg. bolus followed by a 2-4 mg/min, drip. In the event the dysrhythmia is refractory to lidocaine, medications such as procainamide or bretylium should be on hand. With juntional or brady dysrhythmias that become symptomatic, Atropine is the drug of choice. However, if the rhythm is refractory to atropine, isopeternol must be in the drug kit. Bleeding from puncture sites may be controlled by direct pressure. GI bleeding may require the insetion of an NG tube and ice saline lav~ge during transport. Severe bleeding may require plattlets or whole blood. The flight team should alert the receiving facility of any current or pending complications. The success of a thrombolysis depends on many variables. However, the care given during transport cannot be overly emphasized. Precious minutes may be saved by a flight team capable of completing procedures while airborne. Key elements of inflight care such as: maintaining adequare oxygenation, relief of pain, minimizing the anxiety and stress associated with an acute myocardial infarction, and delivering the patient within the allotted time ready for the catheterization laboratory, are critical
elements 0fsuccess. In the case discussed in this article, the patient arrived within the critical time period, the procedure successful, and the loss of an extensive amount of myocardium prevented. The patient's arteriograms revealed only single vessel disease, thus the need for coronary bypass surgery was ruled out. With appropriate follow-up, diet, exercise and medication he, like many others, may continue to lead a normal and relatively unrestricted and productive life. Without rapid aeromedical transport and highly trained transport personnel, the victim of an AMI may not reach a medical center in time to receive the benefit of the thrombolysis procedure. However with helicopters equipped with the latest in advanced cardiac life support equipment and staffed by R. N. s and paramedics well versed in ACLs and the thrombolysis procedure, the victim of the AMI may reach the facility with time to spare, ready to go into the cath lab after only a short admission period. Aeromedical transport with skilled personnel is that vital link needed in getting a critical AMI from a rural area into a major medical center if a large portion of the myocardium is to be saved. References: (1) Caroline, N.L., Emergency Care In The Streets; Third edition. (2) The American Heart Association "Text: Advanced Cardiac Life Support. (3) Dubins, Dale, Rapid Interpretation of EKG's. (4) Dr. Loft Basta, MD, Cardiologist, St. John Medical Center; an interview. (5) Luckmann and Sorensen, Medical-Surgical Nursing; Second edition. (6) Sister Julie Mantermach, RN, MSN; Assistant Vice President, St. John Medical Center, Cardiovascular Institute; an interview. (7) Drury, Doug, NREMT-A, Chief Pilot, Central Air Ambulance; An interview. (8) Photography by Theresa Thompson, Medical photographer St. John Medical Center. (9) Kloner, Robert A., Ellis, E.G., Ruediger L. and Braunwald, E.:
Studies of Experimental Coronary Artery Reperfusion. Effects on infarct size, myocardial function, biochemistry, ultrastructure and microvascular damage. Circulation, Part II: pg I-8, 1983. (10) Marder, V.J.; Pharmacology of Thrombolytic agents. Implication for therapy of coronary artery thrombosis. Circulation, Part II; pg 1-2; 1983. (11) Jennings, R. B. and Reimer, K.A., Factor involved in salvaging ischemic myocardium: Effect of Reperfusion of Arterial Blood. Circulation, Part II: pg 1-25: 1983. Randy Hunt RN, EMT-P has been employed by Central Air Ambulance since 1967. He began his career as a base EMT, and completed paramedic training in 1973. Completing his requirements for ADN in 1976, and BSN in 1984, Mr. Hunt is currently certified as an ACLS instructor, BLS inst/trainer and state EMT and EMT-P instructor. He has been chief flight nurse for Central for the past five years. Appreciation is given to the following individuals for their interviews and for sharing their experiences with the author in regards to the Thrombolysis procedure: 1) Drs. Neal, Raines, Zoller MDS, St. John Medical Center 2) Diana Ritter, RN, Cardiovascular Institute, St. John Medical Center. 3) Dr. Deleon MD; Cardiovascular Institute, St. John Medical Center.
COMMENT
Anderson et al (a Randomized Trial of Intrac0ronary Streptokinase in the Treatment of Acute Myocardial Infarction, NEJM, Vol 308, pages 1312-1318, June 1983) and Khaka et. al. (Intracoronary Fibrinolytic Therapy in Acute Myocardial Infarction: Report of a Prospective Randomized Trial, NEJM, Vol 308, pages 1305-1311, June 1983) point to the importance of early thrombolytic therapy. Alexander Jablonowski, M.D. (Helicopter Transport of Patients with Acute Myocardial Infarction for Intracoronary Streptokinase Thrombolysis and Percutaneous Transluminal Coronary Angioplasty. Abstract presented at the Third Annual Ashbeams/NFNA Conference, Jacksonville, Florida, December 1982) was one of the first to suggest the use of helicopters in providing rapid transport of patients suitable for this mode of treatment. This article reemphasizes these benefits. HOSPITAL AVIATION, MAY 1985 11