Part 8: Stabilization of the Patient With Acute Coronary Syndromes Iv-9 if needed, early CPR(see Part 4: Adult Basic Life Support") therapy. We recommend that out-of-hospital paramedics and early access to an automated external defibrillator(AEd acquire and transmit either diagnostic-quality ECGs or their through community AED programs(see Part 5:"Electrical interpretation of them to the receiving hospital with advance Therapies").28 EMS and dispatch system personnel should be notification of the arrival of a patient with ACS( Class IIa). If trained to respond to cardiovascular emergencies. EMS providers identify STEMI on the ECG, it is reasonable Dispatchers and EMs providers must be trained to recog- for them to begin to complete a fibrinolytic checklist(Figure nize symptoms of ACS. Dispatchers should advise patients with no history of aspirin allergy or signs of active or recent strointestinal bleeding to chew an aspirin(160 to 325 mg) Out-of-Hospital Fibrinolysis hile awaiting the arrival of EMS providers(Class Ila). 29 Clinical trials have shown the benefit of initiating fibrinolysis EMS providers should be trained to determine the time of as soon as possible after onset of ischemic-type chest pain in onset of symptoms and to stabilize, triage, and transport the patients with STEMI or new or presumably new left bundle patient to an appropriate facility and to provide prearrival branch block(LBBB). 67. 71 Several prospective studies(LOE notification. EMS providers should monitor vital signs and 1)72-74 have documented reduced time to administration of cardiac rhythm and be prepared to provide CPr and defibril- fibrinolytics and decreased mortality rates when out-of lation if needed hospital fibrinolytics were administered to patients with EMS providers may administer oxygen to all patients STEMI and no contraindications to fibrinoly the patient is hypoxemic, providers should titrate therapy Physicians in the Grampian Region Early Anistreplase based on monitoring of oxyhemoglobin saturation(Class Trial(GREAT)73 administered fibrinolytic therapy to patients ).30-44 If the patient has not taken aspirin and has no history at home 130 minutes earlier than to patients at the hospital of aspirin allergy and no evidence of recent gastrointestinal bleeding, EMs providers should give the patient nonenteric and noted a 50% reduction in hospital mortality rates and greater l-year and 5-year survival rates in those treated aspirin(160 to 325 mg) to chew( Class I). 45-48 earlier 75,76 Delaying fibrinolytic treatment by I hour in- EMS providers should administer up to 3 nitroglycerin creased the hazard ratio of death by 20%o, which is equivalent tablets(or spray) for ongoing symptoms at intervals of 3 to 5 to the loss of 43 lives per 1000 patients over 5 years minutes if permitted by medical control and if the patient A meta-analys of out-of-hospital fibrinolytic trials found remains hemodynamically stable(systolic blood pressure a relative improvement of 17% in outcome associated with [!>90 mm Hg or no more than 30 mm Hg below out-of-hospital fibrinolytic therapy, particularly when therapy baseline], heart rate between 50 and 100 beats per minute was initiated 60 to 90 minutes earlier than in the hospital. 71A [bpm)).4950 EMS providers can administer morphine for chest pain unresponsive to nitroglycerin if authorized by protocol documented decreased all-cause hospital mortality rates hospital stabilization and care is included in the following among patients treated with out-of-hospital fibrinolysis com- pared with in-hospital fibrinolysis(odds ratio [OR]: 0.83 95% confidence interval [CI]: 0.70 to 0.98)with a number Out-of-Hospital ECGs needed to treat of 62 to save I extra life with out-of-hospital Out-of-hospital 12-lead ECGs and advance notification to the ibrinolysis. Results were similar regardless of the trainin receiving facility speed the diagnosis, shorten the time to fibrinolysis, and may be associated with decreased mortality The ECC Guidelines 200077 recommended consideration rates.51-64 The reduction in door-to-reperfusion therapy in- of out-of-hospital fibrinolysis for patients with a transport terval in most studies ranges from 10 to 60 minutes. EMS time >l hour. But in a recent Swiss study (LOE 1), 74 providers can efficiently acquire and transmit diagnostic prehospital administration of fibrinolytics significantly de- quality ECGs to the ED53-58. 65. 6 with a minimal increase(0.2 creased the time to drug administration even in an urban to 5.6 minutes)in the on-scene time interval. 52-56, 65-68 setting with relatively short transport intervals (<15 Qualified and specially trained paramedics and prehospital minutes) nurses can accurately identify typical ST-segment elevation In summary, out-of-hospital administration of fibrinolytics (I mm in 2 or more contiguous leads) in the 12-lead ECG to patients with STEMI with no contraindications is safe with specificity ranging from 91% to 100% and sensitivity feasible, and reasonable( Class lla). This intervention may be ranging from 71% to 97% when compared with emergency performed by trained paramedics, nurses, and physicians fo medicine physicians or cardiologists. 69. 0 Using radio or cell patients with symptom duration of 30 minutes to 6 hours phone, they can also provide advance notification to the System requirements include protocols with fibrinolytic eceiving hospital of the arrival of a patient with ACS.56,61-64 checklists, ECG acquisition and interpretation, experience in We recommend implementation of out-of-hospital 12-lead ACLS, the ability to communicate with the receiving institu- ECG diagnostic programs in urban and suburban EMS tion, and a medical director with training/experience in systems( Class I). Routine use of 12-lead out-of-hospital ECG management of STEMI. A process of continuous quality and advance notification is recommended for patients with improvement is required. Given the operational challenge signs and symptoms of ACS(Class Ila). A 12-lead out-of- required to provide out-of-hospital fibrinolytics, most EMS hospital ECG with advance notification to the ED may be systems should focus on early diagnosis with 12-lead ECG beneficial for STEMI patients by reducing time to reperfusion rapid transport, and advance notification of the ED(verbalif needed, early CPR (see Part 4: “Adult Basic Life Support”) and early access to an automated external defibrillator (AED) through community AED programs (see Part 5: “Electrical Therapies”).28 EMS and dispatch system personnel should be trained to respond to cardiovascular emergencies. Dispatchers and EMS providers must be trained to recog￾nize symptoms of ACS. Dispatchers should advise patients with no history of aspirin allergy or signs of active or recent gastrointestinal bleeding to chew an aspirin (160 to 325 mg) while awaiting the arrival of EMS providers (Class IIa).29 EMS providers should be trained to determine the time of onset of symptoms and to stabilize, triage, and transport the patient to an appropriate facility and to provide prearrival notification. EMS providers should monitor vital signs and cardiac rhythm and be prepared to provide CPR and defibril￾lation if needed. EMS providers may administer oxygen to all patients. If the patient is hypoxemic, providers should titrate therapy based on monitoring of oxyhemoglobin saturation (Class I).30 – 44 If the patient has not taken aspirin and has no history of aspirin allergy and no evidence of recent gastrointestinal bleeding, EMS providers should give the patient nonenteric aspirin (160 to 325 mg) to chew (Class I).45– 48 EMS providers should administer up to 3 nitroglycerin tablets (or spray) for ongoing symptoms at intervals of 3 to 5 minutes if permitted by medical control and if the patient remains hemodynamically stable (systolic blood pressure [SBP]
90 mm Hg [or no more than 30 mm Hg below baseline], heart rate between 50 and 100 beats per minute [bpm]).49,50 EMS providers can administer morphine for chest pain unresponsive to nitroglycerin if authorized by protocol or medical control. Additional information about out-of￾hospital stabilization and care is included in the following sections. Out-of-Hospital ECGs Out-of-hospital 12-lead ECGs and advance notification to the receiving facility speed the diagnosis, shorten the time to fibrinolysis, and may be associated with decreased mortality rates.51– 64 The reduction in door-to–reperfusion therapy in￾terval in most studies ranges from 10 to 60 minutes. EMS providers can efficiently acquire and transmit diagnostic￾quality ECGs to the ED53,58,65,66 with a minimal increase (0.2 to 5.6 minutes) in the on-scene time interval.52,56,65– 68 Qualified and specially trained paramedics and prehospital nurses can accurately identify typical ST-segment elevation (
1 mm in 2 or more contiguous leads) in the 12-lead ECG with specificity ranging from 91% to 100% and sensitivity ranging from 71% to 97% when compared with emergency medicine physicians or cardiologists.69,70 Using radio or cell phone, they can also provide advance notification to the receiving hospital of the arrival of a patient with ACS.56,61– 64 We recommend implementation of out-of-hospital 12-lead ECG diagnostic programs in urban and suburban EMS systems (Class I). Routine use of 12-lead out-of-hospital ECG and advance notification is recommended for patients with signs and symptoms of ACS (Class IIa). A 12-lead out-of￾hospital ECG with advance notification to the ED may be beneficial for STEMI patients by reducing time to reperfusion therapy. We recommend that out-of-hospital paramedics acquire and transmit either diagnostic-quality ECGs or their interpretation of them to the receiving hospital with advance notification of the arrival of a patient with ACS (Class IIa). If EMS providers identify STEMI on the ECG, it is reasonable for them to begin to complete a fibrinolytic checklist (Figure 2). Out-of-Hospital Fibrinolysis Clinical trials have shown the benefit of initiating fibrinolysis as soon as possible after onset of ischemic-type chest pain in patients with STEMI or new or presumably new left bundle branch block (LBBB).67,71 Several prospective studies (LOE 1)72–74 have documented reduced time to administration of fibrinolytics and decreased mortality rates when out-of￾hospital fibrinolytics were administered to patients with STEMI and no contraindications to fibrinolytics. Physicians in the Grampian Region Early Anistreplase Trial (GREAT)73 administered fibrinolytic therapy to patients at home 130 minutes earlier than to patients at the hospital and noted a 50% reduction in hospital mortality rates and greater 1-year and 5-year survival rates in those treated earlier.75,76 Delaying fibrinolytic treatment by 1 hour in￾creased the hazard ratio of death by 20%, which is equivalent to the loss of 43 lives per 1000 patients over 5 years. A meta-analysis of out-of-hospital fibrinolytic trials found a relative improvement of 17% in outcome associated with out-of-hospital fibrinolytic therapy, particularly when therapy was initiated 60 to 90 minutes earlier than in the hospital.71 A meta-analysis of 6 trials involving 6434 patients (LOE 1)72 documented decreased all-cause hospital mortality rates among patients treated with out-of-hospital fibrinolysis com￾pared with in-hospital fibrinolysis (odds ratio [OR]: 0.83; 95% confidence interval [CI]: 0.70 to 0.98) with a number needed to treat of 62 to save 1 extra life with out-of-hospital fibrinolysis. Results were similar regardless of the training and experience of the provider. The ECC Guidelines 200077 recommended consideration of out-of-hospital fibrinolysis for patients with a transport time
1 hour. But in a recent Swiss study (LOE 1),74 prehospital administration of fibrinolytics significantly de￾creased the time to drug administration even in an urban setting with relatively short transport intervals (15 minutes).74 In summary, out-of-hospital administration of fibrinolytics to patients with STEMI with no contraindications is safe, feasible, and reasonable (Class IIa). This intervention may be performed by trained paramedics, nurses, and physicians for patients with symptom duration of 30 minutes to 6 hours. System requirements include protocols with fibrinolytic checklists, ECG acquisition and interpretation, experience in ACLS, the ability to communicate with the receiving institu￾tion, and a medical director with training/experience in management of STEMI. A process of continuous quality improvement is required. Given the operational challenges required to provide out-of-hospital fibrinolytics, most EMS systems should focus on early diagnosis with 12-lead ECG, rapid transport, and advance notification of the ED (verbal Part 8: Stabilization of the Patient With Acute Coronary Syndromes IV-91