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Podcast 88 - The Logistics of a STEMI Transport w/Andrew Merelman

A few weeks ago Andrew Merelman (@amerelman) and I did part one of our "Routine (N)STEMI Transport" series. In this episode we get down to an anecdotal granular level and discuss:

Which infusions can I turn off until I get to the ambulance/helicopter?

Heparin is typically given as a bolus and then maintenance infusion. The maintenance infusion can be paused while moving the patient to the ambulance/helicopter.

Nitroglycerin is a little bit more nuanced. Even though sublingual nitroglycerin has never been studied for a mortality benefit, IV nitrates actually have and showed an overall reduction mortality. My friend Salim has a nice break-down of this here

If patient is on a nitro infusion, MAP's support an acceptable coronary perfusion pressure, and is currently feeling relief from chest discomfort - I will continue this infusion with no interuption.

If patient is on a nitro infusion and is still complaining of chest discomfort that is unrelived by nitro - I will give fentanyl and pause the nitro infusion till we get in the helicopter. This allows me to evaluate the pressures after fentanyl and re-evaluate the dosing for the infusion. The last thing you want to do to an ischemic heart is drop the diastolic pressure below an adequate coronary perfusion pressure.

Preparation?

Defib pads placed in the anterior/posterior position.

LUCAS back-plate placed if ominous assessment.

I made this graph to illustrate when I do a 12 lead on scene versus in-flight.

Should we be giving P2Y12 inhibitors in-transport if not provided by the facility?

My shop uses ticagrelor and it is preferred in this region. 

What areas should we avoid placing IV's when going to the cath-lab.

Not only should we avoid the right wrist, we should place an additional IV in the left arm if we see the referring EMS or hospital has placed an IV in the right wrist.

Ultrasound and point of care labs to rule out differentials.

These patients come in and get shipped out fast. Typically no imaging or labs has been performed by the time we scoop em up. I like to rule out:

1.Thoracic Aneurysm/ Pericardial Tamponade.

2.H&H for unknown bleed causing type 2 ischemia.

3.Hyperkalemia fooling the ECG.

Now check out the podcast!

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