Managing Therapeutic Interventions for Cardiovascular Problems in a Pre-Hospital Setting - Essay Example

Evaluation and management of acute myocardial infarction This assignment is to elaborate on what I, as a paramedic technician, would do in a an emergency situation in which a case of acute myocardial infarction has to be handled and saved for further management in hospital. Acute myocardial infarction and sudden cardiac arrest are the major incidents in the emergency medical services. These are life-threatening conditions which are nontraumatic and are community emergencies involving adults. This paper provides the procedure that I would adopt to quickly observe, evaluate and provide timely intervention to change the patient’s immediate danger of losing his life into a situation in which he can be further managed in hospital. This paper also provides information on the various aspects that I have highlighted in the process. The patient John, 54 years, had a chest pain while he was washing his car at nine in the morning. His wife saw him clutching his chest and collapsing onto the car. She immediately understood that he was having chest pain with a history of angina of recent onset but not recurring frequently or suddenly. His habit of heavy smoking has probably contributed to his present complaint. She immediately sent a call to the ambulance I was attached to. We rushed to the scene. Arrangements in the ambulance The arrangements in the ambulance are all ready to help John. The defibrillator is in working condition and other resuscitation equipment of cardio-pulmonary conditions is ready. Two other staff are available to help me in my endeavours. It just took 2 minutes to reach the spot. Initial assessment John is sweating profusely and lying on a sheet on the ground. He is almost out of breath and his face is pale. He is cold and sweaty to the touch and having a constrictive pain in the retrosternal region. Having vomited once before we reached the spot, he is thirsty and asks for water. On enquiry, he admits he has a pain in his shoulder which is probably a radiating pain. His pulse is fast, 90 per minute. Consent will be obtained from John and confirmed by his wife before we start our management. The presumptive diagnosis is acute myocardial infarction which is the commonest cause of death in the UK. The other reasons for noncardiac chest pain are automatically ruled out by the positive history of angina and the fact that the pain occurred while he was doing some exercise (washing the car). An ECG taken before transferring him would confirm the diagnosis and exclude nontraumatic chest pain. Reaching him to hospital without delay, providing necessary pre-hospital management for the patient and preventing sudden death constitute the management in a case of acute myocardial infarction. John and his wife will be given ample information on what he is to be given as treatment and how he is being transported. Possible complications and side effects will be explained precisely. The complications that could arise from pre-hospital treatment would be mentioned. Patient is also told that he can change his mind about the consent later and opt out of pre-hospital treatment (Fisher, 2006). John and his wife are not expected to refrain from treatment as they called the ambulance however the procedure of preliminary survey cannot be eliminated. The ECG machine would be strapped into position and the ECG taken. The 12-lead ECG is the diagnostic feature for an ambulance technician to act. Mere elevation of ST may not be the only feature looked for. ECGs would be repeated at definite intervals. BP is checked. A quick auscultation rules out further complications like pulmonary oedema recognized by the rales or noisy chest. Preventing sudden death will be my main aim. My colleagues would be simultaneously doing things. One person gets the ECG recording. The other starts a lifeline. Another does the recording. We are used to working together on such emergencies so we do not disturb each other. Our actions would be complementary but I would be the leader who makes decisions. John will be given oxygen immediately on seeing him using the nonreservoir bag and mask and the pulse oxymeter placed in position. John’s wife would provide past history and symptoms seen. After a quick assessment John will be transferred into the ambulance which immediately would set off to the hospital. He would then be connected to the ventilator in the ambulance for oxygen administration. Oxygen would be provided at 8-10L / minute depending on the oxygen saturation on the pulse oxymeter. The saturation would be maintained at 95%. and noninvasive positive pressure ventilation will be given (Grimm, 2006). Patient’s airway must be adequate always and respiration must be proceeding normally. John did not have an ST elevation in his ECG. A sublingual tablet of 300microgm of glyceryl trinitrate will be placed under John’s tongue. A tablet of 150mg of aspirin will be given orally. A single bolus dose of intravenous heparin of 5000 units will be given before the thrombolysis drug and the canula well flushed with saline. John will then be given 7 ml. of Tenecteplase (for thrombolysis), for his weight of 70 kg., as intravenous bolus dosage after ruling out contraindications and checking that his BP is normal. If John cannot be handed over to the hospital authorities so that he gets the heparin infusion within 45 minutes of Tenecteplase, he will be administered a repeat dose of bolus heparin IV injection. Further management en route would ensure that a live patient would be handed over at the hospital. ECG must be monitored for arrythmias. The life line or intra-venous access must be in situ. Vital signs must be monitored. The dose of glyceryl trinitrate must be repeated if chest discomfort continues. Pain score must be checked and morphine administered (Fisher, 2006). The 12-lead ECG is recorded. The hospital would be pre-alerted to the condition of the patient and whether he needs to go in for percutaneous perfusion. Reperfusion treatment Pre-hospital thrombolytic treatment will be provided. Reperfusion by thrombolytic treatment or percutaneous intervention is significant and time-bound for restoring coronary blood flow. (Fisher, 2006). Those with STEMI (ST elevation in myocardial infarction) who are contraindicated for the thrombolytic treatment must necessarily go in for percutaneous interventions which can be done only in the hospital. People in advanced age, severe hypertension and had recent surgery or in cardiogenic shock are contraindicated for thrombolysis. The hands of the ambulance technician are tied and the chances of a high mortality rate exists. Percutaneous perfusion is the only resort for such patients. Those with non STEMI or have unstable angina should be also treated as medical emergencies. John has no STEMI and can be given thrombolytic treatment (Fisher, 2006). Heparin is given to prevent reinfarction. The Department of Health state that about 275000 people in the UK have acute myocardial infarctions every year (DH, 2007). Total obstruction of a coronary artery causes ischaemia and cell death in the cardiac muscle. Commonest cause is atherosclerosis plaques which break up into thrombi and block an artery causing a disturbance in the circulation. The thrombus can break away and cause embolism in another part of the body in a smaller vessel (Gould, 2006). Reperfusion therapy aims at limiting heart damage by restoring the coronary blood flow to the heart (Fisher, 2006). Thrombolysis and primary percutaneous perfusion are the two methods employed now. Pre-hospital thrombolysis shortens the delay in treatment by 60 minutes at least and reduces mortality greatly. Percutaneous perfusion is superior to hospital thrombolysis but not when compared to the thrombolysis done within three hours. The delay in either treatment is associated with poor long-term outcomes regardless of the method selected (Dudek et al, 2007). Thrombolysis is the process by which blood clots are dissolved by thrombolytic enzymes which activate the endogenous fibrinolytic system (Rosser, 2008). Thrombolytic drugs help in converting tissue plasminogen to plasmin and plasma proteins. The plasmin degrades the fibrin and thereby breaks up the thrombi (Prosser et al, 2000). The drugs used for thrombolysis usually are alteplase derivatives. Tenecteplase is one which is administered by bolus intravenous doses (Nordt and Bode, 2003). 6ml. of tenecteplase is given to a person of weight less than 60kg (Fisher, 2006). Upto 70 kg, 7000 units or 7ml. of the drug is given. Dosage increases by weight. Infusion thrombolysis has the disadvantage that it takes longer to prepare than the bolus thrombolysis (Castle and Owen, 2004). Contraindications to the drugs are haemorrhage, trauma and surgery (British National Formulary, 2008). The drugs for thrombolysis may be administered by the ambulance technician while the primary percutaneous perfusion is done by the cardiac surgeon. This latter method is believed to be better but has to be done in a hospital setting. The delay in the patient getting to the receiving area is one flaw in the system for doing PPI. The National Infarct Angioplasty Project has said that PPI produces best results if done within two hours of the patient’s call (DH, 2008). The ambulance technicians or the paramedics see 75% of patients with chest pain within 8 minutes of the pain appearing (DH, 2007b). The ability of the paramedics to administer the tenecteplase ensures the speedy delivery of the thrombolytic drugs. This early dosing produces better outcomes in future. Aspirin Aspirin is given for primary and secondary prevention of myocardial infarction (The Medical Research, 1998) due to its inhibitory action on platelets. It prevents thrombosis through inhibiting platelet aggregation. 75 to 150mg. daily dosage is sufficient. Results have shown one-third reduction of non fatal events and one-sixth decrease in mortality in high-risk patients (MacKinnon, 2006). Aspirin is associated with 50% reduction in nonfatal first MI in the Physicians Health Study where the placebo groups had the fatal MIs (Steering Committee, New England Journal of Medicine). Unstable angina also had a 70% reduction in MIs with aspirin alone and a greater reduction when a combination of aspirin and heparin were used (Theroux, 1988). In STEMI cases, there was a one-third reduction in the risk of nonfatal MI and a one-fourth decrease in the occurrence of MI, stroke or vascular death (MacKinnon, 2006). Glyceryl trinitrate Glyceryl trinitrate may be given to patients with adequate blood pressure (Grimm, 2006). Side-effects of this drug are hypotension and headache. High initial doses may be needed. The drug acts in two manners. It dilates the arteries that carry blood to the heart muscle and relaxes the veins that carry blood away from the heart. More blood and oxygen thereby reach the heart and help to prevent the ischaemia. Contraindications include a previous heart disease, hypotension, trauma, recent heart attack, anaemia, thyroid problems, glaucoma, using drugs for erectile dysfunction and malnutrition. Sublingual tablets are usually used in the management for acute myocardial function. The dose is 1 tablet of 300 microgm., repeated once more if there is no relief of pain. Morphine is given to patients with pulmonary oedema. It reduces breathlessness and central sympathetic tone and produces venodilation and mild arterial dilatation (Grimm, 2006). The significance of the primary survey The primary survey is the first procedure. It is useful for the first assessment of a patient. Time-critical issues would be revealed at the primary survey. However remembering that every second counts, I, as a first responder, have the responsibility of doing just that much as early as possible to save John’s life and reduce the risk of his condition worsening. John appears to be in a critical stage and needs immediate transport. I do not have to read the guidelines provided to us for the job responsibilities. I know fully well what is expected of me. Haste and appropriate action is my personal policy. Human rights requires of me to respect the diversity of people, the dignity of their life and value differences across people as per the Equality Impact Assessment (Ambulance Service, NHS Trust, 2008). All people would be treated with courtesy and patience. No one would be ignored or made to feel small or excluded or disadvantaged. Delivering appropriate clinical care is my only concern when on an emergency. I basically have the vocation to help people selflessly and that was the main reason that I was selected for this post apart from my basic qualification. Consent Patients have a tendency to refuse pre-hospital treatment occasionally (Fisher, 2006). Valid consent will be obtained from the patient who is conscious and able to understand the management to be executed. Facts and interventions planned will be conveyed to the patient and wife. The consent needs to be voluntarily given by the patient or by his bystanders (Fisher, 2006). Decision to refuse treatment must be respected, provided the patient is without the capacity to make a decision. A really ill person is not necessarily one without capacity to decide. If doubts arise, a general practitioner or a carer must be asked. The ambulance clinician has no right to refuse or withhold treatment. He can be held legally responsible for such an action (Fisher, 2006). The clinical record must contain the details of the information imparted before the signed consent is taken with a third party confirming. A child who can understand matters is allowed to give consent confirmed by his parent. The European Court of Human Rights has ruled that treatment without consent amounts to inhuman or degrading treatment. Oxygen administration Oxygen must be administered and a pulse oxymeter placed in position. It is provided with an automatic ventilator which can control the flow of oxygen into the lungs or a mask and tubing. The masks could be nonreservoir type to give low concentrations or reservoir type for higher concentrations. If the patient has accompanying bronchospasm he must be better oxygenated but can be maintained at 90-92%. The pulse oxymeter measures oxygen saturation. Normal person has 95-100% saturation. Evidence of hypoxia would be noted when the saturation is between 90-95%. When it goes further down to below 90%, it becomes serious hypoxia and below 85 it is critical. A laryngectomy patient is administered oxygen directly into his stoma. If necessary, an intra-tracheal tube may be placed especially in an unconscious patient and oxygenation allowed to proceed through this. To shorten delays Delays can occur due to the disease itself or the patient, the physician, the transportation or the receiving area of the hospital. My duty is to reduce the delay during transportation. In cities, it is due to the congestion that delay occurs. In rural areas, facilities for transportation may not be readily available and the distance to hospitals may be more causing the delay (Yu, 1972). The media in my city have appropriately conveyed the information that the first few minutes are critical in deciding the fate of an acute myocardial infarction case and the public appear to be well aware of the fact. Here, the roads are four-lane and traffic have to make way for ambulances which make their presence heard through the sirens. The possibility of saving more of our patients is high. Reasons for sudden death and prevention Those who had a previous episode of myocardial infarction or coronary artery disease are prone to sudden death. Recent onset of angina which has recurred suddenly is another factor. Patients with a history of having multiple arterial blocks or obstructions as seen in the angiogram and who had no remedial procedures can also have a sudden death. People with coronary artery disease who have arrythmias are candidates for sudden death (Yu, 1972). Those who have multiple risk factors like diabetes mellitus, hypertension, obesity and smoking can have sudden deaths. Ventricular fibrillation can occur without any warning and sudden death is the result within a few hours from the beginning of symptoms and must be expected at all times. Watching the ECG monitor may give a hint of the beginning of fibrillations. Being ready with the defibrillator is extremely important and can change the statistics of mortality. Using the defibrillator in time can save the patient from death. The mortality which could be as high as 40% in such patients comes down to 29% with the defibrillator (Yu, 1972). Conclusion The acute myocardial infarction patient is the commonest patient who has the greatest risk of dying in the hands of a technician like me. Saving such a patient from death is a challenge. The biggest challenge would be to thrombolyse the patient within minutes of talking him up and not even delay it for “within 3 hours”. The earlier the better is the dictum as far as outcomes are concerned. I intend to be thorough about the legal procedures and the guidelines. The contraindications for each drug that I use on the patient would be at my fingertips. These precautions that I take would help save lives. My team would be always brushing up our theory and the practical aspects in order to really enjoy what we are doing and make patients live. References: Ambulance Service (East Midlands) NHS Trust, June 2008. Policy for the implementation of Joint Royal Colleges Ambulance Liaison Committee (JRCALC) Clinical Practice Guidelines, Clinical Service Department , UK British National Formulary (2008) British National Formulary No 56. British Medical Association and theRoyal Pharmaceutical Society of Great Britain, London. Castle N, Owen R (2004) Challenging delays in thrombolysis. Emergency Nurse. 12, 8, 18-22. Department of Health (2007) Coronary Heart Disease. www.dh.gov.uk/en/Healthcare/ NationalServiceFrameworks/Coronaryheartdisease/index.htm. Department of Health (2007b) Improving Ambulance Response Times: High impact changes and response time algorithms for NHS ambulance trusts. 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