Professionals who provide emergency medical services may be called upon to administer prehospital fibrinolysis at some point in their careers. This is because several studies have shown that fibrinolytic agents given to people who are suffering from an acute cardiac event have better outcomes if they receive fibrinolysis (a clot-busting drug) before they reached the hospital. This is especially true in rural settings where the time to
reach a hospital can be substantial. However, this may also apply in urban settings where wait times in emergency departments can be equally substantial. Fibrinolysis can be effective for the treatment of ST-segment elevation myocardial infarction. The medication can dissolve the thrombus/embolus that is lodged in a coronary artery, thus restoring blood flow to the heart. Because of the possibility of serious adverse events, including serious bleeding events such as intracranial
hemorrhage, the decision to administer fibrinolysis should not be entered into lightly. Anyone who is going to administer a clot-busting drug must be qualified to do so (including knowledge of ECG interpretation) and must only do so in patients who meet certain criteria. Who may need prehospital fibrinolysis? An ST-segment elevation myocardial infarction can be diagnosed using a 12-lead ECG obtained prior to reaching the hospital (in a patient with myocardial
infarction symptoms such as crushing chest pain, for example). As the name implies, the ECG tracing shows an elevation between S and T waves. Roughly speaking, this means that the QRS complex connects to the T wave. Colloquially, clinicians refer to this as a “tombstone” because of its periods and what it used to mean for patients. In specific terms, an ECG that shows ST segment elevation in which the J point is greater than 2 mm in leads V2 and V3 and 1 mm or more in other leads is in ST
segment elevation myocardial infarction. Likewise, a new or a likely new left bundle branch block may also receive fibrinolysis (See ECGs in Acute Myocardial Infarction). Many electrocardiograms will include software that analyzes the ECG waveform and help direct users in making a diagnosis. However, given the seriousness of fibrinolysis, emergency medical services personnel (or anyone about to administer a fibrinolytic agent, for that matter) should be able to read the ECG independent from a software rating. Absolute contraindications If any of these factors exist, you should NOT administer a fibrinolytic agent1:
Relative contraindications If any of these factors exist, you should consider NOT administering a fibrinolytic agent1:
Good intravenous access and continuous cardiac monitoring should be instituted before fibrinolysis is given. Prehospital Fibrinolytic Checklist*
Table 1
Table 2 * Contraindications for fibrinolytic use in STEMI are viewed as advisory for clinical decision making and may not be all-inclusive or definitive. These contraindications are consistent with the 2004 ACC/AHA Guidelines for the Management of Patients With ST-Elevation Myocardial infarction. ✝ Consider transport to primary PCI facility as destination hospital. Which of the following is an absolute contraindication for fibrinolytic therapy?Contraindications to Fibrinolytic Therapy. Which of the following is an absolute contraindication to the use of thrombolytic therapy?Absolute contraindications for fibrinolytic use in STEMI include the following: Prior intracranial hemorrhage (ICH) Known structural cerebral vascular lesion.
What are the clear contraindication to the use of fibrinolytic agents?The contraindications for fibrinolytic therapy include previous intracranial hemorrhage, malignant intracranial neoplasm, known structural cerebrovascular lesion (e.g., arteriovenous malformation), ischemic stroke within 3 months except for acute ischemic stroke within 4.5 h, significant facial trauma or closed-head ...
When should you not use Fibrinolytics?Fibrinolytic therapy should not be routinely administered in patients who present >12 hours after symptom onset, as efficacy has not been established.
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