http://www.12lead.net/index.cfm?dspPage=research#hospital "Evidence supports the contention that out of hospital 12-lead ECG diagnostic programs are cost effective and may be underused. We recommend implementation of out-of-hospital 12-lead ECG diagnostic programs in urban and suburban paramedic systems (Class 1)." Circulation 2000; 102 (suppl I):1-176 RESEARCH Quick Links Should Paramedics utilize 12-Lead Electrocardiography in the field? Does the 12-lead extend on scene times or reduce door to drug times? How often is general weakness a sign of AMI? List of Indications for pre-hospital 12 lead List of Indications for Transcutaneous Pacing Does Performing a 12-lead ECG reduce mortality? Do paramedics administer Aspirin when indicated? Should Paramedics utilize 12-Lead Electrocardiography in the field? Personal note: I have been fighting for acceptance of prehospital 12-lead ECG since 1980. The evidence has finally caught up with the facts. Paramedics can and should utilize 12-lead ECG's in the field. These references are provided for your convenience. They may be useful in preparing requests for funding of a 12-lead ECG program for your service. -Gary Denton Consider the following statements and the associated references. Here is the statement that says it all... "Evidence supports the contention that out of hospital 12-lead ECG diagnostic programs are cost effective and may be underused. We recommend implementation of out-of-hospital 12-lead ECG diagnostic programs in urban and suburban paramedic systems (Class 1)." Circulation 2000; 102 (suppl I):1-176 References and works that led to this decision are outlined below. Statement: A diagnosis of AMI can be made sooner when the 12-lead ECG is obtained before the patient arrives in the hospital than if the ECG is performed after arrival. Source: Circulation 2000; 102 (suppl I):I-175 Reference: Circulation 2000; 102 (suppl I):I-175 , column 2, paragraph 2. Statement: The use of out -of hospital ECG's and a chest pain evaluation form leads to more rapid initiation of reperfusion therapy without substantially delaying out-of hospital time. Source: Circulation 2000; 102 (suppl I):I-175 Reference: Kereiakes DJ, Gibler WB, Martin LH, Pieper KS, Anderson LC. Relative importance of emergency medical system transport and the prehospital electrocardiogram on reducing hospital time delay to therapy for acute myocardial infarction: a preliminary report from the Cincinnati Heart Project. Am Heart J. 1992;123:835-840. Karagounis L, Ipson SK, Jessop MR, et al. Impact of field transmitted electrocardiography on time to in-hospital thrombolytic therapy in acute myocardial infarction. Am J Cardiol 1990;66 786-791. Grim P, Feldmen T, Martin M, et al. Cellular telephone transmission of 12-lead electrocardiograms from ambulance to hospital. Am J Cardiol. 1987;60:715-720 Kudenchuck PJ, Ho MT, Weaver WD, et al. Accuracy of computer interpreted electrocardiography in selecting patients for thrombolytic therapy: MITI Project Investigators. J Am Coll Cardiol. 1991;17 1486-1491. Statement: A 12-lead ECG transmitted to the hospital speeds diagnosis and shortens time to fibrinolysis. Source: Circulation 2000; 102 (suppl I):I-175 Reference: Kereiakes DJ, Gibler WB, Martin LH, Pieper KS, Anderson LC. Relative importance of emergency medical system transport and the prehospital electrocardiogram on reducing hospital time delay to therapy for acute myocardial infarction: a preliminary report from the Cincinnati Heart Project. Am Heart J. 1992;123:835-840. Karagounis L, Ipson SK, Jessop MR, et al. Impact of field transmitted electrocardiography on time to in-hospital thrombolytic therapy in acute myocardial infarction. Am J Cardiol 1990;66 786-791. Grim P, Feldmen T, Martin M, et al. Cellular telephone transmission of 12-lead electrocardiograms from ambulance to hospital. Am J Cardiol. 1987;60:715-720 Kudenchuck PJ, Ho MT, Weaver WD, et al. Accuracy of computer interpreted electrocardiography in selecting patients for thrombolytic therapy: MITI Project Investigators. J Am Coll Cardiol. 1991;17 1486-1491. Statement: The US National Heart Attack Alert Program recommends that EMS systems provide out-of-hospital 12-lead ECGs to facilitate early identification of AMI and that all advanced life saving vehicles be able to transmit a 12-lead ECG to the hospital. Source: Circulation 2000; 102 (suppl I):I-175 Reference: National Heart Attack Alert Program Coordinating Committee Access to Care Subcommittee. Staffing and equipping emergency medical services system: rapid identification and treatment of acute myocardial infarction. Am J Emerg Med. 1995;13:58-66. Statement: Multiple studies have shown the feasibility of obtaining a 12-lead ECG during the out of hospital period. Source: Circulation 2000; 102 (suppl I):I-175 Reference(s): Weaver WD, Cerqueria M, Hallstrom AP, et al. Pre-hospital-initiated vs hospital initiated thrombolytic therapy: the Myocardial Infarction Triage and Intervention Trial. JAMA. 1993;270:1211-1216 Karagounis L, Ipson SK, Jessop MR, et al. Impact of field transmitted electrocardiography on time to in-hospital thrombolytic therapy in acute myocardial infarction. Am J Cardiol 1990;66 786-791. National Heart Attack Alert Program Coordinating Committee. Access to timely and optimal care of patients with acute coronary syndromes-community planning considerations: a report by the National Heart Attack Alert Program. J Thromb Thrombolysis. 1998;6:19-47 National Heart Attack Alert Program Coordinating Committee Access to Care Subcommittee. Staffing and equipping emergency medical services system: rapid identification and treatment of acute myocardial infarction. Am J Emerg Med. 1995;13:58-66. Kereiakes DJ, Gibler WB, Martin LH, Pieper KS, Anderson LC. Relative importance of emergency medical system transport and the prehospital electrocardiogram on reducing hospital time delay to therapy for acute myocardial infarction: a preliminary report from the Cincinnati Heart Project. Am Heart J. 1992;123:835-840. Foster DB, Dufendach JH, Barkdoll CM, Mitchell BK, Prehospital recognition of AMI using independent nurse/paramedic 12-lead ECG evaluation: impact on in-hospital times to thrombolysis in a rural community hospital. Am J Med. 1994;12:25-31. Aufderheide TP, Kereiakes DJ, Weaver WD, Gibler WB, Simoons ML. Planning, implementation, and process monitoring for prehospital 12-lead diagnostic programs. Prehospital Disaster Med. 1996;11:162-171 Aufderheide TP, Hendley GE, Woo J, Lawrence S, Valley, V, Teichman SL. A prospective evaluation of prehospital 12-lead ECG application in chest pain patients. J Electrocardiol. 1992;24(suppl):8-13. Statement: The 12-lead ECG stands at the center of the decision pathway in the management of patients with ischemic chest pain, and delays in obtaining the 12-lead must be eliminated. Source: Textbook of Advanced Cardiac Life Support, American Heart Association, 1997 Reference: Chapter 9: 9-13. Textbook of Advanced Cardiac Life Support, American Heart Association, 1997 Statement: ...short door to needle times are often due to the alerting function of the pre-hospital 12-lead ECG, which is becoming routine in EMS systems in most cities. Source: Textbook of Advanced Cardiac Life Support, American Heart Association, 1997 Reference: Chapter 9: 9-14. Textbook of Advanced Cardiac Life Support, American Heart Association, 1997 Statement: Early diagnosis and treatment of AMI significantly reduces mortality. Source: Textbook of Advanced Cardiac Life Support, American Heart Association, 1997 Reference(s): Brouwer MA, Martin JS, Maynard C, et al. Influence of early pre-hospital thrombolysis on mortality and event free survival. (the MITI randomized trial): MITI project investigators. Am J Cardiol. 1989;13:998-1005 Statement: The full spectrum of emergency personnel - physicians, nurses, emergency medical technicians, paramedics, and all allied healthcare personnel - needs to know the core principles of diagnosis and treatment of the acute coronary syndromes. Source: Textbook of Advanced Cardiac Life Support, American Heart Association, 1997 Reference: Chapter 9: 9-1. Textbook of Advanced Cardiac Life Support, American Heart Association, 1997 Statement: A 12-Lead ECG transmitted to the hospital speeds diagnosis and shortens time to thrombolysis. Source: Textbook of Advanced Cardiac Life Support, American Heart Association, 1997 Reference(s): Grim P, Feldmen T, Martin M, et al. Cellular telephone transmission of 12-lead electrocardiograms from ambulance to hospital. Am J Cardiol. 1987;60:715-720 Karagounis L, Ipson SK, Jessop MR, et al. Impact of field transmitted electrocardiography on time to in-hospital thrombolytic therapy in acute myocardial infarction. Am J Cardiol 1990;66 786-791. Kudenchuck PJ, Ho MT, Weaver WD, et al. Accuracy of computer interpreted electrocardiography in selecting patients for thrombolytic therapy: MITI Project Investigators. J Am Coll Cardiol. 1991;17 1486-1491. Statement: Prehospital 12-lead ECG's and a chest pain check list lead to more rapid prehospital and hospital care. Source: Textbook of Advanced Cardiac Life Support, American Heart Association, 1997 Reference(s): Weaver WD, Cerqueria M, Hallstrom AP, et al. Pre-hospital-initiated vs hospital initiated thrombolytic therapy: the Myocardial Infarction Triage and Intervention Trial. JAMA. 1993;270:1211-1216 Pre-hospital 12-lead reduces hospital door to drug time. An interesting study was presented at EMS Today 2000 in Orlando, Florida in March 2000. Paramedic Kenneth White and others studied the effect of pre-hospital 12-lead ECG on emergency department door to drug times and on scene times. The study compared 429 patients without pre-hospital 12-lead ECG to 279 patients with pre-hospital 12-lead ECG. The study noted that pre-hospital 12-lead extended on scene times by an average of 3.7 minutes. The study also noted that in the emergency department door to thrombolytic drug administration was reduced by 16.5 minutes in the pre-hospital 12-lead group. GWD Statement: Recording an ECG increases time spent on the scene of an emergency by only 0-4 minutes. Source: Circulation 2000; 102 (suppl I):I-175 Reference(s): Weaver WD, Cerqueria M, Hallstrom AP, et al. Pre-hospital-initiated vs hospital initiated thrombolytic therapy: the Myocardial Infarction Triage and Intervention Trial. JAMA. 1993;270:1211-1216 National Heart Attack Alert Program Coordinating Committee Access to Care Subcommittee. Staffing and equipping emergency medical services system: rapid identification and treatment of acute myocardial infarction. Am J Emerg Med. 1995;13:58-66. Foster DB, Dufendach JH, Barkdoll CM, Mitchell BK, Prehospital recognition of AMI using independent nurse/paramedic 12-lead ECG evaluation: impact on in-hospital times to thrombolysis in a rural community hospital. Am J Med. 1994;12:25-31. Pantridge JF, Adjey AA, Webb SW. The first hour after onset of acute myocardial infarction. In: Yu PN, Goodwin JF. Progress in Cardiology. Philadelphia, Pa: Lee & Febiger, 1975:173-178. Statement: Many studies have shown significant reductions in hospital-based time to treatment with fibrinolytic therapy in patients with AMI identified before arrival by a 12-lead ECG. Time savings in these studies range from 20 to 55 minutes. Source: Circulation 2000; 102 (suppl I):I-175 Reference: Foster DB, Dufendach JH, Barkdoll CM, Mitchell BK, Prehospital recognition of AMI using independent nurse/paramedic 12-lead ECG evaluation: impact on in-hospital times to thrombolysis in a rural community hospital. Am J Med. 1994;12:25-31. Aufderheide TP, Kereiakes DJ, Weaver WD, Gibler WB, Simoons ML. Planning, implementation, and process monitoring for prehospital 12-lead diagnostic programs. Prehospital Disaster Med. 1996;11:162-171 Aufderheide TP, Hendley GE, Woo J, Lawrence S, Valley, V, Teichman SL. A prospective evaluation of prehospital 12-lead ECG application in chest pain patients. J Electrocardiol. 1992;24(suppl):8-13. BEPS Collaborative Group. Prehospital thrombolysis in acute myocardial infarction. Eur Heart J. 1991;12:965-967 How often is general weakness a sign of AMI? General weakness is considered an anginal equivalent. I have often wondered how often general weakness is due to acute myocardial infarction. A recent study completed by Art Durbin and Diane Bartman from Hemet California may help give us a clue. The study examined 52 cases of general weakness from a group of 1075 pre-hospital care reports. ICD-9 codes were used to elicit a diagnosis. Acute Myocardial Infarction was the cause of the general weakness in 5.8% of the patients in this group. This made Acute Myocardial Infarction the 4th most common cause of general weakness behind syncope (23.1%), sepsis (15.4%), and respiratory failure (7.7%). Direct correspondence to: Art Durbin, RN, MICN, BS, EMT-P, 3527 Anchorage St., Hemet, CA 92545 GWD Lists A. Indications for pre-hospital 12-Lead EKG's. B. Indications for transcutaneous pacing Indications for pre-hospital 12-Lead EKG's. Our instructor program concentrates on the role the 12-lead ECG plays in acute coronary syndrome. The 12-lead ECG is useful for a number of cases aside from acute coronary events. Here is a partial list derived from my personal notes on electrocardiography. Indications for a 12-lead ECG include... 1. Chest pain or anginal equivalents (dyspnea, syncope, near syncope, weakness, DKA, diaphoresis disproportionate to the environment, palpitations, etc.) 2. CVA (CVA is often associated with large anterior wall MI's and/or dysrhythmias) 3. Pre and post cardio-version of stable patients 4. Post cardio-version of unstable patients (including post arrest) 5. Suspected electrolyte disturbances 6. Overdose (unknown or suspected anti-depressant) 7. Blunt chest trauma (only after transport or more urgent care) 8. Dysrhythmia (to aid in the cause and diagnosis of the dysrhythmia) 9. Respiratory failure 10. Ventricular failure (CHF) I'm sure you can come up with many more. GWD. Indications for transcutaneous pacing Indications for stand-by pacing. Stand-by pacing is used for patients with decent heart rates when sudden bradycardia or asystole is expected. Some of the electrocardiographic criteria for use of stand-by pacing includes: · Sick Sinus Syndrome · New of presumably new Bundle Branch Block in suspected AMI · Alternating LBBB and RBBB (Bilateral BBB) · RBBB with alternating anterior and posterior fascicular block (trifascicular block) · BBB with first degree heart block (especially if new onset during AMI) · Large anterior-septal or extensive anterior AMI · True second degree type 2 block, even if it appears only briefly and does not effect BP. Stand-by pacing is not just having the pacer pads ready on the squad bench. You should apply the pads to the patient, set the rate at least 30% or so below the patients intrinsic rate, and adjust the output to a level expected to achieve capture (60-80 milliamps) Some sources recommend trial pacing to ensure the output you selected will capture the heart. GWD Does Performing a 12-lead ECG reduce mortality? Statement: A retrospective study of the US National Registry of Myocardial Infarction database showed a mortality benefit (reduction in mortality) for patients with AMI identified by an out-of-hospital 12-lead ECG. The in hospital mortality rate was 8% among patients with an out-of-hospital ECG and 12% among those without an out-of-hospital ECG. Source: Circulation 2000; 102 (suppl I):I-175 Reference:Canto JG, Rogers WJ, Bowlby LJ, French WJ, Pearce DJ, Weaver WD. National Registry of Myocardial Infarction 2 Investigators. The pre-hospital electrocardiogram acute myocardial infarction: is its full potential being realized? J Am Coll Cardiol. 1997;20-1482-1489 Do paramedics administer Aspirin when indicated? Two abstacts presented at the 19th annual EMS Today Conference indicate we have a compliance problem. Karen Donnahie presented a paper that demonstrated a dismal (36%) of patients with symptoms consistent with suspected acute coronary syndrome received Aspirin. Jennifer Hauler and David Hostler displayed an abstract that also showed poor (38%) compliance with aspirin administration. There was a similar abstract presented last year. This is consistent with what I've been finding in QI studies for the past few years. When will we change? For information on contacting the authors of these studies call me (Gary) at 352-466-0965 or e-mail at [EMAIL PROTECTED] P.S. Hello to Karen Donnahie, my "Old Faithful" buddy and David Hostler, a graduate of my 12-lead ECG Instructor program. Thanks for the great research. __________________________________________________ Do You Yahoo!? Try FREE Yahoo! Mail - the world's greatest free email! http://mail.yahoo.com/ --- S.M.U Vous connaissez quelqu'un desirant devenir membre de la liste du prehospitalier? Demandez-lui d'envoyer un courriel l'adresse de la liste ([EMAIL PROTECTED]) avec, comme sujet, le mot abonnement et son nom dans le corps du message.
