CORRESPONDENCE

Intracoronary Thrombolysis With Streptokinase To the Editor:

Intracoronary thrombolysis with streptokinase in acute myocardial infarction is an aggressive and efficacious en- deavor in appropriately selected candidates. 1'~ Although more data from controlled studies are necessary, the pro- cedure is rapidly gaining acceptance. Hospitals across the country are initiating programs utilizing streptokinase thrombolysis. The euphoria of success should not stimulate reckless attempts with this technique. 3 Rapid, appropriate patient selection is essential.

Time is a critical element, for ischemic cellular injury progresses rapidly. Arrhythmias and other complications in- crease as the ischemic process is allowed to progress. The best candidates have had pain for less than four hours when thrombolysis is attempted. 1'2'4 Therefore, the initial physi- cian-patient contact must set in motion a preconceived plan of diagnosis, selection, preparation, and finally, performance of intracoronary thrombolysis. The emergency physician must be acutely aware of this procedure. Regional availabil- ity of trained personnel and facilities with the capacity to deliver this service may eventually change the EMS pro- tocol for transportation of a select group of patients with an acute myocardial infarction. Intrainstitutional protocols and referral patterns must be well organized to enhance success.

The emergency physician plays a critical role in this new area of cardiology. Tragically, the coronary vessel is often occluded with red tape as well as clot. This bureaucratic impedance must be eliminated if appropriate patients are to be moved from the emergency department to the catheter- ization lab expediently. Personnel and equipment must be

available at all hours. The acute myocardial infarction sel- dom schedules itself during reasonable working hours.

Time and accumulation of data from well-controlled trials will further establish efficacy and patient selection guidelines. Public awareness; physician awareness, and rigid planning will further enhance success. As more institutions of all sizes develop their programs, the emergency depart- ment, cardiology department and allied health personnel must unite to avoid any time delay in reperfusing the ~ ischemic myocardium.

Dale C. Askins, DO Steven Perry, DO Department of Emergency Medicine Grand Rapids Osteopathic Hospital Grand Rapids, Michigan

1. Markis JE, Malagold M, Parker JA, et al: Myocardial salvage after intracoronary thrombolysis with streptokinase in acute myocardial infarction. N Engl J Med 305:777-782, 1981. 2. Lee G, Amsterdam EA, Low R, et al: Efficacy of percutaneous transluminal coronary recanalization utilizing streptokinase throm- bolysis in patients with acute myocardial infarction. Am Heart J 102:1159-1167, 1981.

3. Muller JE, Stone PH, Markis JE, et al: Let's not let the genie escape from the bottle - - again. N Engl J Med 305:1294-1296, 1981.

4. Merx W, Dorr R, Rentrop P, et al: Evaluation of the effectiveness of intracoronary streptokinase infusion in acute myocardial infarc- tion: Postprocedure management and hospital course in 204 pa- tients. Am Heart J 102:1181-1187' 1981.

Emergency Department Thoracotomy To the Editor:

The concept of performing a thoracotomy in the emer- gency department for the resuscitation of a trauma victim is relatively new; the first publications to address this directly were in 1973 and 1974 from Houston, 13 although a few mentioned the possibility as early as 1965. 4-6 Review of the literature on "emergency thoracotomy" in early 1978 re- vealed many reports which did not even mention the emer- gency department as a possible site. r Since then there has been a redefinition of emergency thoracotomy in the litera- ture, and a renewal of interest. It is being redefined in numerous publications as an emergency department pro- cedure performed on patients too unstable to await trans- port to the operating room, and interest has been renewed in its indications and results.

The article entitled "Emergency Department Thoracot- omy" by Flyrm et al (11:413-416, August 1982) adds to the growing number of reports discussing the indications and results of this technique of trauma resuscitation. The au- thors make several conclusions/recommendations based on their study of 33 patients and their review of the literature. Unfortunately their study is seriously flawed and their re-

view is selective and abbreviated; therefore, their con- clusions/recommendations are without objective substance. A more extensive review of the literature reveals data that are more relevant and pertinent to this topic and that de- serve thorough and objective consideration.

Dr. Flyrm's study involved 33 patients who underwent emergency department thoracotomy for traumatic car- diopulmonary arrest, all of whom arrived in the emergency department via helicopter. Twenty flights were to the scene of trauma, and transport time averaged 51 minutes (range 25 to 136); the other 13 transports were from other hospi- tals, with flight time averaging 52 minutes (range 16 to 75). Although median transport times (which were not included) may be more meaningful than averages, it is apparent that these patients who were severely traumatized had very long transport times. More importantly, how long was the time between cardiac arrest and thoracotomy? In 11 of 33 pa- tients, CPR was initiated at the scene; this group had an average flight time of 51 minutes, and length of CPR aver- aged 49 minutes (range 25 of 136). Four of 33 had CPR ini- tiated in the hospital from which the patient was delivered

92/466 Annals of Emergency Medicine 12:7 July 1983