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Pre-hospital Thrombolysis in the UK - looking ahead. Richard Vincent Royal Sussex County Hospital, Brighton. Pre-hospital thrombolysis. Why attempt it? What are the possibilities? Where are we now? What of the future?. Pre-hospital thrombolysis. Why attempt it?. - PowerPoint PPT Presentation
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Pre-hospital Thrombolysis Pre-hospital Thrombolysis in the UKin the UK
- looking ahead- looking ahead
Richard VincentRichard VincentRoyal Sussex County Hospital, BrightonRoyal Sussex County Hospital, Brighton
Pre-hospital thrombolysisPre-hospital thrombolysis
• Why attempt it?Why attempt it?
• What are the possibilities?What are the possibilities?
• Where are we now?Where are we now?
• What of the future?What of the future?
Pre-hospital thrombolysisPre-hospital thrombolysis
• Why attempt it?Why attempt it?
Pre-hospital thrombolysisPre-hospital thrombolysis
• The argument of natural historyThe argument of natural history
Why attempt it?Why attempt it?
Pre-hospital thrombolysisPre-hospital thrombolysis
• The argument of natural historyThe argument of natural history
• Persuasive clinical trialsPersuasive clinical trials
Why attempt it?Why attempt it?
Pre-hospital thrombolysisPre-hospital thrombolysis
0 - 1 hr0 - 1 hr 6565
1 - 2 hrs1 - 2 hrs 3737
2 - 3 hrs2 - 3 hrs 2626
3 - 6 hrs 3 - 6 hrs 2929
Lives saved per 1000 patients treatedLives saved per 1000 patients treatedof those with STof those with ST or LBBB or LBBB
Boersma, Lancet 1996Boersma, Lancet 1996
Pre-hospital thrombolysisPre-hospital thrombolysis
Reducing delay early after the onset of symptoms (A) Reducing delay early after the onset of symptoms (A) gives greater benefit than reducing delay later (B)gives greater benefit than reducing delay later (B)
Pre-hospital thrombolysisPre-hospital thrombolysis
• The argument of natural historyThe argument of natural history
• Persuasive clinical trialsPersuasive clinical trials
• The enthusiasm of a fewThe enthusiasm of a few
Why attempt it?Why attempt it?
Pre-hospital thrombolysisPre-hospital thrombolysis
• The argument of natural historyThe argument of natural history
• Persuasive clinical trialsPersuasive clinical trials
• The enthusiasm of a fewThe enthusiasm of a few
• Improved practicalityImproved practicality
Why attempt it?Why attempt it?
Pre-hospital thrombolysisPre-hospital thrombolysis
• The argument of natural historyThe argument of natural history
• Persuasive clinical trialsPersuasive clinical trials
• The enthusiasm of a fewThe enthusiasm of a few
• Improved practicalityImproved practicality
• The NHS plan and othersThe NHS plan and others
Why attempt it?Why attempt it?
Pre-hospital thrombolysisPre-hospital thrombolysis
• Why attempt it?Why attempt it?
• What are the possibilities?What are the possibilities?
Pre-hospital thrombolysisPre-hospital thrombolysis
• Report clinical and ECG data to hospitalReport clinical and ECG data to hospital
What are the possibilities?What are the possibilities?
recognise clinical AMI then:recognise clinical AMI then:
Pre-hospital thrombolysisPre-hospital thrombolysis
• Report clinical and ECG data to hospitalReport clinical and ECG data to hospital
• Report AMI and transmit ECG to hospitalReport AMI and transmit ECG to hospital
What are the possibilities?What are the possibilities?
recognise clinical AMI then:recognise clinical AMI then:
Pre-hospital thrombolysisPre-hospital thrombolysis
• Report clinical and ECG data to hospitalReport clinical and ECG data to hospital
• Report AMI and transmit ECG to hospitalReport AMI and transmit ECG to hospital
• Seek authorisation for on-site thrombolysisSeek authorisation for on-site thrombolysis
What are the possibilities?What are the possibilities?
recognise clinical AMI then:recognise clinical AMI then:
Pre-hospital thrombolysisPre-hospital thrombolysis
• Report clinical and ECG data to hospitalReport clinical and ECG data to hospital
• Report AMI and transmit ECG to hospitalReport AMI and transmit ECG to hospital
• Seek authorisation for on-site thrombolysisSeek authorisation for on-site thrombolysis
• Liaise with GP on siteLiaise with GP on site
What are the possibilities?What are the possibilities?
recognise clinical AMI then:recognise clinical AMI then:
Pre-hospital thrombolysisPre-hospital thrombolysis
• Report clinical and ECG data to hospitalReport clinical and ECG data to hospital
• Report AMI and transmit ECG to hospitalReport AMI and transmit ECG to hospital
• Seek authorisation for on-site thrombolysisSeek authorisation for on-site thrombolysis
• Liaise with GP on siteLiaise with GP on site
• Decide and treat without outside adviceDecide and treat without outside advice
What are the possibilities?What are the possibilities?
recognise clinical AMI then:recognise clinical AMI then:
Pre-hospital thrombolysisPre-hospital thrombolysis
• Why attempt it?Why attempt it?
• What are the possibilities?What are the possibilities?
• Where are we now?Where are we now?
Pre-hospital thrombolysisPre-hospital thrombolysis
• A growing level of interestA growing level of interest
Where are we now?Where are we now?
Pre-hospital thrombolysisPre-hospital thrombolysis
• A growing level of interestA growing level of interest
• A growing level of consultationA growing level of consultation
Where are we now?Where are we now?
Pre-hospital thrombolysisPre-hospital thrombolysis
• A growing level of interestA growing level of interest
• A growing level of consultationA growing level of consultation
• A new level of trustA new level of trust
Where are we now?Where are we now?
Pre-hospital thrombolysisPre-hospital thrombolysis
• A growing level of interestA growing level of interest
• A growing level of consultationA growing level of consultation
• A new level of trust A new level of trust
• Greater permission to use drugsGreater permission to use drugs
Where are we now?Where are we now?
Pre-hospital thrombolysisPre-hospital thrombolysis
• A growing level of interestA growing level of interest
• A growing level of consultationA growing level of consultation
• A new level of trust A new level of trust
• Greater permission to use drugsGreater permission to use drugs
• On-going technical development On-going technical development (equipment and drugs) (equipment and drugs)
Where are we now?Where are we now?
Pre-hospital thrombolysisPre-hospital thrombolysis
Reporting clinical and ECG data to hospitalReporting clinical and ECG data to hospital 2727
Reporting AMI and transmitting ECG to hospitalReporting AMI and transmitting ECG to hospital 2424
Seeking authorisation for on-site thrombolysisSeeking authorisation for on-site thrombolysis 2727
Liasing with GP on siteLiasing with GP on site 1717
Deciding and treating without outside adviceDeciding and treating without outside advice 2121
Ambulance trusts with an interestAmbulance trusts with an interest
JRCALC, Summer 2000JRCALC, Summer 2000
Pre-hospital thrombolysisPre-hospital thrombolysis
• Why attempt it?Why attempt it?
• What are the possibilities?What are the possibilities?
• Where are we now?Where are we now?
• What of the future?What of the future?
Pre-hospital thrombolysisPre-hospital thrombolysis
• Continued technical developmentContinued technical development
The future?The future?
Pre-hospital thrombolysisPre-hospital thrombolysis
• Continued technical development Continued technical development
• Increasing determination to make pre-hospital Increasing determination to make pre-hospital
successful including the use of successful including the use of
thrombolyticsthrombolytics
The future?The future?
Pre-hospital thrombolysisPre-hospital thrombolysis
• Continued technical development Continued technical development
• Increasing determination to make pre-hospital Increasing determination to make pre-hospital
successful including the use of successful including the use of
thrombolyticsthrombolytics
• A hard look at some challenging questions….A hard look at some challenging questions….
The future?The future?
Pre-hospital thrombolysisPre-hospital thrombolysis
MISTAKESMISTAKES
The futureThe futurewill also containwill also contain
Pre-hospital thrombolysisPre-hospital thrombolysis
• Organisation?Organisation?
Challenging questionsChallenging questions
Pre-hospital thrombolysisPre-hospital thrombolysis
• Organisation? Organisation?
• Ownership?Ownership?
Challenging questionsChallenging questions
Pre-hospital thrombolysisPre-hospital thrombolysis
• Organisation? Organisation?
• Ownership?Ownership?
• Competence?Competence?
Challenging questionsChallenging questions
Pre-hospital thrombolysisPre-hospital thrombolysis
• Organisation? Organisation?
• Ownership?Ownership?
• Competence?Competence?
• Training?Training?
Challenging questionsChallenging questions
Pre-hospital thrombolysisPre-hospital thrombolysis
• Organisation? Organisation?
• Ownership?Ownership?
• Competence?Competence?
• Training?Training?
• Psychology?Psychology?
Challenging questionsChallenging questions
Pre-hospital thrombolysisPre-hospital thrombolysis
• Diagnose death + appropriate ECG Diagnose death + appropriate ECG • Four observations + gross ECG changesFour observations + gross ECG changes• No contra-indicationsNo contra-indications• Immediate, visible benefitImmediate, visible benefit
• Patient can’t get worsePatient can’t get worse
Treating VF with a shockTreating VF with a shock
Pre-hospital thrombolysisPre-hospital thrombolysis
• Diagnose death + appropriate ECG Diagnose death + appropriate ECG • Four observations + gross ECG changesFour observations + gross ECG changes• No contra-indicationsNo contra-indications• Immediate, visible benefitImmediate, visible benefit
• Patient can’t get worsePatient can’t get worse
Treating VF with a shockTreating VF with a shock
Treating AMI with thrombolysisTreating AMI with thrombolysis• Diagnose MI + appropriate ECG Diagnose MI + appropriate ECG • Twenty observations + subtle ECG changesTwenty observations + subtle ECG changes• Important contra-indicationsImportant contra-indications• Delayed, invisible benefitDelayed, invisible benefit• Patient will sometimes get worse - early or latePatient will sometimes get worse - early or late
Pre-hospital thrombolysisPre-hospital thrombolysis
• Organisation? Organisation?
• Ownership?Ownership?
• Competence?Competence?
• Training?Training?
• Psychology?Psychology?
• Audit?Audit?
Challenging questionsChallenging questions
Pre-hospital thrombolysisPre-hospital thrombolysis
• Keep discussing Keep discussing
• Pray for wisdomPray for wisdom
So now…..So now…..