pre-hospital thrombolysis in the uk - looking ahead

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?


• The argument of natural historyThe argument of natural history

Why attempt it?Why attempt it?



• Persuasive clinical trialsPersuasive clinical trials



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


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)




• The enthusiasm of a fewThe enthusiasm of a few






• Improved practicalityImproved practicality






• Improved practicalityImproved practicality

• The NHS plan and othersThe NHS plan and others



• 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:



• 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







• Liaise with GP on siteLiaise with GP on site

• Decide and treat without outside adviceDecide and treat without outside advice




• A growing level of interestA growing level of interest

Where are we now?Where are we now?



• A growing level of consultationA growing level of consultation





• A new level of trustA new level of trust





• A new level of trust A new level of trust

• Greater permission to use drugsGreater permission to use drugs





• 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)



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





• What of the future?What of the future?


• Continued technical developmentContinued technical development

The future?The future?


• 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



• 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….



MISTAKESMISTAKES

The futureThe futurewill also containwill also contain


• Organisation?Organisation?

Challenging questionsChallenging questions


• Organisation? Organisation?

• Ownership?Ownership?





• Competence?Competence?






• Training?Training?







• Psychology?Psychology?



• 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


• 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






• Psychology?Psychology?

• Audit?Audit?



• Keep discussing Keep discussing

• Pray for wisdomPray for wisdom

So now…..So now…..

pre-hospital thrombolysis in the uk - looking ahead

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