STEMI, chest pain, prehospital

1. PREHOSPITAL THROMBOLYSIS
(PHT) PROJECT 2019
A propasal presentation for PKD Maran
Dr Sazwan RS & Team ETD HoSHAS

2. Introduction
• Pre hospital thrombolytic therapy for STEMI is
an inititiave of Emergency & Trauma
Department, Hospital Sultan Haji Ahmad Shah
with Pejabat Kesihatan Daerah Temerloh.
• This project involved two Klinik Kesihatan as
pilot project.
• Next: PKD Maran (KK Maran)

3. Current Scenario
• the standard of less than 30 minutes from
door to needle is accepted as best practice.
• in reality this is impossible to achieve if
patient walk-in to Klinik Kesihatan
• journey from a remote area to hospital may
take up to more than one hour in Temerloh.
• delay in the real door-to-needle time for this
patient.

6. KKM Type A Ambulance

7. Bilangan Pesakit STEMI/NSTEMI
JANUARI – OKTOBER 2017
STEMI/NSTEMI
TRIAGE/WALKIN
PHCTEAMHOSHAS
K.KJENGKA22
K.K.PEKANAWAH
K.KBANDAR
METAKAB
K.K.LANCHANG
K.K.SIMPANG
PELANGAI
K.K.CHENOR
K.K.PEKANTAJAU
K.K.TANJUNG
LALANG
K.K.PADANGLUAS
K.K.KEMAYAN
K.K.PURUN
K.K.BERA
K.K.TRIANG
KLINIKRAKYAT
TRIANG
K.KMARAN
K.K.CHEMOMOI
SWASTA
JUMLAHBULANAN
JANUARI
S 1 1 1 2 1 6
N 1 1 1 3
FEBRUARI
S 1 1 1 3
N 2 1 3
MAC
S 1 1 1 1 4
N 1 1 1 3
APRIL
S 1 1 2
N 2 1 1 1 5
MEI
S 1 1 1 1 1 5
N 1 1
JUN
S 1 1 1 3
N 1 1 2
JULAI
S 1 1 2
N 1 1 1 1 1 5
OGOS
S 3 2 1 1 1 8
N 1 1
SEPTEMBER
S 3 1 1 5
N 1 1 2
OKTOBER
S 2 1 1 2 6
N 0
JUMLAH
S 14 1 3 2 5 4 1 0 1 0 2 0 0 1 2 1 1 0 5
69
N 9 0 0 1 2 1 0 2 0 2 1 1 1 0 0 0 0 1 5

8. Literature review
• Started in early 1993
• Recommended in American Heart Association and
American College of Cardiology
• “AHA 2015 recommendation update: where
prehospital thrombolysis is available as part of
STEMI system of care, and in hospital fibrinolysis is
the alternative treatment strategy,it is reasonable to
administer prehospital fibrinolysis when transport
time more than 30minutes (Class 11a)”
• In many European systems, a physician provides
prehospital fibrinolysis, but non physicians can also
safely administer fibrinolytics.

12. The goals for each management step
are the following:
• time from symptom onset to first call to
emergency medical service (EMS): 5 min
• with 1 min EMS dispatch
• EMS on scene within 8 min
• ECG on scene and consider pre-hospital
fibrinolytic therapy by EMS if capable
• time to lytic therapy 30 min; if transportation to
a hospital without PCI capability
• if transportation to a hospital with PCI capability,
EMS-to-balloon time ,90 min

13. AHA/ACC guidelines state that:
• PHT should be performed only following the
confirmation of STEMI on a 12-lead ECG,
interpreted by a physician on site or after
transmission to a specialist.
• A reperfusion checklist should also be
completed to ensure that the patient has no
contraindications to thrombolytics.
• PHT should be performed within 30 min of the
arrival of the emergency services.

14. Objective
The objective of this project are:
1. early recognition of STEMI
2. early fibrinolytic theraphy for STEMI
3. close monitoring and transport to hospital for
STEMI by a trained providers.

15. Choice of Fibrinolytic?
1.Streptokinase
-most widely use
-not fibrin specific
-lower patency rate
-lower risk of ICB
-less reduction in mortality compare to fibrin specific
-antigenic and promotes production of antibodies(less
effective if given within 3days after or even 4yearsafter
first administration
-Regime:1.5mega unit in NS or D5% over 1hr

16. 2.Tenectaplase (TNK-tPA)
-more rapid perfusion (5 to
10 sec bolus) and single
bolus
-Regime ;per BW
30mg if <60kg
35mg if 60-70kg
40mg if 70-80kg
45mg if 80<90kg
50mg if >90kg
-Half dose for >75years age
-Heparin or enoxaparin
should be given
immediately after
complete fibrinolysis

17. Pre project preparation
Topic Time Presenter
Recognising & Predictors for
STEMI
2.30- 3.00 pm Dr Shahrin
ECG in STEMI 3.00 – 3.15 pm Dr Shahrin
Treatment & care of STEMI 3.15 – 3.40 pm Dr Shahrin
Drug, dose & preparation of
STEMI (includes practical)
3.40 – 4.20 pm Cik Izyan
Pre Hospital thrombolysis
algorithm & check list
4.20 – 4.40 pm PPP Hazrol

18. PRE HOSPITAL THROMBOLYSIS
ALGORHYTHM

19. Event of Pre hospital Thrombolysis
Time
1. Patient arrival in Klinik Kesihatan.
2. 1 st ECG.
3. Emergency Physician consult.
4. Decision for fibrinotherapy
5. Metalyse administer.
6. ALS team arrive.

20. READY DRUGS & EQUIPMENT FOR PRE
HOSPITAL THROMBOLYSIS
K.K.B.M K.K
Lanchang
Remark
1. S/L GTN √ √
2. Aspirin 300mg √ √
3. Clopidogrel 300mg × × STEMI Box
4. Metalyse × × STEMI Box
5. ECG machine √ √
6. Defibrillator/AED × × Suggestion to JKNP
for budget

22. Outcome
• This is a pilot project for Pahang. Time from
door to needle will be monitor. 30 days
survival rate will be monitor. All STEMI cases
in this project will be analyze.

23. The pathway
• Meeting PKD : 28/2/2018
• 1st
Bengkel with PKD : 8/3/2018
• 2nd
Bengkel with PKD : 23/3/18
• Moulage 30/3/2018
• Officially PHT start : 1/4/2018
• 1st
PHT patient : 13/5/2018

24. Workshop
Strong support from
Pegawai Kesihatan
Daerah

25. Simulation

26. STEMI BOX

28. Result

30. Thank you
Special thanks to
Dr Mohd Shahrin bin Ahmad Fuad (EP)
for lead this initiative
&
All members of ETD HoSHAS, Temerloh, KKBM
and KK Lanchang.

31. What if strepnokinase can be
infuse faster?

34. Issues
• Mainly about budget
• Streptokinase
RM600/vial
• Metalyse RM3000/vial
• Meeting with JKNP.
• Change to
Streptokinase?
• Metalyse only for AMI
Killip IV?
• PPP ready to stay &
play?
• Do ECG in ambulance?
• Who administer
Metalyse?
• Are our PHC well train
to ALS level?

35. Next step?
• Administration of
fibrinolytic therapy in
ambulance?
• Administration of
fibrinolytic therapy GP?