Prehospital Management of Patients with Chest Pain by 3 Mobile Intensive Care Units
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ORIGINAL ARTICLE Prehospital management of patients with chest pain by 3 mobile intensive care units JAVIER HERNÁNDEZ GARCÍA 1, A NTONIA MEDINA OSUNA 2, R EMEDIOS GARZÓN SIGLER 3 1Equipo Móvil Dispositivo Cuidados Críticos y Urgencias (DCCU) de Montoro, Córdoba, Spain. 2Equipo Móvil DCCU de La Carlota, Córdoba, Spain. 3Equipo Móvil DCCU de Palma del Río, Córdoba, Spain. CORRESPONDENCE : Objectives: Few studies have examined management by of patients with chest pain mobile Javier Hernández García intensive care units in rural areas. We sought to establish the characteristics of patients DCCU de Montoro attended; analyze the ability of mobile intensive care units to resolve the emergency; and Córdoba, Spain assess the application of recommendations, appropriateness of transfer destinations, and E-mail: [email protected] agreement with diagnoses made in the hospital emergency department. Methods: Retrospective observational study of chest pain emergencies attended by the RECEIVED : mobile intensive care units of the Guadalquivir health care district in Cordoba, Spain, between 9-10-2011 June 2009 and June 2010. We reviewed emergency care reports from the mobile units and the ACCEPTED : computerized medical history for each patient, collecting general patient data and 25-10-2011 cardiovascular risk factors. The following emergency care variables were collected: time until arrival on the scene of the emergency and time from the emergency scene until arrival at the CONFLICT OF INTEREST : hospital, probability of ischemic heart disease, diagnosis, treatments, referrals and transfer The authors declare no conflict decisions, and unit providing transport. The following information regarding resolution of the of interest in relation with the emergency was also recorded: destination after evaluation in the hospital emergency contents of the present article. department, diagnostic agreement, application of fibrinolysis, and subsequent events in patients not referred for further care. Results: A total of 278 cases were attended; the mean age was 72.12 years, and 55% were men. Women were older, the prevalence of arterial hypertension was higher in women, and fewer were smokers. Time until provision of emergency care was 9.7 minutes and time until arrival at a hospital emergency department was 93.1 minutes. Low probability of ischemic heart disease was recorded for 59.7%; 83.2% were resolved in the home, and 3.6% of these patients later experienced a coronary event. High probability of ischemic heart disease was recorded for 40.3%; this evaluation was associated with younger age, diabetes, smoking, and number of cardiovascular risk factors. General measures were implemented in over 90% of the cases; nitroglycerin was administered in 83.9%, morphine in 27.7%, and acetylsalicylic acid in 74.1%. Fewer patients received clopidogrel (23.9%) or heparin (17.4%), although use of these drugs improved during the study period. Chest pain unrelated to ischemic heart disease was diagnosed in 47.1%, nonspecific chest pain in 26%, and ischemic chest pain in 26.7%. The mobile unit's diagnosis and the hospital emergency department’s were in agreement in 75.3% overall, and in 100% of cases of acute coronary syndrome with ST-segment elevation and high-risk acute myocardial infarction. Hospital admission was ordered in 71.2%. Fibrinolysis was initiated in 40.6% of cases of acute coronary syndrome with ST-segment elevation. Conclusions: In spite of the wide geographic distribution of cases and advanced age of these rural patients, the mobile intensive care units provided quality care in responding to reports of chest pain. The mobile units were able to resolve many cases and provide a diagnosis. They followed treatment guidelines, but areas for improvement have been identified. [Emergencias 2013;25:13-22] Keywords: Chest pain. Emergency care, prehospital. Acute coronary syndrome. Introduction major one is ischemic coronary heart disease (CHD), which justifies research in this area, espe - Diseases of the circulatory system are the lead - cially taking into account that the highest mortali - ing cause of mortality in Western countries, and a ty occurs before reaching a hospital 1. The Compre - Emergencias 2013; 25: 13-22 13 J. Hernández García et al. hensive Care Plan of heart disease in Andalusia (PI - epidemiological characteristics of these patients, CA) 2005-2009 2 established a framework to identi - and on the measures employed 18-22 . Regarding di - fy and articulate appropriate interventions in pa - agnostic concordance, most of the relevant stud - tient attention, training and research. At the same ies 15-17,23 were performed in the ED and one re - time, it posited redesigning the traditional care ferred to non-traumatic CP 24 , while in the model centered on episodes towards a model of out-of-hospital setting we found one concordance attending chronic processes. This involves analyz - study with ED diagnoses in patients with CP 14 , ing the actions performed from initial demand for along with some references to the issue in work attendance until the end of the process and then with broader objectives 20 . define the recommended actions at each level of In the generic CP process 3, the objective of ini - care, according to scientific evidence. tial evaluation (directed anamnesis, physical ex - Concerning chest pain (CP), six care processes amination and ECG) is to obtain initial risk stratifi - have been published: generic CP 3, stable angina cation of the patient, considering the most serious (SA) 4, unstable angina (UA) / non- ST elevation potential diseases: CHD (SA, UA / NSTEACS, acute coronary syndrome (NSTEACS) 5; ST eleva - STEACS), AAS and PTE. Faced with CP and suspi - tion acute coronary syndrome 6 (STEACS), acute cion of any of these diseases, ten general meas - aortic syndrome 7 (AAS) and pulmonary throm - ures are recommended 1,18,19,22,25 : monitoring, a boembolism (PTE). They include recommenda - nearby defibrillator, rest, venous blood collection, tions that aim to reduce variability of the actions avoid intramuscular (im) injections, pulse oxime - of the professionals at each level of care. try, oxygen, analgesia with sublingual nitroglyc - The evaluation of patients presenting CP is a erin (NTG sl) and / or morphine, consider seda - major challenge for hospital emergency depart - tion and aspirin (except when AAS is suspected). ments (ED). According to various publications 9-11 , Refer potentially serious CP or CP of uncertain ori - there is a group of patients with high probability gin to hospital, by medicalized or conventional of having ACS judged by clinical symptoms, elec - ambulance according to whether the situation is trocardiogram (ECG) or enzyme elevation, and a considered life-threatening or not. second group with very low risk of having ACS In cases of stable angina 4, clinical evaluation because of young age, atypical pain, physical ex - should be widened to rule out UA / ACS, and then amination and normal ECG. Then there is a third the patient should be referred to a family physi - group with low-intermediate risk, which accounts cian, and in cases with pain, NTG sl and acetylsali - for half the patients treated, where a combination cylic acid (ASA) should be prescribed. In cases of of clinical factors and laboratory tests are needed UA/NSTEACS 5 and STEACS 6, in addition to the to reach a diagnosis 9. The medical history and general measures, consider the administration of type of pain are not reliable indicators of ACS 12 . NTG (iv) together with morphine or meperidine iv The same applies to the ECG 13 . In the case of out- until pain relief is achieved; beta blockers (BB) iv in of-hospital care, the challenge is even greater giv - cases of persistent pain, with ECG changes and hy - en the lack of complementary tests. peradrenergic state and no contraindications, and Early and correct diagnosis is essential for pa - dual antiplatelet therapy (aspirin + clopidogrel) in tient management and taking subsequent deci - moderate to high risk UA / NSTEACS and STEACS, sions, and sometimes determines patient progno - accompanied by low molecular weight heparin sis 14-16 . There is no standardized way to objectively (LMWH). Pre-hospital fibrinolysis, available on our express the quality of diagnoses made in the ED 17 , critical care and emergency ambulances (DCCU) although one of the parameters used is concor - since September 2011, is indicated in STEACS clas - dance between ED diagnosis and that made on sified as priority ARIAM I6 (pain typically lasting hospitalization 15 ; this not only allows assessing the >30 minutes and <6 hours which does not re - quality of care provided but also favors evaluation spond to NTG, <75 years without contraindica - of physician diagnostic capacity 15,16 . This may ap - tions, ST elevation >2 mm in at least 2 leads, sys - ply to mobile emergency teams (MET), compar - tolic blood pressure >100 or diastolic BP <100 ing their diagnoses with those made in the ED as mmHg, heart rate >50 bpm without atrioventricu - the reference, but using the latter as the gold lar block or bradycardia or tachycardia). The trans - standard could sometimes be erroneous 17 . fer to hospital, in both processes, involves being In general, few studies have been carried out attended by skilled health personnel. in Spain relating to the assessment and manage - The aims of the present work were to deter - ment of CP in the out-of-hospital setting. Some mine the epidemiological profile and cardiovascu - recent work has