Clinical outcomes of fibrinolytic therapy for prehospital treatment of acute myocardial infarction

Fibrinolytic Therapy (FT) is an important form of treatment for cases of Acute Myocardial Infarction (AMI), especially in those places where Primary Percutaneous Coronary Intervention (PPCI) is not available, which is the main form of treatment and can be used even in the prehospital care. Aimed to describe the clinical outcomes of the use of FT in prehospital care for treating patients with AMI. This research covered a total of 53 patients and was carried out from march to october 2017, referring to the care provided from january 2015 to december 2016 in two stages, in which the first occurred with the Mobile Emergency Service (SAMU) and Walk-in Emergency Care Units (UPA), and the second in the referenced hospital services as gateways to those units. Data were collected from secondary sources. The clinical outcomes of FT considered in the form of absolute and relative frequencies and measures of central tendency were considered. The main signs and symptoms at admission were chest pain (84.62%), sweating (36.54%), dyspnea (26.92%), hypertension (19.23%), nausea (17.31%), malaise (17.31%) and emesis (13.46%). The main characteristic of chest discomfort was chest pain (70.45%). The FT drug administered in all patients was tenecteplase. The median time from symptom-to-door was 180 minutes, while symptom-reperfusion was 300 minutes and door-to-needle 160 minutes. Regarding the outcome, 74.47% had clinical improvement, 19.15% died, 4.25% had refractory AMI and 2.13% had reinfarction. The main characteristic of clinical improvement was the reversal of chest pain (68.57%), characterized as myocardial reperfusion criteria. The present study presented the main outcomes of FT use with improvement of those patients who were treated with it, and shorter times related to chest discomfort and the administration of FT were responsible for increasing the outcomes of clinical improvement and decreasing the outcome of death.

Post-Hypoxic Myoclonus Status following Out-of-Hospital Cardiac Arrest—Does It still Predict a Poor Outcome? A Retrospective Study

In patients with out-of-hospital cardiac arrest (OHCA), the initial prehospital treatment and transfer of patients directly to intervention clinics—bypassing smaller hospitals—have improved outcomes in recent years. Despite the improved treatment strategies, some patients develop myoclonic status following OHCA, and this phenomenon is usually considered an indicator of poor outcome. With this study, we wanted to challenge this perception. The regional prehospital database in Odense in the Region of Southern Denmark was searched for patients with OHCA from the period of 2011–2016. All 900 patients presenting with a diagnosis of OHCA were included in the study. Patients surviving to the hospital and presenting with myoclonic status were followed for up to one year. Only 2 out of 38 patients with myoclonic status and status epilepticus verified by an EEG survived more than one year. Eleven out of 36 patients with myoclonic status but without status epilepticus survived for more than one year. We found no evidence that myoclonic status is an unmistakable sign of poor outcome when not associated with EEG-verified status epilepticus. The conclusion for clinicians involved in post-resuscitation care is that myoclonic status is uncomfortable to witness but does not necessarily indicate that further treatment is futile.

Factors associated with inappropriate reduced doses of non-vita-min K antagonist oral anticoagulants in patients with atrial fibrillation

The objective was to study the factors associated with inappropriate reduced doses of non-vitamin K antagonist oral anticoagulants (NOACs) in patients with non-valvular atrial fibrillation (AF) in real outpatient practice.Methods and materials. 10663 case histories of patients hospitalized to the therapeutic clinic of the university for 5 years (2014 — 2018) were studied, 1307/10663 (12,3 %) case histories of patients with AF were selected. Factors associated with inappropriate low doses of anticoagulant therapy (ACT) with NOACs at prehospital treatment were studied.Results. NOACs received 57.7 % (384/665) of patients with AF at the outpatient stage: rivaroxaban — 180/384 (46.9 %) patients, dabigatran etexilate — 110/384 (28.6 %) patients, apixaban — 94/384 (24.5 %) patients. Inappropriate reduced doses of NOACs were revealed in 68/384 (17.7 %) patients: apixaban — 22/94 (23.4 %), dabigatran — 18/110 (16,4 %) and rivaroxaban — 28/180 (15.6 %) (p>0,05). Patients who received inappropriate reduced doses of NOACs as compared to those who received standard doses of NOACs had higher frequency of major bleedings in the past (7.4 and 1.0 %; p=0.014) and had higher risk of bleedings (HAS-BLED 1.7±1,1 and 1.2±1.0; p = 0.0002). Proportion of patients who had HAS-BLED≥3 in these groups were 19.1 % and 8.6 % (p=0.033). All patients who received inappropriate reduced doses of NOACs had modifiable risk factors of bleedings. 85.3 % of patients with AF who received inappropriate reduced doses of NOACs had high risk of stroke according to CHA2DS2-VASc scale.Conclusion. In real outpatient practice, NOACs were recommended to 57.7 % of patients with AF. 17.7 % of patients received NOACs s in inappropriate reduced doses. Frequency of major bleedings in the past and bleeding risk in AF patients with inappropriate reduced doses was higher than in patients with standard doses.

Clinical presentation and outcome of snakebite cases in a teaching hospital

Background: Snake bite is an important but under recognised public health issue in Bangladesh. It is one of the important cause of mortality in our country specially in this southern part of Bangladesh. Objective: This study was carried out to evaluate the common type of snake bite in local area with their clinical presentation and outcome of admitted patients in hospital. Methods: Patients of snake bite diagnosed by history and clinical examination were consecutively selected for the study after fulfillment of inclusion criteria in the inpatient department of medicine ward, Khulna Medical College Hospital from July 2017 to June 2018. Data were collected and analysed afterwards. Results: Among 54 snake bite patients 27 (50%) were female and 27 (50%) were male. Twenty nine (53.7%) were venomous snake bite and 25 (46.3%) were non venomous. The common victims were farmers 14 (25.9%) and housewife 19 (36.2%). The bites were commonly encountered during walking (30%) in rural area. Bite also occured during sleeping (20%). The majority of the snake bite was observed during the month of June & July. Total 95% patient applied multiple tight tourniquet in the affected limb. A common local practice was to receive prehospital treatment from 'Ohzas'. Among 29 poisonous cases, drooping of the upper eyelid was present in 29 (100%) patients, External Opthalmoplegia and broken neck sign were present in 19 (66.6%) patients. Among the venomous snake bite cases 25 (93%) patients recovered completely after getting antivenom. Conclusion: Neurological manifestation (Ptosis, Opthalmoplegia, Broken neck sign) are very common in venomous snake bite. Early detection and application of antivenom is needed for better outcome. Treatment of venomous snake bite with Polyvalent serum is successful and safe. Bang Med J Khulna 2020: 53 : 23-26

Prehospital treatment of rhabdomyolysis in people who fall

Of people aged 65 and older, 30% will fall at least once per year—for people aged over 80, this rises to 50%. Patients who remain on the floor for a long time are at risk of developing rhabdomyolysis. If a person cannot move or get off the floor, tissue necrosis can occur at the point of contact and skeletal muscle is destroyed, releasing its contents into the bloodstream. This can eventually lead to crush syndrome, which includes rhabdomyolysis, hyperkalemia, dysrhythmias and acute kidney injury, and can be fatal. There are no guidelines for a time period when rhabdomyolysis is more likely to occur nor international consensus on how to best treat this condition in and out of hospital. This article looks at rhabdomyolysis resulting from falls in elderly people, and how to recognise and manage it. The aim is to improve awareness of rhabdomyolysis among prehospital practitioners so they can improve its management and advise patients at home.

Prehospital unfractionated heparin and primary percutaneous coronary intervention

Unfractionated heparin (UFH) is an anticoagulant used by some, but not all, ambulance services in the treatment of patients who will undergo primary percutaneous coronary intervention (PPCI) due to ST-elevation myocardial infarction (STEMI). This study reviews the effectiveness and safety of prehospital unfractionated heparin administration to STEMI patients prior to PPCI, and considers whether it should be used more widely for these purposes across international ambulance services. A literature search was conducted to identify articles relevant to prehospital UFH administration prior to PPCI. The reviewed literature unequivocally demonstrates that early anticoagulant administration is safe, effective and highly appropriate for STEMI patients who subsequently undergo PPCI. This study find that anticoagulants such as UFH or, in some jurisdictions, enoxaparin—should be strongly considered as a standard feature of prehospital treatment regimens for STEMI patients who will subsequently undergo PPCI.