PPCI
Target:
Door to balloon 90min
Criteria Time:
Chest pain within 12hrs (or worsened within 12hrs)
ECG:
ST elevation MI (2 contiguous: 1mm Limb or 2mm Chest leads)
New LBBB.
(Posterior MI do posterior leads and discuss with LGI)
Actions:
Resuscitate as required
Contact PPCI team @ LGI (Mobile No. up in Resus)
Arrange blue light (P1) ambulance to LGI
Medication:
Prasagrel 60mg if – no previous CVA
Ticagrelor 180mg if previous CVA and Aspirin 300mg
Anti-coagulated Discuss with PPCI team
PPCI – POSTER
Trouble shooting
- Intubated patient: Often LGI would accept but need to arrange Cardiac ICU. If no bed patient could go for PPCI to return locally immediately after PPCI to our ICU’S?
- LGI Refusal: Occasionally the Leeds can’t/don’t accept your patient
- On Call Cardiology @CHT: they may be able to find alternatives or re discuss with LGI
- Calling Manchester and Sheffield: It’s worth a go but they don’t have agreements with us so having your patient accepted can be difficult
- Don’t Forget Thrombolyisis: We need to open up the patients artery, if there is no quick decision to go for PPCI – Consider Thrombolysis
Thrombolysis
This may not have all the advantages of PPCI but if unavailable within the 90min we should be thinking of thrombolysis. and the contraindications ESC
Thombolysis
Target:
Door > Needle 20min
Criteria/ECG:
As PPCI
Actions:
Resuscitate
Consider Contraindications
Consent
ECG monitoring
Repeat ECG 60min – If ST elevation remains Re-Refer for PPCI
Transfer to CCU
Medication options:
Tenectoplase – Best
Altaplase – Often reserved for Stroke
Streptokinase
Thrombolysis Contraindications
|
Absolute |
Relative |
|---|---|
|
Previous intracranial haemorrhage or stroke of unknown origin at any time |
Transient ischaemic attack in the preceding 6 months |
|
Ischaemic stroke in the preceding 6 months |
Oral anticoagulant therapy |
|
Central nervous system damage or neoplasms, or arteriovenous malformation |
Pregnancy or within 1-week post-partum |
|
Recent major trauma/surgery/head injury (within the preceding month) |
Refractory hypertension (systolic blood pressure >180 mmHg and/or diastolic blood pressure >110 mmHg) |
|
Gastrointestinal bleeding within the past month |
Advanced liver disease |
|
Known bleeding disorder (excluding menstrual) |
Infective endocarditis |
|
Aortic dissection |
Active peptic ulcer |
|
Non-compressible punctures in the past 24h (e.g. liver biopsy, lumbar puncture) |
Prolonged or traumatic resuscitation |
Pregnancy/Post-Partum
There is limited amount of data from the use of Tenectaplase in pregnant women. The benefit of treatment must be evaluated against the potential risks in case of myocardial infarction during pregnancy.
Consent
Improves the chances of surviving by approximately 25%,
Risks include;
- Significant bleeding, which is not normally life threatening and can occur in about 4 in 100 patients
- Life-threatening stroke, which can affect up to 2 in every 100 patients
- Allergic reactions: and other side effects that do not usually cause any major problems.
Drugs
Tenectaplase – National Shortage
***Fondaparinux 2.5mg IV STAT – should also be given with Tenectaplase***
Streptokinase – Preferred agent if alive
- 1’500’000 units over 60 minutes, to be initiated within 12 hours of symptom onset. – BNF
Alteplase – small stock for cardiac arrest only
- 50mg over 1-2 min (consider second dose after 15min if no ROSC)
