Prehospital selection of patients for thrombolysis by paramedics

Heart disease is the major cause of death in Wales. Myocardial infarction accounts for most fatalities either acutely or as a result of late heart failure and unheralded sudden cardiac death. Prompt relief of new coronary occlusions by thrombolytic agents has been shown to reduce significantly both early mortality and subsequent morbidity from acute myocardial infarction. The prehospital delivery of these drugs is feasible, and carries no greater risk than administration in hospital. This study tests the hypothesis that paramedics can identify patients with acute myocardial infarction who are suitable for prehospital thrombolysis, and thus reduce the "call to needle" time.

Paramedics from rural Wales were trained in the acquisition and recognition of 12 lead ECGs, and also in the modified indications for thrombolytic therapy as defined by the Joint Royal Colleges Ambulance Liaison Committee (JRCALC). Ninety six consecutive patients, with possible myocardial infarction, were included in the study. The paramedics made an independent decision regarding the eligibility of the patients for thrombolysis before hospital admission, noting the time that they could have administered the drug. These decisions were compared with the treatment subsequently received in hospital.

No errors were made by the paramedics in case selection (specificity of 100% (95% CI 95.9% to 100%)). There was a potential reduction in call to needle time of 41.2 minutes (95% CI 25.7 minutes to 56.9 minutes, p=0.001).

It was concluded that the paramedic selection of patients for the prehospital administration of a thrombolytic is both feasible and safe.