The Queensland Ambulance Service (QAS) has for several years has been moving towards expanding access to integrated coronary artery reperfusion treatments statewide This has included the implementation of 12-lead ECG devices with interpretive algorithms in all ambulances and the introduction of various pharmacological agents to Critical Care Paramedics (CCPs) and Advanced Care Paramedics Level II (ACPII)

For six years CCPs have autonomously identified treated and referred acute ST-elevation myocardial infarction (STEMI) patients under the QAS reperfusion strategy Expansion of this strategy to include Decision Supported Fibrinolysis Administration (DSFA) and Decision Supported primary Percutaneous Coronary Intervention Referral (DSpPCIR) procedures for ACPII officers extends timely access to care for provincial rural isolated and remote Queenslanders

The decision supported procedures for ACPII level officers involve senior QAS CCPs and doctors or specialist cardiologists (via the QAS pPCI Referral Line) providing ECG review and clinical advice within the overarching QAS Clinical Practice Guidelines Procedures and Drug Therapy Protocols

Audit and clinical quality assurance

raquo All cases involving coronary artery reperfusion require ACPII officers to utilise the 247 QAS Clinical Consultation and Advice Line to obtain decision support from a QAS on-call Senior Critical Care Paramedic or Medical Officer

raquo All calls to the QAS pPCI Referral Line and the 247 QAS Clinical Consultation and Advice Line are recorded and reviewed for clinical quality assurance and ongoing training purposes

raquo All attended cases of suspected AMI (whether referred for pPCI or not) are subject to clinical audit and review The following information is reviewed

rsaquo Fibrinolysis Administration Checklist OR pPCI Referral Checklist rsaquo STEMI Reperfusion Capture Form rsaquo QAS electronic Ambulance Report Form (eARF) rsaquo Diagnostic 12-lead ECG rsaquo Cardiac monitor vital sign (code) summary

Department of Health

Queensland Ambulance Service

Decision Supported Coronary Artery Reperfusion

Strategies

Great state Great opportunity

And a plan for the future

Version November 2014

raquo Proximity to a pPCI facility

rsaquo Patient located gt 60 minutes transport time (from time of diagnostic 12-Lead ECG) to a pPCI capable hospital

raquo Patient assessment

rsaquo GCS = 15 AND rsaquo Classic ongoing ischaemic chest pain lt 6 hours in

duration Note Atypical ischaemic chest pain is excluded

raquo 12-Lead ECG consistent with STEMI

rsaquo Persistent ST-segment elevation of ge 1 mm in at least two contiguous limb leads ANDOR ST-segment elevation of ge 2 mm in at least two contiguous chest leads (V11048586ndash1048586V6) AND

rsaquo Normal QRS width (lt 012 seconds) OR right bundle branch block (RBBB) identified on the 12-Lead ECG

raquo Decision supported

rsaquo Cardiac Monitoring interpretation prints ACUTE MI SUSPECTED on the 12-Lead ECG AND

rsaquo The treating Paramedic has contacted the QAS Clinical Consultation and Advice Line and following review of the 12-Lead ECG via telemetry has been advised that the patient is suitable for pre-hospital fibrinolysis administration

raquo Contraindications

rsaquo gt 75 years of age rsaquo uncontrolled hypertension (systolic BP gt 180

mmHg ANDOR diastolic BP gt 110 mmHg at any stage during current acute episode)

rsaquo known allergy to tenecteplase enoxaparin or clopidogrel

rsaquo left BBB identified on 12-Lead ECG rsaquo current or history of thrombocytopenia rsaquo active tuberculosis rsaquo known cerebral disease in particular a malignant

intracranial neoplasm OR arteriovenous malformation

rsaquo prior intracranial haemorrhage

rsaquo Ischaemic stroke or TIA within last 3 months rsaquo history of significant closed head or facial trauma

within last 3 months rsaquo suspected aortic dissection (including new

neurological symptoms) rsaquo history of major trauma or surgery (including laser

eye surgery) within last 6 weeks rsaquo internal bleeding (eg gastrointestinal (GI) or

urinary tract bleed) within last 6 weeks (excluding menses)

rsaquo bleeding or clotting disorder eg haemophilia rsaquo current use of anticoagulants (eg warfarin)

excluding aspirin or Plavix rsaquo non-compressible vascular punctures rsaquo prolonged (gt10 minutes) CPR rsaquo known pregnancy or delivered within the last 2

weeks rsaquo history of serious systemic disease (advanced

terminal cancer severe liver or kidney disease) rsaquo resident of an aged care facility requiring

significant assistance with activities of daily living rsaquo acute myocardial infarction in the setting of

trauma

The Paramedic will explain to the patient the risks associated with fibrinolysis therapy and will also obtain informed consent from the patient

STEMI patient meets QAS fibrinolysis criteria

Decision support and consent obtained for enoxaparin tenecteplase and clopidogrel

Administer enoxaparin30mg IV tenecteplase and clopidogrel 300mg

Administer enoxaparin 1mg kg (max 100mg) subcutaneous at 15 minutes post initial dose

Transport to hospital

raquo Proximity to a pPCI facility

rsaquo Patient located lt 60 minutes transport time (from time of diagnostic 12-Lead ECG) to a QAS approved decision supported pPCI hospital

Patient assessment 12-Lead ECG consistent with STEMI decision support - refer decision supported fibrinolysis administration

The treating Paramedic contacts the QAS Clinical Consultation and Advice Line and following review of the 12-Lead ECG is advised that the patient is suitable for pPCI referral

raquo Contraindications

rsaquo History of serious systemic disease rsaquo Resident of an aged care facility requiring

significant assistance with activities of daily living rsaquo Myocardial infarction in the setting of acute

traumaThe Paramedic will explain to the patient the risks associated with antiplatelet therapy (as appropriate) and associated drug administration The Paramedic obtains informed consent from the patient and request the patient sign a Decision Supported pPCI Referral Checklist prior to any further action

rsaquo Paramedic will contact the appropriate pPCI facility using the dedicated QAS pPCI referral line (1300 313 952) and speak to the interventional Cardiologist using the following narrative

ldquoCan I confirm I have contacted [hospital] I am an Advanced Care Paramedic with the QAS I have a [XX] year old [gender] located at [suburb] who has had an onset of chest pain at [time] The cardiac monitor indicates lsquoacute MI suspectedrsquo and the 12-Lead ECG is consistent with a(n) [XX] STEMI

The estimated transport time to your facility is [XX] minutes Are you willing to accept this patient for primary PCIrdquo

If the patient is accepted for pPCI the Paramedic will confirm with the interventional cardiologist their preferred antiplatelet agent (180 mg ticagrelor OR 600 mg clopidogrel OR nil) then administer medications (heparin AND EITHER ticagrelor OR clopidogrel OR nil) in accordance with the QAS Codes of Practice

If the patient is unable to be accepted for pPCI the Paramedic will continue treatment in accordance with the relevant QAS Clinical Practice Guideline (CPG)

Patients will be transported lsquoCode 1rsquo (lights and sirens) to hospital

STEMI patient meets pPCI criteria

Decision support amp consent obtained for heparin AND EITHER ticagrelor OR clopidogrel

OR nil administration

Refer patient to pPCI facility (1300 313 952)

Confirmation with the interventional cardiologist their preferred antiplatelet agent

(ticagtrelor OR clopidogrel OR nil)

Administer heparin 5000 units IV

Administer ticagrelor 180 mg oral OR clopidogrel 600 mg oral OR nil as requested by

interventional cardiologist

Transport code 1 to pPCI facility

Rapid recognition of STEMI with prompt restoration of coronary artery perfusion is the key to myocardial salvage and decreasing mortality

Paramedic initiated pre-hospital fibrinolysis has been demonstrated to be safe and effective and can minimise the time to definitive treatment

Decision supported fibrinolysis administration (ACPII) is considered for all patients meeting the following criteria

The triage of STEMI patients by paramedics direct to a primary percutaneous coronary intervention (pPCI) has demonstrated a reduction in mortality

Decision supported pPCI referral (ACP II) is considered for all patients meeting the following criteria

raquo Proximity to a pPCI facility

rsaquo Patient located gt 60 minutes transport time (from time of diagnostic 12-Lead ECG) to a pPCI capable hospital

raquo Patient assessment

rsaquo GCS = 15 AND rsaquo Classic ongoing ischaemic chest pain lt 6 hours in

duration Note Atypical ischaemic chest pain is excluded

raquo 12-Lead ECG consistent with STEMI

rsaquo Persistent ST-segment elevation of ge 1 mm in at least two contiguous limb leads ANDOR ST-segment elevation of ge 2 mm in at least two contiguous chest leads (V11048586ndash1048586V6) AND

rsaquo Normal QRS width (lt 012 seconds) OR right bundle branch block (RBBB) identified on the 12-Lead ECG

raquo Decision supported

rsaquo Cardiac Monitoring interpretation prints ACUTE MI SUSPECTED on the 12-Lead ECG AND

rsaquo The treating Paramedic has contacted the QAS Clinical Consultation and Advice Line and following review of the 12-Lead ECG via telemetry has been advised that the patient is suitable for pre-hospital fibrinolysis administration

raquo Contraindications

rsaquo gt 75 years of age rsaquo uncontrolled hypertension (systolic BP gt 180

mmHg ANDOR diastolic BP gt 110 mmHg at any stage during current acute episode)

rsaquo known allergy to tenecteplase enoxaparin or clopidogrel

rsaquo left BBB identified on 12-Lead ECG rsaquo current or history of thrombocytopenia rsaquo active tuberculosis rsaquo known cerebral disease in particular a malignant

intracranial neoplasm OR arteriovenous malformation

rsaquo prior intracranial haemorrhage

rsaquo Ischaemic stroke or TIA within last 3 months rsaquo history of significant closed head or facial trauma

within last 3 months rsaquo suspected aortic dissection (including new

neurological symptoms) rsaquo history of major trauma or surgery (including laser

eye surgery) within last 6 weeks rsaquo internal bleeding (eg gastrointestinal (GI) or

urinary tract bleed) within last 6 weeks (excluding menses)

rsaquo bleeding or clotting disorder eg haemophilia rsaquo current use of anticoagulants (eg warfarin)

excluding aspirin or Plavix rsaquo non-compressible vascular punctures rsaquo prolonged (gt10 minutes) CPR rsaquo known pregnancy or delivered within the last 2

weeks rsaquo history of serious systemic disease (advanced

terminal cancer severe liver or kidney disease) rsaquo resident of an aged care facility requiring

significant assistance with activities of daily living rsaquo acute myocardial infarction in the setting of

trauma

The Paramedic will explain to the patient the risks associated with fibrinolysis therapy and will also obtain informed consent from the patient

STEMI patient meets QAS fibrinolysis criteria

Decision support and consent obtained for enoxaparin tenecteplase and clopidogrel

Administer enoxaparin30mg IV tenecteplase and clopidogrel 300mg

Administer enoxaparin 1mg kg (max 100mg) subcutaneous at 15 minutes post initial dose

Transport to hospital

raquo Proximity to a pPCI facility

rsaquo Patient located lt 60 minutes transport time (from time of diagnostic 12-Lead ECG) to a QAS approved decision supported pPCI hospital

Patient assessment 12-Lead ECG consistent with STEMI decision support - refer decision supported fibrinolysis administration

The treating Paramedic contacts the QAS Clinical Consultation and Advice Line and following review of the 12-Lead ECG is advised that the patient is suitable for pPCI referral

raquo Contraindications

rsaquo History of serious systemic disease rsaquo Resident of an aged care facility requiring

significant assistance with activities of daily living rsaquo Myocardial infarction in the setting of acute

traumaThe Paramedic will explain to the patient the risks associated with antiplatelet therapy (as appropriate) and associated drug administration The Paramedic obtains informed consent from the patient and request the patient sign a Decision Supported pPCI Referral Checklist prior to any further action

rsaquo Paramedic will contact the appropriate pPCI facility using the dedicated QAS pPCI referral line (1300 313 952) and speak to the interventional Cardiologist using the following narrative

ldquoCan I confirm I have contacted [hospital] I am an Advanced Care Paramedic with the QAS I have a [XX] year old [gender] located at [suburb] who has had an onset of chest pain at [time] The cardiac monitor indicates lsquoacute MI suspectedrsquo and the 12-Lead ECG is consistent with a(n) [XX] STEMI

The estimated transport time to your facility is [XX] minutes Are you willing to accept this patient for primary PCIrdquo

If the patient is accepted for pPCI the Paramedic will confirm with the interventional cardiologist their preferred antiplatelet agent (180 mg ticagrelor OR 600 mg clopidogrel OR nil) then administer medications (heparin AND EITHER ticagrelor OR clopidogrel OR nil) in accordance with the QAS Codes of Practice

If the patient is unable to be accepted for pPCI the Paramedic will continue treatment in accordance with the relevant QAS Clinical Practice Guideline (CPG)

Patients will be transported lsquoCode 1rsquo (lights and sirens) to hospital

STEMI patient meets pPCI criteria

Decision support amp consent obtained for heparin AND EITHER ticagrelor OR clopidogrel

OR nil administration

Refer patient to pPCI facility (1300 313 952)

Confirmation with the interventional cardiologist their preferred antiplatelet agent

(ticagtrelor OR clopidogrel OR nil)

Administer heparin 5000 units IV

Administer ticagrelor 180 mg oral OR clopidogrel 600 mg oral OR nil as requested by

interventional cardiologist

Transport code 1 to pPCI facility

Rapid recognition of STEMI with prompt restoration of coronary artery perfusion is the key to myocardial salvage and decreasing mortality

Paramedic initiated pre-hospital fibrinolysis has been demonstrated to be safe and effective and can minimise the time to definitive treatment

Decision supported fibrinolysis administration (ACPII) is considered for all patients meeting the following criteria

The triage of STEMI patients by paramedics direct to a primary percutaneous coronary intervention (pPCI) has demonstrated a reduction in mortality

Decision supported pPCI referral (ACP II) is considered for all patients meeting the following criteria