Successful cricothyrotomy after thrombolytic therapy for acute myocardial infarction: a report of two cases.

Cricothyrotomy is an emergency airway procedure that is generally performed after failure of primary methods for securing the airway. Coagulopathy has traditionally been considered a relative contraindication to cricothyrotomy, but there is little evidence in the literature to support this. There have been no reports of successful cricothyrotomy in a patient who had received systemic thrombolytic therapy. This report, from the National Emergency Airway Registry, is the first to describe successful cricothyrotomy in this context. We describe 2 patients who received thrombolytic therapy and then had cricothyrotomy performed after failure of other airway measures. The first patient was a 67-year-old man who developed severe pulmonary edema and respiratory failure less than 30 minutes after administration of tissue plasminogen activator using an accelerated regimen. Both intubation and attempts at ventilation using an esophageal/tracheal double-lumen airway (Combitube, Kendall-Sheridan, Argyle, NY) were unsuccessful, and the emergency physician then performed an uneventful cricothyrotomy using a vertical midline incision. There were no complications, and bleeding was minimal. The second patient was a 45-year-old man who developed severe angioedema with respiratory compromise after receiving streptokinase for acute myocardial infarction. Intubation was impossible, and a cricothyrotomy was performed. Significant bleeding was controlled initially with packing and was semielectively explored later in the ICU with ligation of several small bleeding vessels. Prior administration of thrombolytic therapy does not preclude successful cricothyrotomy.

Prehospital thrombolysis: an idea whose time has come.

Aggressive reperfusion therapy for myocardial infarction (MI) characterized by acute ST-segment elevation leads to improved patient outcome. Furthermore, use of thrombolytic therapy is highly time-dependent: reperfusion therapy is beneficial within 12 h, but the earlier it is administered, the more beneficial it is. Thus, the focus of both prehospital and emergency department management of patients with acute MI is on rapid identification and treatment. There are many components to the time delays between the onset of symptoms of acute MI and the achievement of reperfusion in the occluded infarct-related artery. Time delays occur with both the patient and the prehospital emergency medical system, although patient delays are more significant. This article focuses on the prehospital management of acute MI, including (1) the rationale for rapid reperfusion in patients with acute MI, (2) the factors related to time delays in patient presentation to the hospital, and (3) strategies for reducing time delays, both patient- and medical system-based.

Emergency department thrombolysis critical pathway reduces door-to-drug times in acute myocardial infarction.

BACKGROUND: Rapid time to treatment with thrombolytic therapy is an important determinant of survival in acute myocardial infarction (AMI). HYPOTHESIS: We hypothesized that establishment of an AMI thrombolysis critical pathway in the Emergency Department could successfully reduce the "door-to-drug" time, the time between patient arrival and start of thrombolysis. METHODS AND RESULTS: Before establishment of the AMI critical pathway, median door-to-drug time was 73 min, which was reduced to 37 min after critical pathway implementation (p < 0.05). The percentage of patients treated within 30 min rose from 0% prior to establishment of the pathway to 43% (p = 0.03). Similarly, the percentage treated in within 45 min rose from 0 to 67% (p = 0.0005). Door-to-drug times were longer for women than for men (median 105 min for women vs. 70 min for men before pathway implementation). The pathway reduced door-to-drug time for both genders, but the median door-to-drug times were higher for women than for men (Mann-Whitney p = 0.013). The difference between men and women was 35 min before establishment of the pathway to 10 min by the end of the study period. CONCLUSIONS: Our critical pathway was successful in reducing door-to-drug times. We observed a "gender gap" in door-to-drug times, with longer mean times for women, which was reduced by the AMI critical pathway. Thus, our data provide support for the use of critical pathways to reduce door-to-drug times, as recommended by the National Heart Attack Alert Program.

Delay in thrombolysis administration: causes of extended door-to-drug times and the asymptote effect.

We retrospectively analyzed medical records and critical pathway data forms of all patients who received thrombolytic therapy for acute myocardial infarction (AMI) over a 2 1/2-year period. The time spent by each patient in the emergency department (ED) prior to receiving thrombolytic therapy (the door-to-drug time) was determined. Records of those patients with door-to-drug times exceeding the median were closely examined to determine the cause of treatment delays. Results indicated that treatment delays resulted from delays in obtaining the initial electrocardiogram (24%), atypical presentations (11%), the need to rule out a potential contraindication (11%), the need to confirm the diagnosis (14%), and miscellaneous causes (8%). Many patients had no identifiable reason for their delay (32%). A certain population of AMI patients either do not satisfy thrombolytic criteria upon initial ED presentation or require prolonged evaluation to investigate possible contraindications to thrombolysis such as aortic dissection. The inclusion of patients in this separate population in a general analysis of median door-to-drug times results in an artificial asymptote effect and may confound quality initiatives.

Management of the difficult airway in the trauma patient.

Airway management of the multiple trauma patient presents a series of challenges. By definition, many trauma patients present difficult airways that require a different approach and formulation of a planned series of steps before airway management is initiated. Recognition of specific attributes of the difficult airway, knowledge of appropriate techniques, familiarity with various devices, and prompt recognition of failed airway circumstances are necessary for optimal patient outcome. This article reviews the attributes of the difficult airway, the definition of the failed airway, and devices and techniques to be used in the management of difficult and failed airways in the trauma patient.

Clinical correlates and prognostic significance of early negative exercise tolerance test in patients with acute chest pain seen in the hospital emergency department.

An exercise tolerance test (ETT) is often performed to identify patients for early discharge after observation for acute chest pain, but the safety of this strategy is unproven. We prospectively studied 276 low-risk patients who underwent an ETT within 48 hours after presentation to the emergency department with acute chest pain. The ETT was considered negative if subjects achieved at least stage I of the Bruce protocol and the electrocardiogram showed no evidence of ischemia. There were no complications associated with ETT performance. The ETT was negative in 195 patients (71%); there was no identifiable subsets of patients at very low probability of an abnormal test. During the 6-month follow-up, patients with a negative ETT had fewer additional visits to the emergency department (17% vs 21%, respectively; p < 0.05) and fewer readmissions to the hospital (12% vs 17%; p < 0.01) than those with positive or inconclusive ETTs. No patient with a negative ETT died and only 4 patients with a negative ETT experienced a major cardiac event (myocardial infarction, coronary angioplasty, or bypass) within 6 months. Among these 4 patients, only 1 had an event within 4 months. In conclusion, our results suggest that ETT can be safely used to identify patients at low risk of subsequent events. Patients without a clearly negative test are at increased risk for readmission and cardiac events, and should be reevaluated either during the same admission or shortly after discharge.

Acute mesenteric ischemia in a middle-aged patient: case report and discussion.

Mesenteric ischemia usually occurs in elderly patients, especially those with predisposing factors. It has also been described in young patients using oral contraceptive pills or illicit drugs. We present a case of a middle-aged woman who developed acute focal ischemia of the small intestine without predisposing factors. The unusual presentation of this patient, combined with her relative youth, obscured the diagnosis, which was ultimately made at laparotomy. The diagnosis of mesenteric ischemia should be considered in patients of any age presenting with recurrent or severe abdominal pain, particularly when no alternative cause is apparent. The definitive study to diagnose mesenteric ischemia is angiography. Unless identified early in its course, the condition may progress to frank infarction with a significant increase in morbidity and mortality. Because of this, an aggressive approach to the diagnosis and therapy of mesenteric ischemia is essential.