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PRIMARY ANGIOPLASTY FOR ACUTE MYOCARDIAL INFARCTION (During Working Hours 07:30 – 14:30 hours Yahya kiwan Goal: • No delay. Time is muscle and muscle is life. • Applicable to: Cardiology 1st & 2nd on-call doctors, Interventional Cardiologists, cath lab nursing team, cath lab technicians, A/E doctors and nurses. • Hospital must: • Meet minimum requirements for program • Complete prescribed training and ongoing education programs • Adhere to a protocol including the selection of patients, data collection, in-service education and notification of any serious events involving a patient • Collect all data that is relevant • Clinical indications: – As alternative to fibrinolyic therapy (see Attachment I). – Or in fibrinolytic – ineligible patient (See Attachment II)) Clinical protocol • Clinical Selection Criteria (Class 1A) • The following criteria must be met for the selection of patients for the performance of primary angioplasty: • The patient is 18 years or more with no terminal illness. • The patient has no childbearing potential or has a negative pregnancy test • The patient presents with: • 1- > 30 minute ongoing ischemic cardiac pain • And • 2- > 0.1 mv ST- segment elevation in 2 or more contiguous ECG leads • Or • New or suspected new LBBB • Or • >0.1 mv ST segment depression in V and V2 consistent with true posterior infarction • And • 3- Who arrive in the ER < 12 hours after symptom onset Clinical Exclusion criteria Patients will be excluded from primary angioplasty procedures if any of the following conditions apply: • The patient’s symptoms of a myocardial infarction began > 12 hours prior to presentation at the Emergency Department • The patient has a sensitivity to contrast dyes, which cannot be adequately pre-treated with diphenhydramine and/or steroids. • The patient has severe peripheral vascular disease with inability of the operator to obtain vascular access. • Known terminal illness. • Known bleeding risk/ ongoing bleeding • Coronary anatomy not suitable for PCI 3-(Class II A): Primary PCI should be performed for patients in cardiogenic shock within 36 hours of the MI and within 18 hours of the shock 4-(Class II A): It is reasonable to do primary PCI with symptoms onset of 12-24 hours and one or more of the following: A)Severe CHF B)Hemodynamic or electrical instability C)Persistent ischemic symptoms 5- Primary angioplasty should not be performed if: 1. The infarct related artery cannot be identified. 2. There is severe triple vessel disease best treated with CABG (only a bridge balloon angioplasty of infarct related artery, or if the patient still unstable, then other vessels can be done). 3. There is > 50% stenosis of the left main coronary artery. 6- When to transfer patient from A/E to cath lab: - as time is muscle and muscle is related to survival. Every effort should be made to transfer patient without any delay: a) The patient should be given 300 mg Aspirin, 600 mg.Plavix b) I.V. cannula inserted. c) Consent form taken, then immediately transferred to cath lab without any other unnecessary paper work delay. The rest could be done in the cath lab. 7- Admission of patient from ED: A) Priority of admission for patients undergoing emergency PCI over all other admissions. B) Emergency admission shall be done for all cases transferred from the ED to the cath lab by the admission office regardless of the availability of beds in the hospital. This shall be done during transfer &/or during the PCI procedure. [N.B. If the bed is unavailable, a virtual ward can be created on SAM System for this reason through the I.T. Dept.) C) Bed management team & admission office in collaboration with cardiology department and nursing supervisor are responsible for finding a bed for these patients. D) If after the PCI beds are not at all available, then the patient is to be transferred to the CPU until the bed is made available (but the patient remains under cardiology care). All these efforts should not compromise the patient transefer to cath lab which is the most important priority . B) Quality Assurance (QA) • All staff (including, at a minimum, all interventional cardiologists, cath lab nurses, and cath lab technicians) as well as representatives of the Emergency Department and CCU staff shall participate in educational/ awareness creating sessions, emphasis on pain → door → door → cath lab and door to needle. REQUIREMENTS FOR ONGOING PARTICIPATION IN PRIMARY PCI SERVICE PROVISION A) All Physicians performing primary angioplasty Continue to perform no fewer than 100 cardiac catheterization procedures/ year (total diagnostic and therapeutic) of which at least 75 are angioplasty procedures B) In-service Education a) Training of all staff (including, at a minimum, all interventional cardiologists, cath lab nurses, and cath technicians) shall be performed on the intra-aortic balloon pump monthly. b) preferably staff including the interventional cardiologists, nurses, and technicians have a current ACLS certification. c) In-service programs will, at a minimum, be based upon needs identified through staff evaluation and the quality assurance process. C) Regular ongoing quality assurance and improvement Weekly review of door-to-needle time and evaluate means of improving the same.
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