Usefulness of self-administration of intramuscular lidocaine in the prehospital setting for ventricular tachyarrhythmias unassociated with acute myocardial infarction (the "Shahal" experience in Israel)

Part 8: adult advanced cardiovascular life support: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

The goal of therapy for bradycardia or tachycardia is to rapidly identify and treat patients who are hemodynamically unstable or symptomatic due to the arrhythmia. Drugs or, when appropriate, pacing may be used to control unstable or symptomatic bradycardia. Cardioversion or drugs or both may be used to control unstable or symptomatic tachycardia. ACLS providers should closely monitor stable patients pending expert consultation and should be prepared to aggressively treat those with evidence of decompensation.

Potential reduction of costs and hospital emergency department visits resulting from prehospital transtelephonic triage--the Shahal experience in Israel

BACKGROUND

The rising cost of services provided by hospital emergency departments is of major concern. Attempts to reduce the costs of emergency cardiac care have thus far focused primarily on medical and administrative management in the hospital. The role of the patient in appropriate prehospital decision-making has been generally ignored.

HYPOTHESIS

Membership in "Shahal" (an integrative telemedicine system) may have beneficial effects on patient decision-making and national health costs.

METHODS

During a 6-month period, a random group of subscribers who had called for medical assistance during the previous 24 h were asked what action they would have taken had they not been Shahal subscribers. All study patients were followed for at least 7 days.

RESULTS

In all, 1,608 subscribers (age 71 +/- 13 years) were included. Of these, 514 replied that they "would have waited," 363 "would have contacted their physicians," and 731 "would have sought emergency department care." Of the presenting medical problems, 86% were resolved without utilizing hospital facilities. A mobile intensive care unit was dispatched in 412 (26%) cases. A cost estimate of abuse indicated that the service resulted in a savings to the national economy of approximately $830,000 per 10,000 members per year.

CONCLUSIONS

This study demonstrated that Shahal membership can reduce costs of medical care and the number of hospital emergency department visits.

The "SHAHAL" experience in Israel for improving diagnosis of acute coronary syndromes in the prehospital setting

The diagnosis of acute coronary syndromes is frequently missed, and many high-risk patients fail to be admitted to hospital. The aim of this study was to assess the value of cardiac markers in ruling out acute ischemic events in patients with symptoms of possible cardiac origin and nondiagnostic electrocardiograms. The data collected between May 1999 and April 2000 for this prospective cohort study were retrieved from the records of 777 consecutive prehospital patients (mean age 70 years, 62.9% men) whose symptoms lasted for 6 to 48 hours, who were treated by mobile intensive care teams, and for whom the physician could not reach a clear-cut decision whether they should be taken to hospital or left at home. The cardiac markers, creatine kinase (CK-MB), myoglobin, and troponin I, were measured at the scene using a rapid Stat kit to qualitatively detect their presence in whole blood samples. Results were determined after 15 minutes at the scene. The assay was positive in 30 patients, 11 of whom had a definite cardiac diagnosis (acute myocardial infarction in 4 and unstable angina pectoris in 7). Positive and negative predictive values of the assay for detecting a significant coronary event were 36.7% and 100%, respectively. Of the 747 patients with a negative result, 6 patients had a false result (1 with myocardial infarction and in 5 with unstable angina) (99.2% negative predictive value). Thus, cardiac markers are useful in ruling out high-risk coronary syndromes in the prehospital setting when the clinical presentation and electrocardiogram are inconclusive.

The "telepress" system for self-measurement and monitoring of blood pressure (the "SHAHAL" experience in Israel)

No "white coat" effect contaminated the validity of measurements in 30 participants in a "Telepress" program, in which subscribers to a telecardiologic facility transtelephonically transmit their self-measured blood pressure values.