Part 7: The Era of Reperfusion

The acute coronary syndrome--pre-hospital diagnostic quality

BACKGROUND AND OBJECTIVE

In the Austrian emergency medical service (EMS), emergency medical technician-staffed and physician-staffed vehicles are in operation. Patients with suspected acute coronary syndromes (ACS) are treated in the pre-hospital phase and transported to the hospital by an emergency physician (EP). This study evaluates the diagnostic performance of EPs in ACS and the impact of this emergency system on the outcome of ACS in an urban area.

DESIGN

Retrospective case control study.

METHODS

All protocol sheets from the emergency physicians were searched for the diagnosis of ACS. The database of the emergency department (ED) was searched for patients with ACS as an admission diagnosis or ACS as discharge diagnosis. For patients admitted to an intensive care unit (ICU), the medical history from the ICU was reviewed. According to the diagnosis and the aggressiveness of therapy, patients were divided in five categories of severity at each stage of care (pre-hospital category, ED category, ICU category).

RESULTS

A total of 3585 patients was analysed. Only 17.8% of the patients with ACS as the admission diagnosis and 20.3% of the patients with ACS as the discharge diagnosis were transported by an EP. 46.8% of the ACS diagnosis by EPs were confirmed in hospital. Patients transported by EPs showed a higher all-cause mortality in hospital (1.6% vs. 0.6%; p=0.011). There was no significant correlation between the pre-hospital category of patients treated by EPs and the ED category. When a 12-lead-electrocardiogram was recorded, the correlation improved slightly (rho: 0.139; p=0.006).

CONCLUSIONS

The percentage of ACS patients transported to hospital by an EP is very low, and EPs seem to be "over-aware" in the diagnosis of ACS.

European Resuscitation Council Guidelines 2000 for Adult Advanced Life Support. A statement from the Advanced Life Support Working Group(1) and approved by the Executive Committee of the European Resuscitation Council

The European Resuscitation Council (ERC) last issued guidelines for Basic Life Support (BLS) in 1998 [1]. These were based on the 1997 International Liaison Committee on Resuscitation (ILCOR) Advisory Statements [2]. In 1999 and 2000 representatives of ILCOR, at the invitation of the American Heart Association, met on a number of occasions in Dallas to agree a Consensus on Science upon which future guidelines would be based. Representatives from the ERC played a prominent role in the deliberations, which culminated in the publication of "Guidelines 2000 for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care--A Consensus on Science" in August 2000 [3]. The consensus was evidence-based wherever possible. The ERC ALS Working Group has considered this document and has recommended some changes in the guidelines that will be suitable for European practice. These changes, together with a summary of the Sequence of Actions in ALS, are presented in this paper.