title: Pros, cons, and organization of prehospital thrombolysis.
abstract: BACKGROUND
  Early initiation of reperfusion therapy in ST-segment elevation myocardial infarction improves outcome. Prehospital thrombolysis (PHT) is 1 strategy to deliver earlier reperfusion.
  
  
  OBJECTIVE
  The goal of this study was to discuss the pros and cons of PHT and to describe the implementation of a program of PHT in the Hunter Region of Australia.
  
  
  METHODS
  Recent literature on PHT was reviewed to present a critical assessment of the evidence to support PHT. Different models of PHT are presented including the experience of the introduction of the Hunter program.
  
  
  RESULTS
  Meta-analyses of clinical trials and registries have shown that PHT significantly decreases the time to thrombolysis, with reduction in the incidence of cardiogenic shock and a trend to a mortality benefit. The STREAM study reinforces current policy, which favors primary percutaneous coronary intervention (PCI) over thrombolysis, providing that PCI can be performed within an appropriate time interval; emphasizes that timely thrombolysis linked to an early invasive strategy provides an equivalent outcome when timely primary PCI is not possible; and supports other published experience that early-rescue PCI can be performed safely after administration of PHT. Although PHT can be implemented by trained paramedics working with on-board physicians, the Hunter Region has successfully used paramedics and ECG telemetry in consultation with hospital-based physicians. When the time to open the artery is ≤90 minutes, primary PCI is preferred. When the time to open the artery is >90 minutes, PHT with immediate transport postthrombolysis to a PCI-capable hospital is feasible and effective.
  
  
  CONCLUSIONS
  PHT delivered by trained paramedics with telemetery backup to assist ECG interpretation is feasible and delivers the prospect of early reperfusion.
authors: Cardiovascular Department, John Hunter Hospital, New South Wales, Australia. peter.fletcher@hnehealth.nsw.gov.au
authors: Peter J
authors: PJ
authors: Fletcher
authors: Paul
authors: P
authors: Stewart
authors: Lindsay
authors: L
authors: Savage
mesh_terms: D004632:Emergency Medical Services; D004634:Emergency Medical Technicians; D006801:Humans; D009203:Myocardial Infarction / Q000188:drug therapy*; D062645:Percutaneous Coronary Intervention; D012042:Registries; D015912:Thrombolytic Therapy; D013997:Time Factors; D016896:Treatment Outcome
keywords: ambulance; myocardial infarction; prehospital thrombolysis