Prehospital Fibrinolytic Checklist

This figure is the Prehospital Fibronolytic Checklist, which consists of three primary steps and a series of “yes” or “no” questions. Step 1 contains the following question in a blue box: “Has the patient experienced chest discomfort for greater than 15 minutes and less than two hours.” If the answer is “No,” an arrow leads to a “Stop” sign. If the answer is “Yes,” an arrow leads down to another box that asks, “Does ECG show Stemi or new or presumably new LBBB?” If the answer is “No,” an arrow leads to a “Stop” sign. If the answer is “Yes,” an arrow leads to Step 2. It contains the following initial question in a blue box: “Are there contraindications to fibrinolysis? If any of the following [questions] is checked “yes,” fibrinolysis may be contraindicated.” A list of 10 yes-or-no questions follows under step 2.
  • Systolic blood pressure greater than 180 to 200 millimeters of mercury or diastolic blood pressure greater than 100 to 110 millimeters of mercury?
  • Right versus left arm systolic blood pressure difference greater than 15 millimeters of mercury?
  • History of structural central nervous system disease?
  • Significant closed head or facial trauma within the previous 3 months?
  • Stroke greater than 3 hours or less than 3 months?
  • Recent (within 2 two 4 weeks) major trauma, surgery (including laser eye surgery), G.I. or G.U. bleed?
  • Any history of intracranial hemorrhage?
  • Bleeding, clotting problem, or blood thinners?
  • Pregnant female?
  • Serious systemic disease (for example, advanced cancer, severe liver or kidney disease)?
Step 3 contains the following initial question in a blue box: “Is patient at high risk? If any of the following [questions] is checked “yes,” consider transfer to PCI facility.” A list of 5 yes-or-no questions follows under step 3.
  • Heart rate greater than or equal to 100 beats per minute and systolic blood pressure less than 100 millimeters of mercury?
  • Pulmonary edema (rales)?
  • Signs of shock (cool, clammy)?
  • Contraindications to fibrinolytic therapy?
  • Required CPR?
On the next-to-last question, “Contraindications to fibronolytic therapy?” the “yes” answer has a corresponding footnote. It states, “Consider transport to primary PCI facility as destination hospital.” The title of this figure, “Prehospital Fibrinolytic Checklist,” also directs to a footnote. “Contraindications for fibrinolytic use in Stemi are viewed as advisory for clinical decision making and may not be all-inclusive or definitive. These contraindications are consistent with the 2004 ACC / AHA Guidelines for the Management of Patients with ST-Elevation Myocardial Infarction.” This figure is copyright 2015 by the American Heart Association. There is a caption beneath this Figure which reads: “Prehospital fibrinolytic checklist. Adapted from Antman EM, et al. ACC/AHA guidelines for the management of patients with ST-elevation myocardial infarction: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Revise the 1999 Guidelines for the Management of Patients with Acute Myocardial Infarction). Circulation. 2004;110:e82-e292, with permission from Lippincott Williams & Wilkins. Copyright 2004, American Heart Association.”