IFT1 Interfacility Transfer of STEMI Patients IFT2 Interfacility Transfer of Intubated Patients IFT3 Interfacility Transfer of Stroke Patients Interfacility Transfer Guidelines
IFT 1 TRANSFER INTERFACILITY TRANSFER OF STEMI PATIENTS Patients with ST-elevation Myocardial Infarction (STEMI) needing interventional cardiac care require timely transfer. A scene time of 10 minutes or less at the sending facility is ideal. OXYGEN MONITOR IV PROMPT TRANSPORT consider MORPHINE SULFATE BLS: Low flow unless ALOC / respiratory distress / shock ALS: Titrate to spo 2 of at least 94% Maintain TKO or other existing flow rate Transfer for definitive care is the priority in STEMI patients 2-20 mg in 2-4 mg increments for pain relief if BP greater than 90. Patients with STEMI often do not get complete relief with morphine treatment. Do not administer Morphine Sulfate if Right Ventricular MI is suspected Treatment during interfacility transfer varies from field approach to chest pain/acs: Confirmatory ECG for STEMI has been done by hospital and does not need repeat prior to transfer or en route to accepting facility Nitroglycerin treatment is not required and generally ineffective in patients with confirmed STEMI Aspirin or other anti-platelet treatment if indicated should be administered by sending hospital prior to patient departure Patients generally will be directed directly to catheterization laboratory Outcome in STEMI patients directly related to timeliness of intervention to relieve coronary artery blockage. Minimizing time delay in transfer is essential.
IFT 2 TRANSFER INTERFACILITY TRANSFER OF INTUBATED PATIENTS Patients requiring specialty care (most commonly trauma or neurosurgical care) may be transferred with an established endotracheal tube. Sedation may be required if patient agitation present because of risk of inadvertent extubation. NOTE: This treatment guideline pertains to sedation of intubated patients during interfacility transport only (not for patients with field response who are intubated). OXYGEN 100% VENTILATION CARDIAC MONITOR END-TIDAL CO 2 MONITORING PULSE OXIMETRY consider MIDAZOLAM MONITOR PATIENT As needed if patient with apnea or inadequate respiratory rate or effort Continuous monitoring with waveform capnography is required and must be established prior to departure from sending facility. Maintain end-tidal CO 2 between 35 and 45. ETCO 2 may not be reliable in patients with shock or significant lung injury. Maintain at least a minimum respiratory rate of 8-10 breaths per minute. For sedation in agitated or uncooperative patient: 2-5 mg IV in up to 2 mg increments. Repeat dosing with base contact only. Follow vital signs and ETCO 2 closely. If Midazolam administered, anticipate potential respiratory depression. Some patients may need paralysis and require additional nursing or physician staff to administer these medications If inadvertent extubation occurs, manage with basic airway maneuvers unless ventilation cannot be adequately maintained
IFT 3 TRANSFER INTERFACILITY TRANSFER OF STROKE PATIENTS Patients with acute stroke that may not qualify for thrombolytic therapy or that may not respond to thrombolytic therapy, necessitating transfer for potential interventional care OXYGEN CARDIAC MONITOR MONITOR VITAL SIGNS MONITOR IV PROMPT TRANSPORT BLS: Low flow unless ALOC / respiratory distress / shock ALS: Titrate to spo 2 of at least 94% Monitor blood pressure and Glasgow coma scale at least every 15 minutes. Use pulse oximetry - consider non-invasive end-tidal carbon dioxide monitoring if any respiratory difficulty. Maintain TKO or other existing flow rate Transfer for definitive care is the priority in stroke patients. Minimizing time delay is essential. Stroke patients who are transferred may have already received thrombolytic therapy or may not have qualified for thrombolysis based on length of time from stroke onset or other medical contraindications Ongoing administration of thrombolytic therapy requires additional qualified staff (nurse or physician) for transport Thrombolytic therapy in stroke patients is associated with around a 6% incidence of symptomatic intracerebral hemorrhage, and around a 1% of serious hemorrhage elsewhere Close monitoring is important. Significant changes in patient vital signs/gcs during transport should be reported immediately to receiving facility staff as it may affect immediate treatment: Hypotension may occur because of external or internal hemorrhage Hypertension may be related to acute intracranial process or underlying disease Respiratory depression or airway compromise may occur due to stroke or intracerebral hemorrhage Decreasing level of consciousness may occur due to stroke or intracerebral hemorrhage Cardiac dysrhythmias may occur in stroke patients (bradycardia or tachyarrhythmia) Observe for external hemorrhage in patients with prior administration of thrombolytics. Place direct pressure if hemorrhage noted. Related guidelines: Shock/Hypovolemia (A10), Altered level of consciousness (G2), Respiratory Depression or apnea (G12)