Helicopter Retrieval to Small Regional Hospital - Case Study Example

Helicopter Retrieval to Small Regional Hospital xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx Name xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx Course xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx Course Instructor xxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxxx Date Submitted The patient is not too sick to transfer, however the patient will require to be transported to the tertiary level hospital to receive the definitive management. In order to transport the patient, there will be need to provide the prehospital care to the patient which will be aimed at increasing chances of the patients survival before reaching the tertiary hospital for better management. The patient will be able to benefit from the prehospital management before he is transported to the hospital for the definitive management of myocardial ischaemia.The prehospital management of the patients condition(myocardial infarction) will be based on immediate offering of medical intervention since the loss of muscle cells starts to become irreversible in two hours after the infarction has occurred (Whitbread 2002,1967).The management will be aimed at the relieving of pain and the prevention of the occurrence of cardiac arrest. Early care of the patient will be much centered on the provision of reperfusion therapy to limit the infarct size and to prevent the extension as well as the expansion and treating of the immediate complications which include pump failure, shock and arrhythmias which are life threatening. The prevention of further infarction is also of importance and the reduction of the occlusion of the coronary artery on the myocardium. The initial diagnosis of myocardial infarction will be based on the chest pains, progressive dyspnea as well as the activation of the parasympathetic system which is characterized by the presence of hypotension (Bettencourt 2005, p.874). Prehospital management of on the ground before the transportation of the patient will involve the relieving of pain. This will be done not only for humane reasons but because the pain will be associated with the sympathetic activation which will bring about the vasoconstriction which will eventually result in the increase of the amount of work of the heart. The pain will therefore be managed by the use of intravenous morphine. If the opioids fail to relive the pain, repeated doses will then be necessary or then the intravenous beta blockers or the nitrates will also be effective in the management of pain. Intramuscular injections should be avoided since their absorption will be unreliable and the site of injection might bleed when the patient will be offered the thrombolytic therapy. The antiemetics will be given concurrently with the Opioids. Opioids could induce respiratory depression, hypostatic hypotension and bradycardia or tachycardia and muscle spasm which might have the negative effects to the patient since they will aggravate the condition. Other risks of using the opioids would be the setting in of urinary incontinence (Bettencourt 2005, p.874). Thrombolytic treatment is the cornerstone in the management of myocardial infarction. The aim of the therapy will be to complete and maintain the patency f the infacrted as well as the related arteries. The reperfusion therapy will also go ahead to prevent the reduction of cardiac function as a result of the myocardium undergoing irreversible necrosis due to complete occlusion of the blood vessels. The management should begin immediately for this condition since the resultant ischemia will only be reversible within 3 to 6 hours. The choices of reperfusion therapies will range from the use of the percuteneuos transluminal coronary angioplasty, thrombolysis and coronary bypass graft surgery. The choice of the procedure to be used will be based on the patient’s condition, the location and the extent of the ischemic process. Coronary angioplasty in the first is divided into two, primary angioplasty and angioplasty which is combined with thrombolytic therapy. There will also be need to provide ventilation to the patient due to the saturation levels of oxygen in the blood being low. This should also be done because the patient is breathless and is having the features of heart failure or shock. This will be aimed at addressing the need for perfusion of the various organs to prevent ischemia which would lead to necrosis on persisting. Thrombolytic therapy could lead to the patient developing hemorrhagic shock due to increased bleeding internally and this might affect the perfusion of various body organs and could result in end organ damage (McVaney 2005, p. 282). Primary angioplasty will also be done, and this will involve the opening up of the arteries affected by the thrombus through the use of balloon angioplasty. The use of angioplasty enables the successfully dilatation and opening up of the arteries (Lamfers 2003, p. 178). Angioplasty will go ahead to lower the risks of the patient developing stroke and also improves the conditions for coronary assessment. As well as the mortalities associated with cerebral bleeding. Primary angioplasty is the most effective option in the management of myocardial infarction in a prehospital set up. The only reasons why the process becomes disadvantageous is because it will require the provision of trained staff as well as appropriate facilities (Bonnefoy 2002, p. 825).This is what makes the thrombolytic therapy to be used since it is cheaper and also readily available intervention for myocardial ischemia in a prehospital set up. Thrombolytic agents often result in the lysis of the occlusion, removal of the obstruction and restoration of the flow of blood to the myocardium that was ishemic.The thrombolytic agents work by activating the plasmin enzyme which in turn goes ahead to denature fibrin. The thrombolytic agents would include streptokinase, plasminogen activator alteplase and urokinase (Nordt 2003, p. 1360).Thrombolytic therapy still offers the best results when used especially in the prehospital set up in the first three hours. The thrombolytic therapy however should not be initiated in the patient if there is a history of trauma, surgery, head injury or a bleeding disorder. The other thrombolytic agents that could be used would include streptokinase, anistreplase, urokinase and alteplase .The dosage for the thrombolytic agents should be based on the partial thrombin time Angioplasty could lead to various complications which include myocardial infarction, stroke, kidney problems and this could further worsen the condition of the patient since they will affect the maintenance of perfusion to various body organs (Henriques 2002, p. 76). There are various risks which will be associated with the transportation of the patient. We very well know that the patient has a cardiac attack which is one of the contraindications of flying. The transportation of the patient will be done even though he has the risk of developing deep venous thrombosis which will even make the condition of the patient to become worse. It is for this reason that the patient is given the antiplatelets such as aspirin to help in the minimization of the risk of the development of deep venous thrombosis. Also during flying, the patient will be exposed to low oxygen due to the high altitude and this might result in less blood supply to the heart muscles as well as the major body organs and this will end up worsening the condition of the patient. It is for this reason that the patient will be put on the extracorporeal membrane oxygenation to enable the continued oxygenation of the blood hence preventing hypoxia (Fogoros 2007, p.1). Extracorporeal membrane oxygenation is a special procedure that uses an artificial heart lung machine to take over the functions of the lungs and sometimes the heart. Extracorporeal membrane oxygenation is a machine that assists the patients to breath after the inotropic and ventilators not failure to relieve the patient from cardiogenic shock or cardio respiratory failure. The machine supports the systemic circulation and ensures t he diastolic perfusion of the heart muscles or myocardium as well as the reduction of cardiac workload (Martin, 894). There are two types of extracorporeal membrane oxygenation machines and they include the venoarterial extracorporeal membrane oxygenation machine which supports the lungs and is used in patients who have problems with their blood pressures or those having problems in heart functions and respiratory problems. The second type of the extracorporeal membrane oxygenation machine is the venovenous extracorporeal membrane oxygenation machine which is basically used for lung support only. The venoartrial extracorporeal membrane oxygenation machine requires the placing of to carnulas one at the jugular and the other at the carotid artery. In the venovenous, a plastic tube is placed into the jugular vein through a small incision at the neck. The extracorporeal membrane oxygenation machines is a modified  form of a lung bypass that involves the use of the artificial lung(membrane) which is located outside the body(extracorporeal) which facilitates the oxygenation of blood and this will go a long way to maintain the perfusion of body tissues (Martinet al 2006, p. 894). The use of the extracorporeal membrane oxygenation machine is indicated in respiratory failure as well as cardiac failure. It is also used after surgery of the heart to allow it to recover. The extracorporeal membrane oxygenation machine circuit is placed into the large vessels which are normally adjacent to the heart. This will involve a small incision being made along the right side of the neck. A carnula is then placed in the large vein at the neck that normally leads to the right atrium of the heart. Another carnula will be placed in the carotid artery. The carnulas are then connected to the tubing of the extracorporeal membrane oxygenation machine and will therefore bypass the normal circulation. The oxygen rich blood will then be carried to the rest of the body. Then the tubes are connected to the extracorporeal membrane oxygenation machine circuit, the machine is then turned on. The pump pushes blood through the artificial lung membranes where oxygen is added while carbon dioxide is removed. The size of the artificial lung will greatly depend on the size of the patient and some patients can even end up using two lungs. The amount of blood that flows through the extracorporeal membrane oxygenation machine use will be decreased or lowered every time there is shown improvement of the heart functions and this will continue until the heart will now take over its functions fully. When the patient is using the extracorporeal membrane oxygenation machine, he or she will be placed on medication and this will include heparin to prevent the blood from clotting, antibiotics to cover for the infections that are likely to occur, the antibiotics will prevent as well as treat the various infections which are likely to occur. The patient will also be given sedatives to help relieve the patient from pain and also to limit the motion and prevent agitation of the patient.Lasix will be administered to facilitate proper kidney function by getting rid of urine. The patient will also be given various electrolytes in order to maintain the adequate balance of the salts and sugars in the body. While using the extracorporeal membrane oxygenation machine there is likely hood of blood loss hence blood products will need to be transfused (Martin et al 2006, p. 894). During the period the patient uses the extracorporeal membrane oxygenation machine, nutrition will be provided will be intravenously or through a nosogastric tube. The risks and complications during the use of extracorporeal membrane oxygenation machine will be greatly attributed to the duration of usage of the machine. The risks and possible complications of the use of the extracorporeal membrane oxygenation machine will include the bleeding which normally occurs at the site of incision. Intravascular hemorrhage and this will require frequent monitoring by conducting periodic ultra sounds. There will also be increased risks of one getting a stroke when using the extracorporeal membrane oxygenation machine and this is because during the use of the venoartrial extracorporeal membrane oxygenation machines, the carotid artery is normally tied. Infections could also occur at the site of incision off and this is one of the arteries that take blood to the brain and whenever sterile procedures are not adhered to while placing the carnulas as well as during the insertion of the tubes. Transfusions that are normally done when one is using the extracorporeal membrane oxygenation machine will normally lead to transfusion related lung injuries as well as infections that are blood borne such as hepatitis and aids. Injury to other parts of the body can also result from small clots and air bubbles getting into the blood from the tubes and this could lead to embolism which can have fatal repercussions. The blood to other complications would include renal failure that will result from decreased perfusion of the kidneys (Martin et al 2006, p. 894). References Bonnefoy, E, Steg, PG, Chabaud, S, 2002.Comparison of Angioplasty and Prehospital Thrombolysis in Acute Myocardial Infarction study group, Primary angioplasty versus prehospital fibrinolysis in acute myocardial infarction: a randomized study, Lancet 360825–829. Henriques JPS,F Zijlstra, A W J van ’t Hof, M-J de Boer, J-H E Dambrink, A,T,M Gosselink, JCA, Hoorntje ,J, P, Ottervanger, H, Suryapranata , 2006. Primary PCI versus thrombolytic therapy: long‐term follow‐up according to infarct location, Heart 9275–79. Nordt, T K, Moser, M, Kohler, B, 2003. Thrombolysis: Newer thrombolytic agents and their role in clinical medicine. Heart, 891358–1362. Whitbread, M, Leah, V, Bell, T, Coats, T,J, 2002. Recognition of ST elevation by paramedics. Emerg Med J. 1966–67. Lamfers, E, J, Lapostolle, F, Leizorovicz, A, 2003. Primary angioplasty or thrombolysis for acute myocardial infarction? Lancet, 36177–78. Bettencourt, N, Gonçalves, C, Simões, L, 2005. Impact of pre‐hospital emergency in the management and prognosis of acute myocardial infarction. Rev Port Cardiol 24863–872. McVaney , KE, Macht, M, Colwell,CB, Pons PT, 2005.Treatment of suspected cardiac ischaemia with aspirin by paramedics in an urban emergency medical services system. Prehosp Emerg Care 2005:9:282e4. Martin, R, Fanaroff, A, Walsh, M, eds.Fanaroff and Martin's, 2006. Neonatal-Perinatal Medicine, 8th ed. Philadelphia, Pa: Mosby Elsevier, 894. Fogoros R., (2007).Guidelines for Flying with Heart Disease, The New York Times Company, New York. Read More