What is the role of thrombolytic therapy in pre-hospital treatment settings?

Updated: Aug 04, 2021
  • Author: Wanda L Rivera-Bou, MD, FAAEM, FACEP; Chief Editor: Erik D Schraga, MD  more...
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For some years, there has been controversy regarding the administration of thrombolytic drugs in the prehospital setting. Previously, out-of-hospital fibrinolysis was recommended only when patient transport time was longer than 1 hour. However, several studies and clinical trials have now demonstrated that out-of-hospital fibrinolysis is safe and reasonable. [75, 76] It can be performed by skilled, trained paramedics, nurses, or physicians under strict protocols.

The STREAM trial compared a pharmacoinvasive strategy of prehospital fibrinolysis with primary PCI in patients presenting within 3 hours who could not receive primary PCI within 1 hour of first medical contact. [76]

Patients who could not undergo primary PCI, received a bolus of tenecteplase. This was followed by rescue angioplasty if fibrinolysis failed or angiography 6-24 hours after randomization if fibrinolysis was successful. The tenecteplase dose was halved in patients older than 75 years after the suggestion of excess intracranial hemorrhage (ICH).

The study showed that prehospital phamacoinvasive strategy was equivalent to primary PCI in patients presenting within 3 hours after symptom onset and when a delay in primary PCI was anticipated.

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