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Thanks for the excellent scenario, Dave.

A few points to add about POC troponin and STEMI / NSTEMI care:

* Troponins can take a long time to bump, so a single negative troponin is not an effective cardiac rule-out

* Conversely, most NSTEMI patients don't require emergent catheterisation

* The presence of absence of STEMI indicates the need for emergent reperfusion therapy. If there's a STEMI pattern, they need to either be lysed or cathed, depending on their risk factors, comorbidities, the availability of cathlab, and the age of their MI.

* In the first 2 hours, field fibrinolysis may actually outperform PCI (*Unless your site is basically always ready to go, and has an open suite 24-7, it is extremtly hard to actually cath someone in the first 60-90 mins of an MI -- a paramedic team can have someone lysed in 25 minutes, sometimes quicker), and has at least comparable benefit in carefully selected patients.

Re: TXA

* CRASH-2 is a great study because it shows that even in a broad, poorly differentiated population, there was no real increase in thromboembolic events. No one really infarcted or stroked out. The only patients who did badly were those with non-recent injuries.

* MATTERS is another good study to look at; this was performed by the military, so it used predominantly younger and baseline-healthier individuals, but they were also much more severely injured. It showed a much greater mortality benefit, suggesting that some of the benefit of TXA may have been masked in CRASH-2 by a subgroup of less severely injured patients who were at little risk of dying, and little risk of benefiting from the TXA, making the effect seem smaller.

* It's a very safe drug, with a pretty large benefit. More places should be using it.

Thanks Systemet, that's good information to have.

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Systemet, you are correct that an istat trop is not good for a rule out, but it is good for ruling in. If you get a trop of 2, that pt should probably head to the cardiac center and not the local hospital. They may not get an emergent cath but they will get one.

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Systemet, you are correct that an istat trop is not good for a rule out, but it is good for ruling in. If you get a trop of 2, that pt should probably head to the cardiac center and not the local hospital. They may not get an emergent cath but they will get one.

Agreed. We draw POC troponins at my place, and would likely direct them to a site with PCI capabilities. That being said, as I'm sure you'd agree, plenty of people with NSTEMIs walk into random ERs and get secondarily transferred.

My viewpoint may be skewed by working in an environment with very limited PCI capability serving a large population and a ridiculous geographic area. Where I am, at night the only two PCI capable centers are call-in, and a lot of worrisome cases are waiting for the a.m.

Edited by systemet

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Agreed. We draw POC troponins at my place, and would likely direct them to a site with PCI capabilities. That being said, as I'm sure you'd agree, plenty of people with NSTEMIs walk into random ERs and get secondarily transferred.

My viewpoint may be skewed by working in an environment with very limited PCI capability serving a large population and a ridiculous geographic area. Where I am, at night the only two PCI capable centers are call-in, and a lot of worrisome cases are waiting for the a.m.

Agree again. One of my shops does not have a cath lab and we get plenty of chest pain. Those with positive trops get sent to the big house those that don't get admitted here for rule out and stress testing. POC trops are one of the few lab tests that I think have a place in prehospital care. They can change your destination, saving pts multiple hospital visits/bills. It needs to be understood by the providers that a negative trop does not r/o cardiac pathology.

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Agree again. One of my shops does not have a cath lab and we get plenty of chest pain. Those with positive trops get sent to the big house those that don't get admitted here for rule out and stress testing. POC trops are one of the few lab tests that I think have a place in prehospital care. They can change your destination, saving pts multiple hospital visits/bills. It needs to be understood by the providers that a negative trop does not r/o cardiac pathology.

Absolutely, I never rule out a cardiac problem with a negative troponin but it does guide my initial routing on where I would send those patients.

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Yeah, I wasn't really looking at is as a tool to rule out MI, rather use as another tool to justify rerouting to the nearest cardiac center with a positive result.

Thanks for the info on TXA! It was very helpful. Once this licensing exam business is finished, I'm definitely going to do my research and draft up a proposal.. Maybe once its completed, I could post it on here for some tips/feedback being that it will be my first one.

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