From the Guidelines
A paramedic should transport a patient with an arterial occlusion to the hospital immediately, as this is a medical emergency requiring prompt intervention. Upon identifying signs of arterial occlusion, such as the 6 P's: pain, pallor, pulselessness, paresthesia, paralysis, and poikilothermia, paramedics should initiate rapid transport while providing supportive care 1. The goal is to "recognize and mobilize" with on-scene time being as short as possible, ideally a median time of 20 minutes or less for patients who present within the treatment time window 1.
Pre-Transport Assessment
Before transport, paramedics should use validated acute stroke out-of-hospital diagnostic screening tools, such as FAST (Face, Arm, Speech, and Time), to assess the patient 1. They should also obtain information from the patient, family members, or other witnesses about the suspected stroke event, comorbid conditions, current medications, and any formal or informal advance directives that may influence care 1. Initial assessment should include capillary blood glucose measurement 1.
Transport and Care
En route, paramedics should administer oxygen as needed, establish IV access, monitor vital signs continuously, and position the affected limb at heart level without elevation. Pain management with medications like morphine or fentanyl may be appropriate based on protocols. Paramedics should not delay transport to attempt field interventions that could address the occlusion itself, as definitive treatment typically requires surgical intervention or catheter-based procedures available only in hospital settings 1. Time is critical in arterial occlusions because prolonged ischemia can lead to tissue death, limb loss, or even death, with the window for limb salvage generally being 4-6 hours from symptom onset.
Transport Strategies
The choice of transport strategy, such as drip-and-ship, mothership, or the use of a Mobile Stroke Unit (MSU), depends on local geography, hospital efficiencies, and treatment times 1. The drip-and-ship model predicts best outcomes in many scenarios where transfer time between thrombolysis and EVT centers is long, but the utilization of the mothership transport method increases with increasing door-to-needle/door-in-door-out times at the thrombolysis center 1. The MSU, a CT-equipped specialized ambulance, can lead to shorter onset to decision/treatment times, but data on long-term outcomes are still emerging 1.
Key Considerations
The key to optimal outcomes is minimizing delays and ensuring rapid transport to a facility capable of providing definitive care. Paramedics play a critical role in this process by quickly identifying arterial occlusion, providing initial care, and facilitating rapid transport to an appropriate medical facility 1.
From the Research
Paramedic Transport of Arterial Occlusion
- The decision to transport a patient with arterial occlusion should be based on the severity of the condition and the availability of medical facilities 2, 3.
- Acute arterial occlusion is a medical-surgical emergency that requires prompt treatment to prevent limb loss or death 2.
- The cause of the occlusion, whether it is an embolism or thrombosis, should be determined to guide treatment 4, 2.
- Patients with acute limb ischemia may benefit from thrombolytic therapy, percutaneous mechanical thrombectomy, or primary surgical revascularization 4, 3, 5.
Treatment Options
- Thrombolytic agents, such as urokinase, alteplase, and reteplase, can be used to dissolve the thrombus 4, 5.
- Catheter-directed thrombolysis has become a commonly employed technique in the treatment of acute limb ischemia 3.
- Surgical thrombectomy and bypass procedures may be necessary in some cases 2, 5.
- The choice of treatment should be based on the individual patient's condition and the availability of medical facilities 4, 3, 5.
Transportation Considerations
- If transportation to a hospital is necessary, 5000 IU of heparin should be administered intravenously prior to transport 2.
- The paramedic should monitor the patient's condition closely during transport and provide updates to the receiving hospital 2, 3.
- The use of thrombolytic agents or other treatments during transport should be guided by medical direction and hospital protocols 4, 3, 5.