What is the protocol for transferring a resuscitated out-of-hospital cardiac arrest (OHCA) patient with ST-elevation myocardial infarction (STEMI) from a non-percutaneous coronary intervention (PCI) capable hospital to a PCI center?

Protocol for Transfer of Resuscitated OHCA Patients with STEMI from Non-PCI to PCI Center

For resuscitated out-of-hospital cardiac arrest patients with STEMI at a non-PCI capable hospital, immediately transfer to a PCI center without administering fibrinolysis, with a door-in-door-out time goal of ≤30 minutes and overall first medical contact-to-device time of ≤120 minutes. 1

Immediate Actions at Non-PCI Hospital

Confirm STEMI Diagnosis and Cardiac Etiology

• Obtain 12-lead ECG immediately upon arrival to confirm ST-elevation or STEMI equivalent (hyperacute T-waves, true posterior MI, multilead ST depression with ST elevation in aVR, or diagnostic criteria with left bundle branch block) 1
• Document that cardiac arrest was of suspected cardiac origin based on clinical presentation and ECG findings 1

Initiate Transfer Protocol Immediately

• Activate transfer to PCI center without delay—do not wait to assess neurologic recovery or hemodynamic stability 2
• Contact receiving PCI center and arrange direct admission to cardiac catheterization laboratory 1
• Target door-in-door-out time of ≤30 minutes at the referring facility 1
• Overall system goal: first medical contact-to-device time ≤120 minutes 1

Do NOT Administer Fibrinolysis

• Fibrinolytic therapy is contraindicated in this scenario—immediate transfer for primary PCI is superior 1
• The combination of fibrinolysis followed by immediate PCI causes harm compared to immediate PCI alone 1
• Even with anticipated delays, transfer for PCI remains the Class I recommendation for post-arrest STEMI patients 1

Stabilization During Transfer Preparation

Airway and Ventilation Management

• Ensure adequate airway protection (intubation if comatose or unable to protect airway) 2
• Maintain oxygen saturation >94% but avoid hyperoxia 2

Hemodynamic Support

• Establish IV access with two large-bore lines 3
• Initiate vasopressor support if systolic blood pressure <90 mmHg (norepinephrine or dopamine preferred) 3
• Consider intra-aortic balloon pump insertion only if causing delay is documented as acceptable exception 1

Antiplatelet and Anticoagulation Therapy

• Administer aspirin 150-325 mg (oral or IV) immediately 3, 4
• Administer clopidogrel 300 mg loading dose (or ticagrelor 180 mg if available) 3, 4
• Initiate anticoagulation with enoxaparin IV followed by subcutaneous dosing (preferred) or weight-adjusted unfractionated heparin bolus and infusion 3, 4

Neurologic Status Documentation

• Document whether patient is awake/responsive or comatose 1, 2
• Document favorable prognostic features if present: witnessed arrest, bystander CPR, initial shockable rhythm (VF/VT), CPR duration <30 minutes 2, 5
• Do not delay transfer based on comatose state—these patients still benefit from emergent PCI 1, 2

Transport Considerations

Personnel and Equipment

• Primary care paramedics can safely transport initially stable post-arrest STEMI patients, though advanced care paramedics are preferred when available 6
• Ensure defibrillator availability during transport (26% of patients experience adverse events during transfer, though most are minor) 6
• Transport times up to 210 miles are feasible with median door-to-balloon times of 120 minutes for distant facilities 7

Communication Protocol

• Transmit 12-lead ECG to receiving PCI center if not already done 1
• Provide report including: arrest circumstances, downtime, initial rhythm, number of defibrillations, ROSC timing, current hemodynamics, neurologic status, and ECG findings 2
• Confirm catheterization laboratory activation and expected arrival time 7

Management at Receiving PCI Center

Immediate Coronary Angiography

• Proceed directly to emergent coronary angiography regardless of neurologic status (Class I recommendation for OHCA with STEMI) 1
• Awake/non-comatose patients have survival rates comparable to STEMI patients who never arrested 2
• Comatose patients with favorable prognostic features (witnessed arrest, bystander CPR, shockable rhythm, CPR <30 minutes) have significantly improved survival with immediate PCI 2, 5

Expected Outcomes

• In-hospital mortality for resuscitated OHCA-STEMI patients treated with primary PCI: 4.1% 8
• 30-day mortality: 4.1%; one-year mortality: 5.2% 8
• Survival to hospital discharge can reach 66% with optimized systems 5

Critical Pitfalls to Avoid

Do Not Delay Transfer

• Never delay transfer while waiting to assess neurologic recovery—this results in missed opportunities to improve both cardiac and neurologic outcomes 2
• Every 30-minute delay in reperfusion increases mortality 3, 4
• Acceptable exceptions for delay include ongoing cardiopulmonary arrest requiring active resuscitation, balloon pump insertion, or respiratory failure requiring intubation 1

Do Not Administer Fibrinolysis at Referring Hospital

• Fibrinolysis is not indicated for post-arrest STEMI patients presenting to non-PCI hospitals when transfer is feasible 1
• The only scenario where fibrinolysis might be considered is when transfer cannot be accomplished in a timely manner (>120 minutes expected delay), but this is rare and represents system failure 1

Do Not Keep Patient for Observation

• Do not keep patients at the non-PCI facility for observation after resuscitation—even stable-appearing patients can deteriorate or have recurrent arrest 2, 6
• Immediate transfer is indicated regardless of apparent clinical stability 1

Do Not Assume Comatose Patients Cannot Benefit

• While overall survival-to-discharge in comatose post-arrest patients is <10% in general populations, those with witnessed arrest and shockable rhythm have significantly improved survival with immediate PCI 2, 5
• The decision to proceed with PCI should be made at the receiving center, not at the referring facility 1, 2

Special Considerations

Cardiogenic Shock

• Immediate transfer for PCI is especially critical in patients with cardiogenic shock or acute severe heart failure, irrespective of time delay from MI onset 1
• These patients have the highest mortality benefit from reperfusion therapy 3

Non-STEMI Post-Arrest Patients

• For electrically or hemodynamically unstable comatose patients without ST elevation, emergency coronary angiography is reasonable (Class IIa) 1
• For stable post-arrest patients without STEMI, immediate angiography is not recommended (Class III: No Benefit) 2

Regional System Integration

• Optimal outcomes require integrated regional STEMI systems with prospective standardized transfer protocols 7, 9
• Prehospital 12-lead ECG with transmission to receiving PCI center reduces time to treatment 2
• Shared protocols between EMS, referring hospitals, and PCI centers are essential 7, 9