Reperfusion Decisions at a Hospital Without a Catheterisation Laboratory

Framing the trade-off

• Fibrinolysis works best early; at 4 hours he is still within the window, but his bleeding history is the decisive factor. A recent GI bleed requiring transfusion and endoscopic haemostasis, three weeks ago, is a major contraindication to lysis, not a trivial relative one. Intracranial and GI haemorrhage risk are both elevated.
• Primary PCI is preferred when it can be delivered within about 120 minutes of first medical contact. Here the lab is on diversion for two hours plus 95 minutes of transport, so PCI is effectively 3.5 or more hours away - normally that favours lysis.
• However, the diversion is a logistics problem, not a physiological absolute. The receiving centre can usually be persuaded to accept a STEMI, or an alternative PCI-capable centre identified.

Recommendation

• Do not give the lytic. Start evidence-based medical therapy (aspirin, P2Y12 inhibitor per local protocol, heparin per ACS dosing), resuscitate, and arrange immediate transfer with a cath-lab acceptance.
• Escalate simultaneously to the on-call cardiologist and the receiving interventionalist, stating the contraindication explicitly.
• If transfer were genuinely impossible and he were deteriorating, that calculation would change - but not before every transfer option is exhausted.

Points I would make, respectfully but clearly

1. "Fine now" is not reperfusion. Pain relief after nitrate is analgesia, not proof of restored flow; the ST segments remain elevated. Ongoing ST elevation with a pain-free patient can still mean an occluded artery.
2. The bleed is a major contraindication. A three-week-old duodenal ulcer that bled and needed two units and clipping carries a substantial risk of recurrent GI haemorrhage and intracranial bleeding with tenecteplase.
3. Rescue capability is absent locally. If lysis fails, he needs transfer anyway - so we should be transferring him for definitive care rather than accepting lytic risk without its backstop.
4. If lysis is still chosen, I would ask for: documented rationale, correction of modifiable bleeding risk (IV PPI), crossmatched blood available, a plan for rescue PCI, and the receiving centre alerted before the drug is given.

I would ask for the plan to be written in the notes, document my concerns, and continue escalating to the ED consultant and the receiving interventionalist. The nurse's role is to surface the risk, not to overrule - but a contraindication this significant should not go unspoken.

Differential

• Failed reperfusion (or re-occlusion) - return of ischaemic pain with persistent ST elevation after lysis. This mandates rescue PCI.
• Upper GI bleeding - coffee-ground emesis, likely related to antiplatelet/anticoagulant therapy plus the known ulcer, with the added fibrinolytic effect.
• Consider also a mechanical complication (new murmur, pulmonary oedema, hypotension) driving the deterioration.

Actions

1. Continuous monitoring, two large-bore IVs, repeat 12-lead, full blood count, coagulation profile, fibrinogen, group and crossmatch, troponin, renal function, lactate.
2. Resuscitate with crystalloid; hold further anticoagulation and discuss withholding the second antiplatelet with the prescriber.
3. IV proton pump inhibitor as prescribed; keep nil by mouth; monitor for haematemesis, melaena and hypotension.
4. Alert the receiving PCI centre immediately for rescue angiography, and tell them about the GI bleed so bleeding cover is available.
5. Arrange urgent transfer; have blood products available for the journey where feasible.
6. Reassess for cardiogenic shock and document serial findings - the story here is a failed reperfusion plus a bleeding complication, both of which change destination and urgency.