62-Year-Old Man with Anterior STEMI: Reperfusion When the Cath Lab Is Far Away

Estimate total ischaemic time for each option rather than comparing labels.

• Symptom onset to first medical contact: 50 min. Door-to-needle here is realistically 15–20 min, giving a first-medical-contact-to-needle time of about 70 min.
• Primary PCI option: door-in–door-out of at least 35–40 min (ambulance still returning), then 75 km of transport, realistically 75–90 min plus checkpoint delay. Expected first balloon well beyond 150 min from first medical contact, and possibly later still.

Guidelines prefer primary PCI when it can be delivered within about 120 min of first medical contact; beyond that, and especially within the first 2–3 hours of symptoms, fibrinolysis is the better trade-off. This patient is within 12 hours, has a large anterior infarct (V2–V4, 3 mm), no contraindications, and drug is on site.

Decision: give weight-adjusted tenecteplase immediately with adjunctive anticoagulation per protocol, continue dual antiplatelet therapy, and arrange transfer anyway for pharmaco-invasive angiography at 2–24 hours. Document that PCI remains preferred if the ambulance had been available and first balloon achievable within 120 min - the choice depends on the clock, not on hierarchy of treatments.

This is failed reperfusion with cardiogenic shock (Killip III). Failure is defined by less than 50% resolution of ST elevation at 60–90 minutes, and here there is none, with ongoing pain and haemodynamic decompensation.

Actions, in order:

1. Do not re-lyse. Repeat fibrinolysis is not indicated and adds bleeding risk.
2. Activate rescue PCI now - call the interventionalist, and escalate to the hospital director if the ambulance is still unavailable. The indication is electrical and haemodynamic failure, which is time-critical.
3. Support the circulation: start dobutamine at 2.5 µg/kg/min and titrate; give oxygen to target saturation; avoid nitrates and avoid large fluid boluses with clear crackles; treat hypokalaemia and hypomagnesaemia; keep continuous monitoring and defibrillator at hand.
4. Look for a mechanical complication - new murmur, a bedside ultrasound if available, or disproportionate hypoxia may indicate ventricular septal rupture, acute mitral regurgitation or free-wall rupture. These change the destination (surgery) rather than the urgency.
5. Discuss with the family honestly that reperfusion has failed and transfer is needed; document the conversation.

If transfer is genuinely impossible, continue inotropic support and monitoring while re-escalating - but the default should be rescue PCI.

Treat the case as a system signal, not only a clinical event.

• Documentation: record symptom onset, first medical contact, door, needle and transfer times, the reasoning for fibrinolysis, contraindication screen, and the failed-reperfusion decision. Complete a structured transfer/referral form and an incident report if the ambulance delay contributed to harm.
• Audit metrics: report median door-to-needle time, proportion of eligible STEMI patients receiving reperfusion within target, and the number of patients in whom PCI was achievable within 120 min but not delivered. A single case is a story; twelve consecutive cases are evidence.
• Fix the transmission barrier: the printer failure delayed specialist discussion. Agree a standard route (phone photograph with patient identifiers obscured, direct interventionalist hotline) so no one ever delays treatment to obtain a faxable copy.
• Ambulance availability: raise with hospital management that a single-ambulance system is a patient-safety risk for time-critical transfers; a written escalation pathway for the second call is needed.
• Debrief the team and share learning without blame; feed results into the next departmental meeting.