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MOBILE CORONARY CARE UNIT Out of Hospital

ICU
Mobile Intensive Care Unit (MICU) A specialized
ambulance staffed by Paramedics.

Introduction
Inappropriate intervention at appropriate time.

Short and safe, never be prolonged.

1971 Cox Medical Center became one of the first hospitals in the nation with a Mobile
Coronary Care Unit.Prehospital coronary care is becoming a common feature of community
emergency medical systems. About 80% of OHCAs out of hospital cardiac arrest are cardiac in
origin and likely to benefit from admission to a centre with acute coronary care facilities,
including immediate access to percutaneous coronary intervention (PCI). Selected patients with a
high suspicion of coronary obstructive disease, for whom ROSC is not achieved at scene, may
benefit from early transport for coronary intervention while CPR is continued and this is an area
of continuing research .More than half the patients dying from myocardial infarction do not
reach the hospital. A specially designed mobile coronary care unit has been introduced of
coronary care. The monitored infarct patient is stabilized and taken to the nearest hospital having
a coronary care unit.

Since the majority of deaths from coronary heart disease occur early and outside the
hospital, the importance of the prehospital phase is emphasized. The delay in this period, which
is very dangerous for the patient, should be reduced and mobile coronary care units (MCCU's)
are one possibility to reduce the rate of sudden coronary death. Differentt systems of MCCU's
are discussed: (1) those based on a hospital coronary care unit, usually accompanied by a nurse
and/or a doctor and (2) those integrated into an already existing decentralized emergency system
(e.g. fire department) run by paramedics. Although long-term survival of patients resuscitated
from ventricular fibrillation is not so good, the results of many of these units are remarkable.
The prompt delivery of high quality coronary care to patients following acute coronary
syndromes is of paramount importance. This is especially so in acute myocardial infarction
(AMI) with ST elevation on the presenting electrocardiogram, where the rapid restoration of
patency of the infarct related artery improves survival .Early fibrinolytic therapy for many years
has been the gold standard, with studies consistently showing reduced mortality following
appropriate administration of these agents. In America, 400,000 people die of heart attacks every
year, out of which 1,00,000 people die in their houses or offices. 1,00,000 people die of
ventricular fibrillation, viz. irregular fast heart. This defibrillation can be effectively treated by a
defibrillator, by giving electrical shock treatment, which can be given in one’s house itself. Some
patients develop "heart blocks", for which a "pace maker" is required to be implanted.

However timing of treatment is of the essence with the greatest benefit in those patients in whom
the ‘pain-to-needle’ time is short. Delay in initiating treatment after AMI may be categorized
into two phases:

 patient delay, i.e. the time between symptom onset and call for help and healthcare
system delay which encompasses the response to patient call, transport to the institution,
and
 the time to appropriate treatment follow-ing arrival at hospital. Over the years various
methods have been proposed to reduce these delays.

Provision of out-of-hospital mobile coronary care in the community with staff trained in
the recognition and management of acute myocar-dial ischaemia/infarction reduces transport and
hospital delay times. The efficacy and safety of such pre-hospital initiated treatment has been
demonstrated in many early studies. Patients with ST segment elevation on the initialECG and
suitable for fibrinolytic therapy have been studied out-of-hospital. A small number of
randomized trials have also compared the efficacy of pre-hospital initiated fibrinolytic therapy
with therapy first commenced in-hospital These studies have demonstrated consistently a
reduced pain to needle time with pre-hospital treatment, with an average gain of 1 hr.A
physician-staffed pre-hospital coronary care unit in addition to providing early fibrinolytic
therapy has the advantage of prompt identification and treatment of the early complications of
acute myocardial ischemia/infarction. We therefore compared prospectively the in-hospital
mortality associated with pre-hospital coronary care where patients were initially managed out-
of-hospital by a24 h physician-manned mobile coronary care unit with those presenting in-
hospital and managed initially by the Emergency Department, other hospital wards/departments
e.g. Chest Pain Clinic before transfer to the hospital coronary care unit. All patients had a
discharge diagnosis of AMI.

Mobile Coronary Care Unit (Mobile CCU) is an intensive care unit on wheels that
transports cardiac and critical care patients to Hospital from outlying areas. This specially
equipped ambulance is outfitted with the same state-of-the-art monitoring systems, equipment
and life-saving pharmaceuticals used in the hospital's intensive care units. On-board equipment
includes a full array of comprehensive monitoring devices as well as a team of highly-skilled
professionals. The healthcare team includes a paramedic/emergency medical technician and a
registered nurse, with extensive cardiovascular/critical care training.

Once a patient is aboard the Mobile CCU ambulance, he or she receives the same level of
care as if he or she were just admitted to Hospital. The Mobile CCU also will transport patients
for outpatient services or direct hospital admission from other hospitals, physician's offices or
urgent care facilities, or long term care facilities. For more information, call (803) 434-7222. The
mobile coronary care unit consists of a team of physicians and nurses. This team carries, via
ambulance, battery-operated portable instruments. With these the team sets up a coronary care
unit outside the hospital at the site of a call from a patient with an acute myocardial infarction.
On arriving at the site an electrocardiogram is taken, the monitor is attached to the patient, and
an intravenous is begun. Appropriate treatment for arrhythmia may be given by drugs or
electrical cardio version. The successful operation of coronary care units (CCU)throughout the
country, resulting in sub-stantial reduction in mortality rate, has been most gratifying and
instructive.The success of these in-patient units in saving lives has been almost en-tirely confined
to early detection and control of life-threatening arrhythmia. Therefore, it is likely that if one
could reach the patient sooner, more pa-
tientliveswouldbesavedbycontrollingthelifethreateningarrhythmias, the major cause of mortality.
There is a variety of ways of getting to the pa-tient sooner and controlling arrhythmias,
including:

1) have the patients instructed to seek medical help sooner;

2) move the hospital services out of the hospital to the site of the patient (thus saving valuable
time transporting the patient to the hos-pital;and

3) Reorganize emergency room services so that the time lost in the preliminary examination and
considerationofthepatientintheadmittingdepartmentisbypassedandshortened.Theconceptof

moving the coronary care unit outside the hospital to the patient's side was
called"MobileCoronaryCareUnit"byPantridgeand Geddesl in 1967.

The mobile coronary care unit consists of the standard hospital ambulance with the following
portable equipment: a battery-powered defibrillator monitors a battery-powered
electrocardiograph and a case of cardiac medications.' Tis of paramount importance in our
particular community, atleast, that the equipment be battery-operated. There have been numerous
occasions when a source of electrical power was simply not available, eg, in a church, subway
station,in the small rooming houses of some of the"under-privileged,"where the only source of
electrical outlet is consumed by a single electric bulb.The battery-operated equipment, which has
been used by this team ,has functioned remarkably well.

Golden Hour!
If a victim of heart attack has to be saved, the treatment must be commenced within the first sixty
minutes, which is called the "Golden Hour". Any delay results in the heart muscle dying and this results
in more damage to the heart and more chances of death. The time lag between the development of chest
pain and injection of a clot-buster (thrombolysis) should be less than 60 minutes. If this is done timely,
the ischemic muscle completely revives and thus the heart is saved totally. Achieving PROMPT
MEDICAL ATTENTION is THE MOST IMPORTANT FACTOR for an improved prognosis with a
heart attack. Rapid evaluation allows early treatment of potentially life-threatening arrhythmias, and
permits early "reperfusion" (return of blood flow)of the heart muscle. The sooner that reperfusion is
established, the smaller the resultant heart attack will be.Mobile Coronary Care Van (RESPONDER)
instituted for the first time in Tamil Nadu!For transporting serious heart attack victims to Hospital from
their houses or primary care hospitals. victims have been shifted safely and saved.

DEFINITION
The mobile coronary care unit consists of a team of physicians and nurses. This team
carries, via ambulance, battery-operated portable instruments. With these the team sets up a
coronary care unit outside the hospital at the site of a call from a patient with an acute
myocardial infarction. On arriving at the site an electrocardiogram is taken, the monitor is
attached to the patient, and an intravenous is begun. Appropriate treatment for arrhythmia may
be given by drugs or electrical cardioversion.

A mobile coronary care unit(MCCU)is a facility which enables personnel trained in


coronary care to reach patients at the site of a heart attack(at home or elsewhere)as soon as
possible,to start emergency treatment immediately and to continue observation and transport to
hospital.
INDICATIONS
 Cardiac arrhythmias

Ventricular arrhythmias

Supraventricular tachycardia

Supraventricular bradyarrhythmia

 Cardiac arrest
 Cardiac failure
 Cardiogenic shock.

MCCU TEAM

The personnel includes an

 Attending physician,
 Resident physician,
 Emergency room nurse,
 ECG technician, as well
 Student nurse
 Observer,
 Driver
 Assistant.

This team is summoned from various points in the hospital to the emergency room by a
personalPaging system which each member of the team cames this team has 4% minutes to get to
the emergency room, obtain their equipment and board the ambulance. Anyone who is not there
‘within this time is left behind. The calls to which the team responds are initiated by the Police
Department and designated as "cardiac" over the telephone.ThePolice Department may have
received their call from apatrolmanor from any person who calls the De-partment on the
emergency telephone number911.The ambulance transporting the team and their equip-ment
travels tothesiteofthecall as rapidly as possible. The ambulance does not have an escort or
siren,but uses only a flashing red light. On arrival at the all site, which may be anywhere in
Hospital ambulance area
The patient is immediately in the same environ-ment as in the hospital CCU.The patient's
vital signs are recorded and an electrocardiogram is taken. If the patient's problem is a cardiac
one ,an intravenous is started and ECG monitoring is begun. Adequate time is taken to stabilize
the patient's condition, if necessary, before the trip back to the hospital. There turn to the hospital
is made as calmly as possible and without police sirens,etc.The patient is taken directly to the
coronary care unit unless this is not clearly indicated, in which patient is held in the emergency
room where further tests and treatment may be carriedout.On arrival at the hospital, the team
turns the patient responsibility over to the coronary care units af for the emergency room staff.
The mobile coronary care unit team is then free to organize their equipment in preparation for
another call. No special ambulance is used. The vehicle used is there outine hospital ambulance
which transports the team and its battery-powered, portable equipment. Bonafide calls include:

1) patient with a myocar-dial infarction or whose symptoms and ECG find-ings are sufficiently
severe to consider him a R/O coronary patient;

2) patient with heart disease ,having manifestation of congestive heart failure;

3)patient who has chest pain and/or shortness of breath not due to cardiac disease but mistaken
for it by theperson summoning the ambulance.

PROBLEMS IN CALLS
Unnecessary calls Include:

1) Cancelled call by the Police Department after the ambulance has left the hospital;

2) false alarm-an unjustified call, eg,someone feels that an ambulance will come more quickly if
he calls "cardiac patient;"

3) anob-viously intoxicated patient, and that is there-dominant problem;

4) Ambulance left without the doctors on board.

Other calls include:

1) dead on arrival;

2)death in ambulance;

3)a patient who is seriously ill but does not have a cardiac coronary disorder,

e.g., patient with a stroke.


PROBLEMS WHICH WERE FACED BY THE MCCU TEAM
1:Can such a team be mobilized from the hospital staff, join with the ambulance crew and
proceed to the site there by overcoming the organization, traffic and communication problems of
the hospital and the metropolitan community? his team can be mobilized quickly from the hos-
pital, can be transported to the site, a CCU can be setup at anysite-home,office,subway
station,restaurant,church, etc.

Thefollowingdataindicatingthelengthoftimebetweenthereceptionofthecallatthehospitalandthearriv
alat the site bears on this point the ambulance reached the site in eight to nine minutes. On one
occasion the problem was re-lated to breakdown in the hospital paging system and in the second
case it is not clear why the doc-tors did not get therein time.

2: Can a CCU be setup outside of the hospital and can this CCU deal effectively with life-
threatening arrhythmias? His life-threatening arrhythmias we have
seenCanbeeffectivelydealtwithunderthecircum-stancesofaMCCU.Thepatientcanthenbetrans-
ported back to the hospital effectively after the life-threatening arrhythmia has been controlled.

3:Will there be too many" false alarms? “The problem with"falsealarms"or "nuisance calls
“seems to be rather serious at the present time and it is rather discouraging to the team to rush to
the site and then find an individual who is simply intoxicated. The team has decided that a
certain number of these calls will have to be made, for such a patient might tell the Police that he
has a cardiac condition and demand an ambulance. At the moment it is very default determine
how to deal with this.

4:Doest the MCCU do any good in terms of saving lives and relieving suffering? The authors
feel that at least one other episode of slowheartrate and its management out-side the hospital
might be considered life-saving Over andabove
savinglivesisthephysician'sandcommunity'sresponsibilitytoalleviatesufferingasquicklyaspossible.
Thereislittledoubt that the prompt attention to serious cardiac disease by the MCCU will result in
more prompt alleviation of suffering and serious symptoms in the patients with heart disease than
by ourp resent system of deliver-ing the patient to the emergency room. These data clearly
indicate that substantial time is saved and that the patient's suffering is alleviated far more
quickly and promptly than was possible by former system

Medications And Supplies Used in the Mobile


Coronary Care Unit
 Meperidine
 Ouabain(Demerol)
 Lanatoside
 Morphine(Cedilanid)
 Atropine
 Furosemide(Lasix)
 Lidocaine
 Epinephrine(Xylocaine)
 (Adrenaline)
 Quinidine
 Isoproterenol
 (Isuprel)
 Metaraminol
 Ampules of(Aramine)bicarbonate
 Diphenylhydantoin
 Bloodpressurecuff
 (Dilantin)
 Oral airway
 CompleteIVset

Although the few existing mobile coronary care units have proved effective, the
establishment of a new unit is expensive. In order to determine the usefulness of such a unit an
evaluation of present patterns for care of the acute myocardial infarct patients and patients dead
on arrival at a hospital was made. The greatest delay in the care of the acute myocardial infarct
patient was his own unwillingness to call for help. The median time for transport of patients to
the hospital was 25 min. The study of patients dead on arrival at the hospital showed that the
time needed for rescue squads to reach the patients was too long in almost all cases for effective
resuscitation to be accomplished. This study shows that present transportation facilities for the
acute myocardial infarct patients in this community are adequate. Added equipment and training
of personnel for the existing units could obviate the need for a centrally based and more costly
mobile coronary care unit. The majority of deaths from myocardial infarction occur soon after
the onset of symptoms and before the victims reach hospital coronary care units. The mobile
scheme described allows intensive care to commence in the patient's own home or at the site of
infarction and thus reduces considerably the interval between the onset of symptoms and the
initiation of intensive care. The prevention of fatal dysrhythmias by early pre-hospital care
should have a significant effect on the early high mortality rates. Since the correction of
ventricular fibrillation outside the hospital is a practical proposition, a further impact on the early
high mortality will result when mobile units are supported by first aid training programs in
methods of resuscitation.
TYPES
Two Ambulance Systems

Two ambulance systems have been developed in nearest standard ambulance(STA)which is


dispatched simultaneously with the MICCU.

Seatle

Most well-known and successful is the Medic system is Seatle where the MCCU is
manned by paramedics,who are ambulance drivers trained to perform endotracheal
intubation,defibrillation,and administration of drugs.

AMBULANCE
Mobile Coronary Care Ambulances are well-equipped ambulances staffed by highly trained
paramedics dispatched to emergency situations where patients require a higher level of care than
a regular ambulance can provide.

Built vehicle on a standard BMC ambulance.

Similar to Belfast with some modifications.


Specially designed mobile central trolley

a. Which adjusts to desired height.


b. Easily tipped into tredelenbergh position for shocked patients.
c. Head end elevation for dyspneic patients
d. Arm rests for intravenous therapy
e. Ample working space around trolley.
f. Shelves and cupboards support and accommodate equipment.
g. Small hand wash basin with pumped up warm water.
h. Efficient heater
i. Seating accommodation for four.
j. Powerful fluroscent lighting
k. Mobile spot light.
l. A static invertor run off an extra 12 volt heavy duty battery provides two 240 volt
outlets for mains apparated equipments if required
m. Two way radio telephone link between the ambulance and the station,and any messages
for the coronary unit are transmitted via the ambulance system.

EQUIPMENT
 Monitoring and Resuscitation equipment all battery powered
 Defibrillator
 Oscilloscope
 Electrocardiograph
 Pacemaker
 Suction apparatus
 Portable Minute Man Automatic respirator-amble supply of o2 in cylinder fixed
in ambulance.
 Respiratory equipment
 Ambu bag
 Brooke airways
 Endotracheal tubes
 Usual nursing dressing and accessories
 Drug case with cardiovascular drug and special drug(usual drug replaced on
arrival to hospital.
 Iv infusion bottles supported by roof mounted brackers.

ACTIVITIES
 Early initiation of intensive care outside may prevent ventricular fibrillation.
 The correction of ventricular fibrillation outside hospital is a practical
proposition.
 A properly organized mobile coronary care unit removes the risk of death
during transport.
 The early initiation of intensive care and the correction or prevention of
dysrhythmias and associated hypotension diminish the incidence of shock
and pump failure by preventing the extension of the initial area of infarction.

CARE
 Initiation of immediate emergency care
 Continue to provide emergency care
 Continue monitoring vital signs.
 Communicate with ED personnel.
 Give a description of what happened.
 Describe patient,age,sexand his condition
 Patient vital signs
 Emergency care that has been provides.
 Estimated time of arrival

CONCLUSION
Historically, the ambulance is associated with a accidents and bleeding. People at the
moment do not seem to request an ambulance for the diagnosis of pain in the chest. It is up to the
medical profession to deliver this message more effectively not only to the members of the
community, but also to them- selves, that the "middle-aged man with a pain in his chest" is a
person of high risk until he is seen and expertly diagnosed