STEMI from a non-PCI hospital — the retrieval decision

This is a time-critical transfer for primary PCI. Apply the three-judgement framework — whether, how, and packaging — in order.^[5]

Whether: transfer for primary PCI is the right decision. Primary PCI is the standard of care for ST-elevation myocardial infarction, and a PCI centre is reachable within window. The decision is taken with the PCI centre at first medical contact; the activation call is the first action, and the clock starts there. Zahran found transfer lengthens pre-PCI delays yet is not consistently tied to worse outcomes in current networks — but minimising prehospital delay remains essential, which is precisely why regional STEMI networks route these patients directly.^[5]

Time targets. Guidelines set first medical contact-to-balloon at 90 minutes or less for direct arrival and 120 minutes for inter-facility transfer — and beyond 120 minutes, in-hospital major adverse cardiac events rise steeply (adjusted odds ratio 3.54).^[11][10] Symptom onset was 60 minutes ago; door-to-balloon via helicopter transfer (35 minutes flight plus packaging and ground legs) is achievable within 120 minutes. If the receiving centre or the weather makes that unachievable, the fallback is fibrinolysis followed by transfer (the pharmaco-invasive strategy), not delayed PCI.

How — mode and team. Helicopter is the correct mode: 35 minutes versus 90 minutes by road protects the window, and the patient is currently stable enough to fly. The team is a physician-staffed or experienced nurse/paramedic retrieval team — this is a stable, non-intubated patient on a short flight, but she is at risk of ventricular fibrillation in transit and must travel with a defibrillator, a trained crew, and the capacity to manage cardiac arrest. The receiving centre confirms the catheter-lab slot before departure.^[2]

Packaging — secure the five systems (ALMVS). Airway: she is self-ventilating, but high-flow oxygen is set up, a suction unit and a bag-valve-mask travel with her. Lines: two large-bore intravenous cannulae, with a bag of saline running slowly; she has had morphine. Monitors: continuous ECG, pulse oximetry, and non-invasive blood pressure cycling every three to five minutes; the defibrillator pads are on the chest and the monitor is in view throughout. Ventilation: she is on oxygen by mask; a ventilator is not required. Sedation: she is pain-free on morphine — the dose is documented and a further bolus is drawn up. Dual antiplatelet therapy (aspirin plus a P2Y12 inhibitor) and anticoagulation are given per the local PCI pathway before departure unless the bleeding risk prohibits it.^[2][10]

Anticipate the in-flight risks. Ventricular fibrillation is the feared event — the defibrillator is on and the crew is ACLS-capable; bradycardia, hypotension, and reinfarction are watched for. The receiving centre is given an estimated time of arrival and a structured ISBAR handover is delivered on landing.^[5]