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Prehospital stroke care: new prospects for treatment and clinical research.

ABSTRACT: Brain cells die rapidly after stroke and any effective treatment must start as early as possible. In clinical routine, the tight time-outcome relationship continues to be the major limitation of therapeutic approaches: thrombolysis rates remain low across many countries, with most patients being treated at the late end of the therapeutic window. In addition, there is no neuroprotective therapy available, but some maintain that this concept may be valid if administered very early after stroke. Recent innovations have opened new perspectives for stroke diagnosis and treatment before the patient arrives at the hospital. These include stroke recognition by dispatchers and paramedics, mobile telemedicine for remote clinical examination and imaging, and integration of CT scanners and point-of-care laboratories in ambulances. Several clinical trials are now being performed in the prehospital setting testing prehospital delivery of neuroprotective, antihypertensive, and thrombolytic therapy. We hypothesize that these new approaches in prehospital stroke care will not only shorten time to treatment and improve outcome but will also facilitate hyperacute stroke research by increasing the number of study participants within an ultra-early time window. The potentials, pitfalls, and promises of advanced prehospital stroke care and research are discussed in this review.

SUBMITTER: Audebert HJ

PROVIDER: S-EPMC3776535 | biostudies-other | 2013 Jul

REPOSITORIES: biostudies-other

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Prehospital stroke care: new prospects for treatment and clinical research.

Audebert Heinrich J HJ Saver Jeffrey L JL Starkman Sidney S Lees Kennedy R KR Endres Matthias M

Neurology 20130628 5

Brain cells die rapidly after stroke and any effective treatment must start as early as possible. In clinical routine, the tight time-outcome relationship continues to be the major limitation of therapeutic approaches: thrombolysis rates remain low across many countries, with most patients being treated at the late end of the therapeutic window. In addition, there is no neuroprotective therapy available, but some maintain that this concept may be valid if administered very early after stroke. Re ...[more]

PMID: 23897876

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Project description:BackgroundEmergency medical services (EMS) are the first health care contact for the majority of stroke patients. However, there is a lack of data on the current paramedics' hospital-directed feedback and training needs across different health care settings. We aimed to evaluate paramedics' prehospital stroke care knowledge, training needs, and current status of feedback on suspected stroke patients.MethodsWe surveyed paramedics from the Vilnius region from September to November 2019 and compared the answers between the city and the district agencies. The questionnaire content included questions on paramedics' demographic characteristics, prehospital stroke care self-assessment, knowledge on stroke mimics, stroke training needs, and the importance of hospital-directed feedback on suspected stroke patients.ResultsA total number of 161 paramedics (or 49.4% of all paramedics from our stroke care network) were surveyed, with more district paramedics rating their prehospital stroke care knowledge as inadequate (44.8% (95% confidence interval (CI) 32.8-57.6) vs. 28.1% (95% CI 20.1-27.8), p = 0.028). In addition, more district paramedics indicated a need for additional stroke training (83.1% (95% CI 71.5-90.5) vs. 69.8% (60.0-78.1), p = 0.043). However, respondents reported being the most confident while dealing with stroke (71.3%, 95% CI 63.8-77.7) compared to other time-critical conditions (p < 0.001). Vertigo (60.8%, 95% CI 53.0-68.0), brain tumors (56.3%, 95% CI 48.5-63.8), and seizures (54.4%, 95% CI 46.7-62.0) were indicated as the most common stroke mimics. Only 6.2% (95% CI 3.4-11.1) of respondents received formal feedback on the outcome of suspected stroke patients brought to the emergency department.ConclusionsA high proportion of paramedics self-perceive having inadequate stroke knowledge and an urgent need for further stroke training. The EMS staff indicate receiving insufficient feedback on suspected stroke patients, even though its usefulness is perceived as paramount.

Project description:Importance:Transferring patients with large-vessel occlusion (LVO) or intracranial hemorrhage (ICH) to hospitals not providing interventional treatment options is an unresolved medical problem. Objective:To determine how optimized prehospital management (OPM) based on use of the Los Angeles Motor Scale (LAMS) compares with management in a Mobile Stroke Unit (MSU) in accurately triaging patients to the appropriate hospital with (comprehensive stroke center [CSC]) or without (primary stroke center [PSC]) interventional treatment. Design, Setting, and Participants:In this randomized multicenter trial with 3-month follow-up, patients were assigned week-wise to one of the pathways between June 15, 2015, and November 15, 2017, in 2 regions of Saarland, Germany; 708 of 824 suspected stroke patients did not meet inclusion criteria, resulting in a study population of 116 adult patients. Interventions:Patients received either OPM based on a standard operating procedure that included the use of the LAMS (cut point ?4) or management in an MSU (an ambulance with vascular imaging, point-of-care laboratory, and telecommunication capabilities). Main Outcomes and Measures:The primary end point was the proportion of patients accurately triaged to either CSCs (LVO, ICH) or PSCs (others). Results:A predefined interim analysis was performed after 116 patients of the planned 232 patients had been enrolled. Of these, 53 were included in the OPM group (67.9% women; mean [SD] age, 74 [11] years) and 63 in the MSU group (57.1% women; mean [SD] age, 75 [11] years). The primary end point, an accurate triage decision, was reached for 37 of 53 patients (69.8%) in the OPM group and for 63 of 63 patients (100%) in the MSU group (difference, 30.2%; 95% CI, 17.8%-42.5%; P?<?.001). Whereas 7 of 17 OPM patients (41.2%) with LVO or ICH required secondary transfers from a PSC to a CSC, none of the 11 MSU patients (0%) required such transfers (difference, 41.2%; 95% CI, 17.8%-64.6%; P?=?.02). The LAMS at a cut point of 4 or higher led to an accurate diagnosis of LVO or ICH for 13 of 17 patients (76.5%; 6 triaged to a CSC) and of LVO selectively for 7 of 9 patients (77.8%; 2 triaged to a CSC). Stroke management metrics were better in the MSU group, although patient outcomes were not significantly different. Conclusions and Relevance:Whereas prehospital management optimized by LAMS allows accurate triage decisions for approximately 70% of patients, MSU-based management enables accurate triage decisions for 100%. Depending on the specific health care environment considered, both approaches are potentially valuable in triaging stroke patients. Trial Registration:ClinicalTrials.gov identifier: NCT02465346.

Project description:BackgroundInter-hospital teleconsultation improves stroke care. To transfer this concept into the emergency medical service (EMS), the feasibility and effects of prehospital teleconsultation were investigated.Methodology/principal findingsTeleconsultation enabling audio communication, real-time video streaming, vital data and still picture transmission was conducted between an ambulance and a teleconsultation center. Pre-notification of the hospital was carried out with a 14-item stroke history checklist via e-mail-to-fax. Beside technical assessments possible influences on prehospital and initial in-hospital time intervals, prehospital diagnostic accuracy and the transfer of stroke specific data were investigated by comparing telemedically assisted prehospital care (telemedicine group) with local regular EMS care (control group). All prehospital stroke patients over a 5-month period were included during weekdays (7.30 a.m.-4.00 p.m.). In 3 of 18 missions partial dropouts of the system occurred; neurological co-evaluation via video transmission was conducted in 12 cases. The stroke checklist was transmitted in 14 cases (78%). Telemedicine group (n?=?18) vs. control group (n?=?47): Prehospital time intervals were comparable, but in both groups the door to brain imaging times were longer than recommended (median 59.5 vs. 57.5 min, p?=?0.6447). The prehospital stroke diagnosis was confirmed in 61% vs. 67%, p?=?0.8451. Medians of 14 (IQR 9) vs. 5 (IQR 2) stroke specific items were transferred in written form to the in-hospital setting, p<0.0001. In 3 of 10 vs. 5 of 27 patients with cerebral ischemia thrombolytics were administered, p?=?0.655.ConclusionsTeleconsultation was feasible but technical performance and reliability have to be improved. The approach led to better stroke specific information; however, a superiority over regular EMS care was not found and in-hospital time intervals were unacceptably long in both groups. The feasibility of prehospital tele-stroke consultation has future potential to improve emergency care especially when no highly trained personnel are on-scene.Trial registrationInternational Standard Randomised Controlled Trial Number Register (ISRCTN) ISRCTN83270177.

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Prehospital stroke care: new prospects for treatment and clinical research.

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Prehospital stroke care: new prospects for treatment and clinical research.

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