Bringing the Hospital to the Patient: First Treatment of Stroke Patients at the Emergency Site

101

Background and Purpose-Pre-and intrahospital time delays are major concerns in acute stroke care. Telemedicineequipped ambulances may improve time management and identify patients with stroke eligible for thrombolysis by an early prehospital stroke diagnosis. The aims of this study were (1) to develop a telestroke ambulance prototype; (2) to test the reliability of stroke severity assessment; and (3) to evaluate its feasibility in the prehospital emergency setting. Methods-Mobil, real-time audio-video streaming telemedicine devices were implemented into advanced life support ambulances. Feasibility of telestroke ambulances and reliability of the National Institutes of Health Stroke Scale assessment were tested using current wireless cellular communication technology (third generation) in a prehospital stroke scenario. Two stroke actors were trained in simulation of differing right and left middle cerebral artery stroke syndromes. National Institutes of Health Stroke Scale assessment was performed by a hospital-based stroke physician by telemedicine, by an emergency physician guided by telemedicine, and "a posteriori" on the basis of video documentation. Results-In

Section: Discussionmentioning

confidence: 99%

Telestroke Ambulances in Prehospital Stroke Management

Liman

Winter

Waldschmidt

et al. 2012

101

“…11 Two studies have shown that prehospital CT scanning with an appropriately equipped ambulance is feasible and may allow for triage to an appropriate hospital and initiation of ICH-specific therapy. 12,13 …”

Section: Prehospital Managementmentioning

confidence: 99%

Guidelines for the Management of Spontaneous Intracerebral Hemorrhage

Hemphill¹,

Greenberg²,

Anderson³

et al. 2015

2,948

1,196

2032Purpose-The aim of this guideline is to present current and comprehensive recommendations for the diagnosis and treatment of spontaneous intracerebral hemorrhage. Methods-A formal literature search of PubMed was performed through the end of August 2013. The writing committee met by teleconference to discuss narrative text and recommendations. Recommendations follow the American Heart Association/American Stroke Association methods of classifying the level of certainty of the treatment effect and the class of evidence. Prerelease review of the draft guideline was performed by 6 expert peer reviewers and by the members of the Stroke Council Scientific Oversight Committee and Stroke Council Leadership Committee. Results-Evidence-based guidelines are presented for the care of patients with acute intracerebral hemorrhage. Topics focused on diagnosis, management of coagulopathy and blood pressure, prevention and control of secondary brain injury and intracranial pressure, the role of surgery, outcome prediction, rehabilitation, secondary prevention, and future considerations. Results of new phase 3 trials were incorporated. Conclusions-Intracerebral hemorrhage remains a serious condition for which early aggressive care is warranted.These guidelines provide a framework for goal-directed treatment of the patient with intracerebral hemorrhage.

“…4 -7 These scores were tested with medical professionals in primary care, emergency medical services (EMS), and emergency department physicians. 7 Recent developments such as the installation of a CT scanner and point-of-care laboratory in EMS ambulances 8,9 promise a complete diagnostic stroke workup required for thrombolytic treatment before transport to the hospital. The possibility of sending such special ambulances to stroke emergencies might enable new prehospital stroke treatments to be evaluated, for example, ambulance-based neuroprotective trials.…”

mentioning

confidence: 99%

Development and Validation of a Dispatcher Identification Algorithm for Stroke Emergencies

Krebes

Ebinger

Baumann

et al. 2012

Background and Purpose-Recent innovations such as CT installation in ambulances may lead to earlier start of stroke-specific treatments. However, such technically complex mobile facilities require effective methods of correctly identifying patients before deployment. We aimed to develop and validate a new dispatcher identification algorithm for stroke emergencies. Methods-Dispatcher identification algorithm for stroke emergencies was informed by systematic qualitative analysis of the content of emergency calls to ambulance dispatchers for patients with stroke or transient ischemic attack (Nϭ117) and other neurological (Nϭ39) and nonneurological (Nϭ51) diseases (Part A). After training of dispatchers, sensitivity and predictive values were determined prospectively in patients admitted to Charité hospitals by using the discharge diagnosis as reference standard (Part B). Results-Part A: Dysphasic/dysarthric symptoms (33%), unilateral symptoms (22%) and explicitly stated suspicion of stroke (47%) were typically identified in patients with stroke but infrequently in nonstroke cases (all Ͻ10%). Convulsive symptoms (41%) were frequent in other neurological diseases but not strokes (3%). Pain (26%) and breathlessness (31%) were often expressed in nonneurological emergencies (6% and 7% in strokes). Part B: Between October 15 and December 16, 2010, 5774 patients were admitted by ambulance with 246 coded with final stroke diagnoses. Sensitivity of dispatcher identification algorithm for stroke emergencies for detecting stroke was 53.3% and positive predictive value was 47.8% for stroke and 59.1% for stroke and transient ischemic attack. Of all 275 patients with stroke dispatcher codes, 215 (78.5%) were confirmed with neurological diagnosis. Conclusions-Using dispatcher identification algorithm for stroke emergencies, more than half of all patients with stroke admitted by ambulance were correctly identified by dispatchers. Most false-positive stroke codes had other neurological diagnoses. (Stroke. 2012;43:776-781.)Key Words: algorithm Ⅲ diagnostic accuracy Ⅲ dispatch Ⅲ sensitivity Ⅲ specificity Ⅲ stroke E ffective acute stroke therapies such as intravenous thrombolysis and stroke unit treatment have been established over the last decades. 1 However, these treatment options are not available in all hospitals 1 and the effect of thrombolysis on functional outcome is time-dependent. 2,3 Early recognition of patients with acute stroke in the prehospital setting is helpful in triaging patients and increasing admission rates of patients with stroke to specialized facilities. Prehospital stroke scores have been developed to assist in identifying stroke and show acceptable sensitivity (between 66% and 91%) and positive predictive values (78% and 90%). 4 -7 These scores were tested with medical professionals in primary care, emergency medical services (EMS), and emergency department physicians. 7 Recent developments such as the installation of a CT scanner and point-of-care laboratory in EMS ambulances 8,9 promise a complete diagno...