Shifting acute stroke management to the prehospital setting

2021 ◽  
Vol Publish Ahead of Print ◽  
Author(s):  
Martin Ebinger ◽  
Heinrich J. Audebert
Keyword(s):  
Acute Stroke ◽  
Prehospital Setting ◽  
Stroke Management

scholarly journals Effects of state-wide implementation of the Los Angeles Motor Scale for triage of stroke patients in clinical practice

2021 ◽  
Vol 3 (1) ◽  
Author(s):  
Stefanie Behnke ◽  
Thomas Schlechtriemen ◽  
Andreas Binder ◽  
Monika Bachhuber ◽  
Mark Becker ◽  
...  
Keyword(s):  
Los Angeles ◽  
Acute Stroke ◽  
Unsolved Problem ◽  
Standard Operating Procedure ◽  
Stroke Management ◽  
Stroke Patients ◽  
Vessel Occlusion ◽  
Standard Operating ◽  
Los Angeles Motor Scale ◽  
Triage Decisions

Abstract Background The prehospital identification of stroke patients with large-vessel occlusion (LVO), that should be immediately transported to a thrombectomy capable centre is an unsolved problem. Our aim was to determine whether implementation of a state-wide standard operating procedure (SOP) using the Los Angeles Motor Scale (LAMS) is feasible and enables correct triage of stroke patients to hospitals offering (comprehensive stroke centres, CSCs) or not offering (primary stroke centres, PSCs) thrombectomy. Methods Prospective study involving all patients with suspected acute stroke treated in a 4-month period in a state-wide network of all stroke-treating hospitals (eight PSCs and two CSCs). Primary endpoint was accuracy of the triage SOP in correctly transferring patients to CSCs or PSCs. Additional endpoints included the number of secondary transfers, the accuracy of the LAMS for detection of LVO, apart from stroke management metrics. Results In 1123 patients, use of a triage SOP based on the LAMS allowed triage decisions according to LVO status with a sensitivity of 69.2% (95% confidence interval (95%-CI): 59.0–79.5%) and a specificity of 84.9% (95%-CI: 82.6–87.3%). This was more favourable than the conventional approach of transferring every patient to the nearest stroke-treating hospital, as determined by geocoding for each patient (sensitivity, 17.9% (95%-CI: 9.4–26.5%); specificity, 100% (95%-CI: 100–100%)). Secondary transfers were required for 14 of the 78 (17.9%) LVO patients. Regarding the score itself, LAMS detected LVO with a sensitivity of 67.5% (95%-CI: 57.1–78.0%) and a specificity of 83.5% (95%-CI: 81.0–86.0%). Conclusions State-wide implementation of a triage SOP requesting use of the LAMS tool is feasible and improves triage decision-making in acute stroke regarding the most appropriate target hospital.

Improving the outcome of acute stroke management

1999 ◽  
Vol 60 (1) ◽  
pp. 44-49 ◽  
Author(s):  
Michael Hennerici
Keyword(s):  
Acute Stroke ◽  
Stroke Management

scholarly journals Canadian Stroke Best Practice Recommendations for Acute Stroke Management: Prehospital, Emergency Department, and Acute Inpatient Stroke Care, 6th Edition, Update 2018

2018 ◽  
Vol 13 (9) ◽  
pp. 949-984 ◽  
Author(s):  
JM Boulanger ◽  
MP Lindsay ◽  
G Gubitz ◽  
EE Smith ◽  
G Stotts ◽  
...  
Keyword(s):  
Emergency Department ◽  
Ischemic Stroke ◽  
Acute Stroke ◽  
Transient Ischemic Attack ◽  
Best Practice ◽  
Stroke Care ◽  
Stroke Management ◽  
Practice Recommendations ◽  
Prehospital Emergency ◽  
Ischemic Attack

The 2018 update of the Canadian Stroke Best Practice Recommendations for Acute Stroke Management, 6th edition, is a comprehensive summary of current evidence-based recommendations, appropriate for use by healthcare providers and system planners caring for persons with very recent symptoms of acute stroke or transient ischemic attack. The recommendations are intended for use by a interdisciplinary team of clinicians across a wide range of settings and highlight key elements involved in prehospital and Emergency Department care, acute treatments for ischemic stroke, and acute inpatient care. The most notable changes included in this 6th edition are the renaming of the module and its integration of the formerly separate modules on prehospital and emergency care and acute inpatient stroke care. The new module, Acute Stroke Management: Prehospital, Emergency Department, and Acute Inpatient Stroke Care is now a single, comprehensive module addressing the most important aspects of acute stroke care delivery. Other notable changes include the removal of two sections related to the emergency management of intracerebral hemorrhage and subarachnoid hemorrhage. These topics are covered in a new, dedicated module, to be released later this year. The most significant recommendation updates are for neuroimaging; the extension of the time window for endovascular thrombectomy treatment out to 24 h; considerations for treating a highly selected group of people with stroke of unknown time of onset; and recommendations for dual antiplatelet therapy for a limited duration after acute minor ischemic stroke and transient ischemic attack. This module also emphasizes the need for increased public and healthcare provider’s recognition of the signs of stroke and immediate actions to take; the important expanding role of paramedics and all emergency medical services personnel; arriving at a stroke-enabled Emergency Department without delay; and launching local healthcare institution code stroke protocols. Revisions have also been made to the recommendations for the triage and assessment of risk of recurrent stroke after transient ischemic attack/minor stroke and suggested urgency levels for investigations and initiation of management strategies. The goal of this updated guideline is to optimize stroke care across Canada, by reducing practice variations and reducing the gap between current knowledge and clinical practice.

scholarly journals Acute Stroke Management: Overview and Recent Updates

2021 ◽  
Vol 12 (4) ◽  
pp. 1000
Author(s):  
Mary Hollist ◽  
Larry Morgan ◽  
Rainier Cabatbat ◽  
Katherine Au ◽  
Maaida F Kirmani ◽  
...  
Keyword(s):  
Acute Stroke ◽  
Stroke Management

Acute stroke management and late referrals-Clinician and community unawareness, A one month case series from Tumbi regional referral hospital Pwani, Tanzania

2021 ◽  
Vol 2 (2) ◽  
Author(s):  
Adam M Gembe ◽  
◽  
Erhad Bilaro ◽  
Keyword(s):  
Emergency Department ◽  
Acute Stroke ◽  
Developing World ◽  
Case Series ◽  
Referral Hospital ◽  
Morbidity And Mortality ◽  
High Morbidity ◽  
Stroke Management ◽  
Regional Referral Hospital ◽  
The Common

Stroke is among the common emergency department presentations in Tanzania at large. In the developing world, still there are challenges in diagnosis, management and monitoring of these cases hence high morbidity and mortality. A one month case series is presented here, from Pwani region Tanzania, to demonstrate the encountered challenges. Keywords: Acute stroke management clinician; Community unawareness.

Simulation-Based Assessment of Graduate Neurology Trainees’ Performance Managing Acute Ischemic Stroke

Neurology ◽  
2021 ◽  
pp. 10.1212/WNL.0000000000012972
Author(s):  
Melissa B Pergakis ◽  
Wan-Tsu W Chang ◽  
Ali Tabatabai ◽  
Michael S. Phipps ◽  
Benjamin Neustein ◽  
...  
Keyword(s):  
Ischemic Stroke ◽  
Acute Stroke ◽  
Acute Ischemic Stroke ◽  
Stroke Management ◽  
Delphi Approach ◽  
Cerebral Herniation ◽  
Sum Score ◽  
Simulation Based ◽  
Critical Action ◽  
Attending Physicians

Background and ObjectivesMultidisciplinary acute stroke teams improve acute ischemic stroke management but may hinder trainees’ education which in turn may contribute to poorer outcomes in community hospitals upon graduation. Our goal was to assess graduate neurology trainee performance independent of a multi-disciplinary stroke team in the management of acute ischemic stroke, tissue plasminogen activator (tPA)-related hemorrhage, and cerebral herniation syndrome.MethodsIn this prospective, observational, single-center simulation-based study, participants (sub-interns to attending physicians) managed a patient with acute ischemic stroke followed by tPA-related hemorrhagic conversion leading to cerebral herniation. Critical actions were developed by a modified Delphi approach based on relevant American Heart Association guidelines and the Neurocritical Care Society’s Emergency Neurological Life Support protocols. The primary outcome measure was graduate neurology trainees’ critical action item sum score. We sought validity evidence to support our findings by comparing trainees’ performance across four levels of training.ResultsFifty-three trainees (including 31 graduate neurology trainees) and five attending physicians completed the simulation. The mean sum of critical actions completed by graduate neurology trainees was 15/22 (68%). Ninety percent of graduate neurology trainees properly administered tPA, 84% immediately stopped tPA infusion following patient deterioration, but only 55% reversed tPA according to guidelines. There was a moderately strong effect of level of training on critical action sum score (level 1 mean score [standard deviation (SD)] = 7.2 (2.8) vs. level 2 mean score (SD) = 12.3 (2.6) vs. level 3 mean score (SD) = 13.3 (2.2) vs. level 4 mean score (SD) = 16.3 (2.4), p < .001, R2 = 0.54).DiscussionGraduate neurology trainees reassuringly perform well in initial management of acute ischemic stroke, but frequently make errors in the treatment of hemorrhagic transformation after thrombolysis, suggesting the need for more education surrounding this low frequency, high-acuity event. High-fidelity simulation holds promise as an assessment tool for acute stroke management performance.

scholarly journals The significant gap between international standards and stroke management practices at Queen Elizabeth Central Hospital (Malawi): An audit report

2019 ◽  
Vol 31 (4) ◽  
pp. 249-255 ◽  
Author(s):  
Yohane Gadama
Keyword(s):  
Risk Factors ◽  
Cardiovascular Risk ◽  
Acute Stroke ◽  
Cardiovascular Risk Factors ◽  
Management Practices ◽  
Vital Signs ◽  
Central Hospital ◽  
Stroke Management ◽  
The Mean ◽  
Queen Elizabeth Central Hospital

BackgroundThe Queen Elizabeth Central Hospital (QECH) is preparing to set up the first stroke unit in Blantyre, Malawi. We conducted this audit to assess current stroke management practices and outcomes at QECH and identify priority areas for intervention.MethodsFrom April to June 2018, we prospectively enrolled patients with acute stroke and collected data on clinical presentation, cardiovascular risk factors, investigations and interventions, in-hospital outcomes, and follow-up plans after discharge. The American Heart Association/American Stroke Association (AHA/ASA) guidelines were used as the standard of care for comparison.ResultsFifty patients with acute stroke were enrolled (46% women, 54% men). The mean age was 63.1 years (95% CI: 59.7–66.6). The diagnosis of stroke was based on the World Health Organization criteria. The diagnosis was made within 24 hours of admission in 19 patients (38%). Acute revascularisation therapy was not available. Forty-eight patients (96%) had their vital signs checked at baseline and <10% had their vital signs checked more than three times within the first 24 hours. Essential blood tests including random blood sugar (RBS), full blood count (FBC), urea/creatinine, and lipid profiles were performed in 72%, 68%, 48%, and 4%, respectively. An electrocardiogram was performed on 34 patients (68%). Blood pressure on admission was >140/90 mmHg in 34 patients (68%), including 4 with values >220/120 mmHg. Nine patients had an RBS >10 mmol/L and four received insulin. Prophylaxis for deep venous thrombosis was offered to 12 patients (24%). Aspiration pneumonia was reported in 16 patients (32%) and was the most common hospital complication. The mean duration of hospitalisation was 10.4 days (95% CI: 5.6–15.2), and case fatality was 18%. The modified Rankin scale at discharge was ≤2 in 32% of patients. Only four patients (8%) were transferred to a rehabilitation centre. At the time of discharge, only 32% of patients received education on stroke.ConclusionAcute stroke care is less than optimal in this setting. Simple interventions such as reducing the delay in making a stroke diagnosis, early swallow assessments, and closer monitoring of vital signs could make a significant difference in stroke outcome. Furthermore, treating cardiovascular risk factors and setting up health education programmes to improve secondary prevention represent key priorities.

scholarly journals The role of cardiologists on the stroke unit

2020 ◽  
Vol 22 (Supplement_M) ◽  
pp. M3-M12
Author(s):  
Wolfram Doehner ◽  
David Manuel Leistner ◽  
Heinrich J Audebert ◽  
Jan F Scheitz
Keyword(s):  
Acute Stroke ◽  
Stroke Unit ◽  
Stroke Care ◽  
Cardiovascular Complications ◽  
Large Artery ◽  
Stroke Management ◽  
Acute Stroke Care ◽  
Daily Work ◽  
Cardiovascular Comorbidity ◽  
Treatment And Prevention

Abstract Cardiologists need a better understanding of stroke and of cardiac implications in modern stroke management. Stroke is a leading disease in terms of mortality and disability in our society. Up to half of ischaemic strokes are directly related to cardiac and large artery diseases and cardiovascular risk factors are involved in most other strokes. Moreover, in an acute stroke direct central brain signals and a consecutive autonomic/vegetative imbalance may account for severe and life-threatening cardiovascular complications. The strong cerebro-cardiac link in acute stroke has recently been addressed as the stroke-heart syndrome that requires careful cardiovascular monitoring and immediate therapeutic measures. The regular involvement of cardiologic expertise in daily work on a stroke unit is therefore of high importance and a cornerstone of up-to-date comprehensive stroke care concepts. The main targets of the cardiologists’ contribution to acute stroke care can be categorized in three main areas (i) diagnostics workup of stroke aetiology, (ii) treatment and prevention of complications, and (iii) secondary prevention and sub-acute workup of cardiovascular comorbidity. All three aspects are by themselves highly relevant to support optimal acute management and to improve the short-term and long-term outcomes of patients. In this article, an overview is provided on these main targets of cardiologists’ contribution to acute stroke management.

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