Abstract 3468: Correlation of the Miami Emergency Neurologic Deficit (MEND) Exam Performed in the Field by Paramedics with an Abnormal NIHSS and Final Diagnosis of Stroke for Patients Airlifted from the Scene.

Introduction Early recognition and rapid transport to a stroke center by prehospital providers is essential in the care of stroke patients. In this study, prehospital providers were trained to perform the Miami Emergency Neurologic Deficit (MEND) exam as part of an 8-hour comprehensive course, Advanced Stroke Life Support (ASLS ® ). The MEND exam was devised to facilitate communication between healthcare providers throughout the continuum of care for stroke patients. It can provide a baseline exam in the prehospital setting, and then be used by nurses for initial evaluation and subsequent exams in the ED, ICU or hospital floor. The MEND exam incorporates all three components of the Cincinnati Prehospital Stroke Scale (CPSS) and six additional components from the NIHSS (level of consciousness, orientation, commands, visual fields, gaze, leg motor, limb ataxia, sensation). The exam takes less than 2 minutes and requires no tools, making it ideal for the Prehospital environment. Purpose Determine the correlation of the MEND exam completed by a prehospital provider on scene to the initial NIHSS performed by the neurologist at the receiving facility, and the final diagnosis. Methods All prehospital providers from three Fire Rescue agencies participated in the training (96 EMT-P, 68 EMT, 5 RN). The Prehospital providers conducted the CPSS, and if abnormal, placed the helicopter team on standby. They then completed the MEND exam and communicated their findings to a receiving hospital stroke neurologist. We retrospectively reviewed the MEND exam performed by the prehospital providers to determine the correlation with the same components of the initial NIHSS at the hospital. While the NIHSS assigned a numerical value to those specific components, the MEND exam did not. Additionally, we examined the final discharge diagnosis to determine how many patients had a stroke or transient ischemic attack (TIA). Results From Sept. 2008 to June 2011, 51 patients met the criteria of having both a MEND exam and NIHSS completed. There were 32 males (63%) and 19 females (37%) with a median age of 67 years (44-98 years). The average NIHSS score was 9 (range 0-30). 90.2% (46 of 51) of patients had an NIHSS that correlated to the findings on the MEND (95% C.I. 90.1-90.3). Of the 5 remaining patients, 1 completely recovered on the flight (diagnosed with a TIA), and 3 had a NIHSS score of 0 and were diagnosed with other conditions. Stroke or TIA was diagnosed in 40 patients (78.4%). Of 37 strokes, 32 were ischemic (86.5%) and 5 hemorrhagic (13.5%). The 11 patients not diagnosed with a stroke had several other pathologies (e.g. seizure, hypertensive crisis, viral encephalitis, complex migraine). Conclusion The MEND exam completed in the Prehospital setting correlated well with the initial NIHSS performed at the receiving facility. The MEND exam is a valuable tool when assessing stroke patients and determining need for air transport.

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Abstract TP295: Predictability of Stroke Symptoms in Acute Stroke

Stroke ◽

10.1161/str.47.suppl_1.tp295 ◽

2016 ◽

Vol 47 (suppl_1) ◽

Author(s):

Maria J Bruzzone ◽

Luka Vlahovic ◽

Ramon Durazo ◽

Sean Ruland

Keyword(s):

Acute Stroke ◽

Mental Status ◽

Healthcare Providers ◽

Signs And Symptoms ◽

Altered Mental Status ◽

Final Diagnosis ◽

Facial Weakness ◽

Stroke Patients ◽

Accurate Identification ◽

Limb Weakness

Background: Prompt signs and symptoms recognition and intervention are essential to achieve the best outcome after stroke. Stroke codes were developed to expedite assessment and treatment. Their optimal use requires accurate identification of stroke patients. In order to improve diagnostic accuracy in our institution, we analyzed the predictive value of individual stroke signs and symptoms in patients in whom stroke codes were activated from the emergency department (ED) by physicians and nurses and from inpatient wards by nurses, residents and hospitalists. Methods: We retrospectively analyzed 501 consecutive stroke codes in our stroke log from May 2013 to May 2015. Age, gender, presenting signs and symptoms, medical history and final diagnosis were assessed. Patients were classified as stroke (ischemic and hemorrhagic) or non-stroke based on the final impression after the completed work-up. X2 statistic was utilized to assess associations. Results: Overall, 202 (40.3%) patients were classified as stroke and 299 (59.7%) non-stroke. 78% of stroke codes were activated from ED and 22% from the inpatient wards. Unilateral limb weakness, aphasia and facial weakness were associated with stroke (p<0.05) with PPVs of 0.57 (95%CI 50-64%), 0.56 (43-68%), 0.51 (43-60%), respectively. Altered mental status (AMS) and sensory symptoms were associated with non-stroke (p<0.05). The PPV and NPV for stroke were 0.21 (95%CI 13-31%) and 0.55 (50-60%) for AMS respectively and 0.25 (14-39%) and 0.58 (43-63%) for sensory symptoms. Location of the stroke code (ED or inpatient ward) did not impact the results. Conclusion: Previous studies, based on evaluation of acute stroke by paramedics and ED physicians, demonstrated that some signs or symptoms are more likely to be present in patients experiencing acute stroke. In our experience, unilateral limb weakness, aphasia, and facial weakness as identified by diverse provider disciplines and experience levels are associated with a final diagnosis of acute stroke. However, isolated altered mental status or sensory symptoms seldom result in a final diagnosis of stroke. These data can assist healthcare providers, to more accurately identify stroke patients, thus improving outcomes as well as resources utilization.

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In situ deteriorating patient simulation in general practice

British Journal of General Practice ◽

10.3399/bjgp20x711425 ◽

2020 ◽

Vol 70 (suppl 1) ◽

pp. bjgp20X711425

Author(s):

Joanna Lawrence ◽

Petronelle Eastwick-Field ◽

Anne Maloney ◽

Helen Higham

Keyword(s):

Life Support ◽

Early Recognition ◽

Phase 1 ◽

Patient Simulation ◽

Medical Emergency ◽

Phase 2 ◽

Action Plans ◽

Integrated Simulation ◽

Deteriorating Patient

BackgroundGP practices have limited access to medical emergency training and basic life support is often taught out of context as a skills-based event.AimTo develop and evaluate a whole team integrated simulation-based education, to enhance learning, change behaviours and provide safer care.MethodPhase 1: 10 practices piloted a 3-hour programme delivering 40 minutes BLS and AED skills and 2-hour deteriorating patient simulation. Three scenarios where developed: adult chest pain, child anaphylaxis and baby bronchiolitis. An adult simulation patient and relative were used and a child and baby manikin. Two facilitators trained in coaching and debriefing used the 3D debriefing model. Phase 2: 12 new practices undertook identical training derived from Phase 1, with pre- and post-course questionnaires. Teams were scored on: team working, communication, early recognition and systematic approach. The team developed action plans derived from their learning to inform future response. Ten of the 12 practices from Phase 2 received an emergency drill within 6 months of the original session. Three to four members of the whole team integrated training, attended the drill, but were unaware of the nature of the scenario before. Scoring was repeated and action plans were revisited to determine behaviour changes.ResultsEvery emergency drill demonstrated improved scoring in skills and behaviour.ConclusionA combination of: in situ GP simulation, appropriately qualified facilitators in simulation and debriefing, and action plans developed by the whole team suggests safer care for patients experiencing a medical emergency.

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Bilateral periorbital necrotising fasciitis associated with invasive group: a Streptococcus infection

BMJ Case Reports ◽

10.1136/bcr-2020-236800 ◽

2020 ◽

Vol 13 (12) ◽

pp. e236800

Author(s):

Grace Anne McCabe ◽

Thomas Hardy ◽

Thomas Gordon Campbell

Keyword(s):

Group A Streptococcus ◽

Early Recognition ◽

Skin Grafting ◽

Final Diagnosis ◽

Necrotising Fasciitis ◽

Invasive Group ◽

Group A ◽

Tissue Microscopy ◽

Periorbital Swelling ◽

Multidisciplinary Teamwork

A previously independent 56-year-old immunocompetent woman presented with septic shock in the setting of periorbital swelling and diffuse infiltrates on chest imaging. Blood cultures were positive for growth of group A Streptococcus (GAS). Broad spectrum antimicrobials were initiated with the inclusion of the antitoxin agent clindamycin. Necrosis of periorbital tissue was noted and surgical consultation was obtained. Débridement of both eyelids with skin grafting was performed. GAS was isolated from wound cultures and also observed on periorbital tissue microscopy. The final diagnosis was bilateral periorbital necrotising fasciitis (PONF) associated with invasive GAS infection. The patient had a prolonged intensive care unit course with input from multiple specialist teams. This case demonstrates the importance of early recognition and treatment of PONF, the profound systemic morbidity caused by these infections, and illustrates successful multidisciplinary teamwork.

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Early recognition of PIMS-TS: a single centre retrospective review

BMJ Paediatrics Open ◽

10.1136/bmjpo-2020-001011 ◽

2021 ◽

Vol 5 (1) ◽

pp. e001011

Author(s):

Roshni Mistry ◽

Nicola Scanlon ◽

James Hibberd ◽

Fionnghuala Fuller

Keyword(s):

Early Recognition ◽

Febrile Illness ◽

Final Diagnosis ◽

University Hospital ◽

Single Centre ◽

Retrospective Case ◽

Reactive Protein ◽

Review Reports ◽

Specific Symptoms

IntroductionResearch into paediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2 (PIMS-TS) has focused on tertiary level management. This review reports on symptoms and investigations at presentation.MethodsSingle centre retrospective case note analysis of patients fulfilling PIMS-TS diagnostic criteria from March to May 2020 in a London district level university hospital.ResultsSix patients presented in the week prior to their final diagnosis with fever and non-specific symptoms. Raised C-reactive protein (CRP), lymphopenia and hyponatraemia were noted. Kawasaki-like symptoms were under-represented in all patients.InterpretationThe results suggest that a proportion of children with early PIMS-TS present with a non-specific febrile illness and abnormal blood results. Further research is needed to determine the most appropriate identification and follow-up of these children.

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Prehospital time of suspected stroke patients treated by emergency medical service: a nationwide study in Thailand

International Journal of Emergency Medicine ◽

10.1186/s12245-021-00361-w ◽

2021 ◽

Vol 14 (1) ◽

Author(s):

Phantakan Tansuwannarat ◽

Pongsakorn Atiksawedparit ◽

Arrug Wibulpolprasert ◽

Natdanai Mankasetkit

Keyword(s):

Emergency Medical Service ◽

Medical Service ◽

Life Support ◽

Demographic Data ◽

National Database ◽

Stroke Patients ◽

Emergency Medical ◽

Significant Difference ◽

Suspected Stroke ◽

Prehospital Time

Abstract Background This work was to study the prehospital time among suspected stroke patients who were transported by an emergency medical service (EMS) system using a national database. Methods National EMS database of suspected stroke patients who were treated by EMS system across 77 provinces of Thailand between January 1, 2015, and December 31, 2018, was retrospectively analyzed. Demographic data (i.e., regions, shifts, levels of ambulance, and distance to the scene) and prehospital time (i.e., dispatch, activation, response, scene, and transportation time) were extracted. Time parameters were also categorized according to the guidelines. Results Total 53,536 subjects were included in the analysis. Most of the subjects were transported during 06.00-18.00 (77.5%) and were 10 km from the ambulance parking (80.2%). Half of the subjects (50.1%) were served by advanced life support (ALS) ambulance. Median total time was 29 min (IQR 21, 39). There was a significant difference of median total time among ALS (30 min), basic (27 min), and first responder (28 min) ambulances, Holm P = 0.009. Although 91.7% and 88.3% of the subjects had dispatch time ≤ 1 min and activation time ≤ 2 min, only 48.3% had RT ≤ 8 min. However, 95% of the services were at the scene ≤ 15 min. Conclusion Prehospital time from EMS call to hospital was approximately 30 min which was mainly utilized for traveling from the ambulance parking to the scene and transporting patients from the scene to hospitals. Even though only 48% of the services had RT ≤ 8 min, 95% of them had the scene time ≤ 15 min.

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Pre-Admission CHADS2 and CHA2DS2-VASc Scores on Early Neurological Worsening

Cerebrovascular Diseases ◽

10.1159/000513396 ◽

2021 ◽

pp. 1-8

Author(s):

Ki-Woong Nam ◽

Chi Kyung Kim ◽

Sungwook Yu ◽

Jong-Won Chung ◽

Oh Young Bang ◽

...

Keyword(s):

Ischemic Stroke ◽

Stroke Risk ◽

Multivariable Analysis ◽

National Institutes Of Health ◽

Risk Scores ◽

Stroke Patients ◽

Nihss Score ◽

Early Neurological Deterioration ◽

Close Relationship ◽

The Relationship

Background: Stroke risk scores (CHADS2 and CHA2DS2-VASc) not only predict the risk of stroke in atrial fibrillation (AF) patients, but have also been associated with prognosis after stroke. Objective: The aim of this study was to evaluate the relationship between stroke risk scores and early neurological deterioration (END) in ischemic stroke patients with AF. Methods: We included consecutive ischemic stroke patients with AF admitted between January 2013 and December 2015. CHADS2 and CHA2DS2-VASc scores were calculated using the established scoring system. END was defined as an increase ≥2 on the total National Institutes of Health Stroke Scale (NIHSS) score or ≥1 on the motor NIHSS score within the first 72 h of admission. Results: A total of 2,099 ischemic stroke patients with AF were included. In multivariable analysis, CHA2DS2-VASc score (adjusted odds ratio [aOR] = 1.17, 95% confidence interval [CI] = 1.04–1.31) was significantly associated with END after adjusting for confounders. Initial NIHSS score, use of anticoagulants, and intracranial atherosclerosis (ICAS) were also found to be closely associated with END, independent of the CHA2DS2-VASc score. Multivariable analysis stratified by the presence of ICAS demonstrated that both CHA2DS2-VASc (aOR = 1.20, 95% CI = 1.04–1.38) and CHADS2 scores (aOR = 1.24, 95% CI = 1.01–1.52) were closely related to END in only patients with ICAS. In patients without ICAS, neither of the risk scores were associated with END. Conclusions: High CHA2DS2-VASc score was associated with END in ischemic stroke patients with AF. This close relationship is more pronounced in patients with ICAS.

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Abstract 118: Diffusion Lesion Volume Reduction after Recanalization Therapy for Anterior Circulation Stroke with Major Vessel Occlusion: Analysis from the RESCUE-Japan Registry Study

Stroke ◽

10.1161/str.45.suppl_1.118 ◽

2014 ◽

Vol 45 (suppl_1) ◽

Author(s):

Mikito Hayakawa ◽

Hiroshi Yamagami ◽

Kazunori Toyoda ◽

Yuji Matsumaru ◽

Yukiko Enomoto ◽

...

Keyword(s):

Intravenous Thrombolysis ◽

Volume Reduction ◽

Lesion Volume ◽

Stroke Patients ◽

Anterior Circulation ◽

Vessel Occlusion ◽

Nihss Score ◽

Median Baseline ◽

Point Reduction ◽

Major Vessel

Objective: Although Diffusion-weighted imaging (DWI) lesions are commonly irreversible, DWI lesion volume reduction (DVR) is occasionally observed. We investigated clinical significance and predictors of DVR in acute stroke patients with major vessel occlusion receiving recanalization therapy (RT). Methods: The Recovery by Endovascular Salvage for Cerebral Ultra-acute Embolism (RESCUE)-Japan registry prospectively registered 1,442 stroke patients with major vessel occlusion who were admitted to 84 Japanese stroke centers within 24 hours after onset from July 2010 to June 2011. We retrospectively analyzed all patients with the internal carotid artery or middle cerebral artery (M1 or M2 segments occlusions receiving RT and undergoing MRI both on admission and at 24 hours after onset from the registry. We defined DVR as a 1 or more-point reduction of the DWI-Alberta Stroke Program Early CT Score (ASPECTS), and CT-DWI mismatch (CTDM) as a 2 or more-point lower DWI-ASPECTS than CT-ASPECTS on admission. Reperfusion was defined as TICI grade 2b-3 on catheter angiography or modified Mori grade 3 on MRA immediately after RT. Dramatic recovery (DR) was defined as a 10 or more-point reduction or a total NIHSS score of 0-1 at 24 hours, and favorable outcome (FO) defined as a mRS score 0-2 at 3 months. Results: A total of 390 patients (215 men, 72 years old,) was included. Median baseline NIHSS score was 16 (IQR 10-19) and median baseline DWI-ASPECTS was 8 (6-9). CTDM was seen in 92 patients (28%) on admission. Intravenous thrombolysis and endovascular therapy were performed in 246 patients (63%) and 223 patients (57%), respectively. Reperfusion was obtained in 170 patients (51%). DVR was seen in 51 patients (13%). Eighty-eight patients (23%) obtained DR and 158 patients (41%) achieved FO. On multivariate analyses, DVR was significantly related to DR (OR 3.8, 95%CI 1.5-10) and FO (4.6, 1.8-12). CTDM was an independent predictor of DVR (OR 2.5, 95% CI 1.1-5.8). Conclusions: DVR was significantly related to DR and FO. CTDM is a rough predictor of DVR of which area is considered as a “DWI-bright” ischemic penumbra, and might be a useful marker to identify the adequate candidates for RT in spite of relatively large DWI lesions.

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Abstract TP245: Variance in Ems Run Times by Receiving Hospital for Stroke Patients in San Diego County

Stroke ◽

10.1161/str.51.suppl_1.tp245 ◽

2020 ◽

Vol 51 (Suppl_1) ◽

Author(s):

Amelia Kenner-brininger ◽

Lindsay Olson-Mack ◽

Lorraine Calzone ◽

Kristi L Koenig ◽

Thomas M Hemmen

Keyword(s):

Response Time ◽

San Diego ◽

Life Support ◽

Prehospital Care ◽

Advanced Life Support ◽

San Diego County ◽

Stroke Patients ◽

Transport Time ◽

Stroke Registry ◽

Few Data

Background: Emergency Medical Services (EMS) play an important role as initial providers after stroke. Few data are available that capture Stroke Receiving System and EMS response and transport data. We used a stroke registry from a community of 3.3 million residents, 18 stroke receiving centers, and 19 ground transporting advanced life support EMS agencies to evaluate EMS response time, scene time, and transport times. Our aim was to inform the stroke community about duration of EMS care and guide future prehospital interventions. Methods: We included all cases from the San Diego County Stroke Registry arriving by EMS with associated computer automated dispatch (CAD) record and base hospital record (BHR) from July 2017 through December 2018. Records were linked on the EMS incident number, reviewed for accuracy. We analyzed EMS response, scene, transport and total run times (enroute to arrival) by receiving hospital. Results: Between July 2017 and December 2018 2,376 EMS patients were transported to 18 hospitals. Volume per hospital ranged from 11 to 483 patients over the study period. Mean (±SD) response time was 7.0 (±3.7) minutes, range: 5.3 to 9.3 minutes between hospitals. Mean (±SD) scene time was 13.1 (±5.2) minutes, range: 10.5 to 15.0 minutes between hospitals. Transport time averaged 13.8 (±7.7) minutes, range: 8.3 to 23.8 minutes between hospitals (IQR=8.5-17.9). The mean (±SD) total EMS run time was 33.8 (±10.8) minutes, range: 26.4 to 44.9 minutes between hospitals (IQR=26.4-39.9). Conclusion: Only minor variations in EMS response and scene times were observed across the Stroke Receiving Centers. However, transport time showed greater variation and contributed to the differences in total EMS run times. Many systems had short transport times, limiting prehospital interventions. Next steps include studying factors contributing to transport time variation to inform prehospital care and triage decisions of possible stroke patients to optimize transport times.

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Abstract P862: Successes and Impact of a Statewide Stroke Education Campaign for Healthcare Providers

Stroke ◽

10.1161/str.52.suppl_1.p862 ◽

2021 ◽

Vol 52 (Suppl_1) ◽

Author(s):

Olivia N Jones ◽

Janna Pietrzak ◽

Kylie Picou ◽

Mindy Cook ◽

Adela Santana ◽

...

Keyword(s):

North Dakota ◽

Health Care Providers ◽

Healthcare Professionals ◽

Life Support ◽

Systems Of Care ◽

Everyday Practice ◽

Care Providers ◽

Stroke Patients ◽

Treatment Methods ◽

The Impact

Introduction: The North Dakota Mission: Lifeline Stroke program is a 3-year initiative which aims to improve statewide stroke systems of care. Due to complexities in recognizing and treating stroke patients, effective education of prehospital and hospital health care providers on guideline-based assessments and treatment methods were identified as an essential intervention. In person lectures, conferences, workshops, stroke simulation trainings, online courses, webinars, and a stroke certification program were deployed throughout the project. Purpose: The purpose of the post-education survey was to determine the impact, value, and success of different types of education provided during the project. Methods: North Dakota healthcare professionals (n=221) completed a 20-question online survey about their experiences participating in the stroke trainings provided from 2017 to 2020. Results: Survey respondents consisted of 76 Emergency Medical Service (EMS) providers and 145 hospital-based healthcare professionals. The majority of hospital-based staff respondents were nurses (80.1%), while most EMS-based respondents were paramedics or EMTs (75.0%). Half of all respondents (49.8%) participated in 2 or more educational offerings. Respondents were asked to rank the educational offerings in which they participated in by order of the benefit to their everyday practice. The two highest ranking educational offerings were the Advanced Stroke Life Support Class (mean rank=1.6) and Simulation in Motion (SIM) ND (mean rank=2.3). More than 90% of respondents stated that these trainings were extremely or very applicable to their everyday practice. When asked about the overall impact of all the educational offerings they participated in, almost all (92.6%) respondents indicated they agree that because of the trainings they have a better understanding of the key issues related to caring for stroke patients. Conclusions: Overall, the comprehensive survey provides concrete evidence and feedback that multi-modal education campaigns are well-received and effective in furthering awareness of guideline-based stroke assessments and treatment methods. Activities with a kinesthetic learning approach were found to be especially well-received.

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Abstract 2903: Nutritional Access of Dysphagic Patients 3 Months after Onset of Acute Stroke -From Database of 5,000 Patients in a Single Stroke Center-

Stroke ◽

10.1161/str.43.suppl_1.a2903 ◽

2012 ◽

Vol 43 (suppl_1) ◽

Author(s):

Makoto Nakajima ◽

Yuichiro Inatomi ◽

Toshiro Yonehara ◽

Yoichiro Hashimoto ◽

Teruyuki Hirano

Keyword(s):

Acute Stroke ◽

Chronic Phase ◽

Oral Intake ◽

Continuous Variables ◽

Operating Characteristics ◽

Stroke Patients ◽

Nihss Score ◽

Swallowing Dysfunction ◽

Stroke Center ◽

Dysphagic Patients

Background and purpose: Prediction of swallowing function in dysphagic patients with acute stroke is indispensable for discussing percutaneous endoscopic gastrostomy (PEG) placement. We performed a retrospective study using database of a large number of acute ischemic stroke patients to clarify predictors for acquisition of oral intake in chronic phase. Methods: A total 4,972 consecutive acute stroke patients were admitted to our stroke center during 8.5 years; a questionnaire was sent to all the survivors after 3 months of onset. We investigated nutritional access after 3 months of onset in 588 patients who could not eat orally 10 days after admission, and analyzed predictive factors for their acquisition of oral intake. Continuous variables were dichotomized to identify the most sensitive predictors; the cutoff values were investigated by receiver operating characteristics curve analysis. Results: Out of 588 dysphagic patients, 75 died during the 3 months, and 143 (28%) of the residual 513 achieved oral intake after 3 months. In logistic-regression models, age ≤80 years, absence of hyperlipidemia, absence of atrial fibrillation, modified Rankin Scale score 0 before onset, and low National Institutes of Health Stroke Scale (NIHSS) score independently predicted oral intake 3 months after onset. From two different model analyses, NIHSS score ≤17 on day 10 (OR 3.63, 95% CI 2.37-5.56) was found to be a stronger predictor for oral intake than NIHSS score ≤17 on admission (OR 2.34, 95% CI 1.52-3.59). At 3 months, 17/143 (12%) patients with oral intake were living at home, while only 1/370 (0.3%) patients without oral intake were. Conclusion: A quarter of dysphagic patients with acute stroke obtained oral intake 3 months after onset. Clinicians should be cautious about PEG placement for stroke patients with severe dysphagia who were independent prior to the stroke, aged ≤80 years, and show NIHSS score ≤17 on day 10, because their swallowing dysfunction may improve in a few months.

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