scholarly journals Paramedic Global Impression of Change During Prehospital Evaluation and Transport for Acute Stroke

Stroke ◽  
2020 ◽  
Vol 51 (3) ◽  
pp. 784-791
Author(s):  
Kristina Shkirkova ◽  
Samuel Schuberg ◽  
Emma Balouzian ◽  
Sidney Starkman ◽  
Marc Eckstein ◽  
...  
Keyword(s):  
Emergency Department ◽  
Los Angeles ◽  
Randomized Trial ◽  
Intracranial Hemorrhage ◽  
Prehospital Care ◽  
Early Period ◽  
Screening Tools ◽  
Neurological Deficits ◽  
Emergency Department Arrival ◽  
Global Impression Of Change

Background and Purpose— The prehospital setting is a promising site for therapeutic intervention in stroke, but current stroke screening tools do not account for the evolution of neurological symptoms in this early period. We developed and validated the Paramedic Global Impression of Change (PGIC) Scale in a large, prospective, randomized trial. Methods— In the prehospital FAST-MAG (Field Administration of Stroke Therapy-Magnesium) randomized trial conducted from 2005 to 2013, EMS providers were asked to complete the PGIC Scale (5-point Likert scale values: 1-much improved, 2-mildly improved, 3-unchanged, 4-mildly worsened, 5-much worsened) for neurological symptom change during transport for consecutive patients transported by ambulance within 2 hours of onset. We analyzed PGIC concurrent validity (compared with change in Glasgow Coma Scale, Los Angeles Motor Scale), convergent validity (compared with National Institutes of Health Stroke Scale severity measure performed in the emergency department), and predictive validity (of neurological deterioration after hospital arrival and of final 90-day functional outcome). We used PGIC to characterize differential prehospital course among stroke subtypes. Results— Paramedics completed the PGIC in 1691 of 1700 subjects (99.5%), among whom 635 (37.5%) had neurological deficit evolution (32% improvement, 5.5% worsening) during a median prehospital care period of 33 (IQR, 27–39) minutes. Improvement was associated with diagnosis of cerebral ischemia rather than intracranial hemorrhage, milder stroke deficits on emergency department arrival, and more frequent nondisabled and independent 3-month outcomes. Conversely, worsening on the PGIC was associated with intracranial hemorrhage, more severe neurological deficits on emergency department arrival, more frequent treatment with thrombolytic therapy, and poor disability outcome at 3 months. Conclusions— The PGIC scale is a simple, validated measure of prehospital patient course that has the potential to provide information useful to emergency department decision-making. Registration— URL: https://www.clinicaltrials.gov . Unique identifier: NCT00059332.

Abstract TP235: Deterioration and Improvement in the Field: Comparative Detection by Los Angeles Motor Scale and Glasgow Coma Scale in Acute, EMS-transported Stroke Patients

Stroke ◽  
2017 ◽  
Vol 48 (suppl_1) ◽  
Author(s):  
Anita Tipirneni ◽  
Kristina Shkirkova ◽  
Nerses Sanossian ◽  
Sidney Starkman ◽  
Scott Hamilton ◽  
...  
Keyword(s):  
Cerebral Ischemia ◽  
Los Angeles ◽  
Glasgow Coma Scale ◽  
Intracranial Hemorrhage ◽  
Stroke Patients ◽  
Coma Scale ◽  
Acute Cerebral Ischemia ◽  
Stroke Evolution ◽  
Global Impression Of Change ◽  
Los Angeles Motor Scale

Background: Stroke evolution after hospital arrival is well characterized for acute cerebral ischemia and intracranial hemorrhage. But with the advent of patient routing to designated stroke centers, and of prehospital stroke therapeutic trials, it is important to characterize stroke evolution in the earliest, prehospital moments of onset. Initial studies have prehospital evolution using serial Glasgow Coma Scale (GCS) assessment; however, GCS assesses level of consciousness rather than focal deficits. Methods: In the NIH FAST-MAG trial database, we analyzed patient deficit evolution from time of first paramedic assessment to early post-arrival assessment in the ED, using serial scores on the GCS, serial scores on the Los Angeles Motor Scale (LAMS) (a prehospital stroke deficit measure), and the Paramedic Global Impression of Change (PGIC) score, a 5 point Likert paramedic-clinician score. Results: Among 1632 acute, EMS-transported neurovascular disease patients, 1,245 (76.3%) had a final diagnosis of acute cerebral ischemia and 387 (23.7%) of acute intracranial hemorrhage. Time of paramedic initial assessment was median 23 mins (IQR 14-41) after onset and time of early ED assessment 58 mins (IQR 46-78). Considering score changes by 2 or more as salient, overall the LAMS and GCS indicated approximately equal frequencies of prehospital deterioration (LAMS 11.1%, GCS 12.0%), but the LAMS indicated higher frequencies of prehospital improvement (LAMS 24.5% vs GCS 5.7%, p<0.001), due to the ceiling constraint of the GCS. The LAMS correlated more strongly than the GCS with the paramedic global impression of change among all patients, r=0.31 vs 0.19, and especially in acute cerebral ischemia patients, r=0.27 vs 0.08). The prehospital course differed by stroke subtype on the LAMS: acute cerebral ischemia: improved 30.7%, worsened 7.1%, stable 62.25%; intracranial hemorrhage: improved 4.5%, worsened 24.2%, stable 71.3%. Conclusions: Focal deficit scales are superior to the GCS in characterizing prehospital stroke evolution. Change in neurologic status occurs in more than one-third of acute stroke patients during transport and the early ED, with improvement more common in acute cerebral ischemia and deterioration more common in ICH.

scholarly journals Keywords reflecting sepsis presentation based on mode of emergency department arrival: a retrospective cross-sectional study

2021 ◽  
Vol 14 (1) ◽  
Author(s):  
Ulrika Margareta Wallgren ◽  
Eric Larsson ◽  
Anna Su ◽  
Jennifer Short ◽  
Hans Järnbert-Pettersson ◽  
...  
Keyword(s):  
Emergency Department ◽  
Emergency Medical Services ◽  
Vital Signs ◽  
Cross Sectional Study ◽  
Screening Tools ◽  
Medical Services ◽  
Cross Sectional ◽  
Emergency Department Arrival ◽  
Emergency Medical ◽  
Sepsis Screening

Abstract Background Current sepsis screening tools are predominantly based on vital signs. However, patients with serious infections frequently present with normal vital signs and there has been an increased interest to include other variables such as symptoms in screening tools to detect sepsis. The majority of patients with sepsis arrive to the emergency department by emergency medical services. Our hypothesis was that the presentation of sepsis, including symptoms, may differ between patients arriving to the emergency department by emergency medical services and patients arriving by other means. This information is of interest to adapt future sepsis screening tools to the population in which they will be implemented. The aim of the current study was to compare the prevalence of keywords reflecting the clinical presentation of sepsis based on mode of arrival among septic patients presenting to the emergency department. Methods Retrospective cross-sectional study of 479 adult septic patients. Keywords reflecting sepsis presentation upon emergency department arrival were quantified and analyzed based on mode of arrival, i.e., by emergency medical services or by other means. We adjusted for multiple comparisons by applying Bonferroni-adjusted significance levels for all comparisons. Adjustments for age, gender, and sepsis severity were performed by stratification. All patients were admitted to the emergency department of Södersjukhuset, Stockholm, and discharged with an ICD-10 code compatible with sepsis between January 1, and December 31, 2013. Results “Abnormal breathing” (51.8% vs 20.5%, p value < 0.001), “abnormal circulation” (38.4% vs 21.3%, p value < 0.001), “acute altered mental status” (31.1% vs 13.1%, p value < 0.001), and “decreased mobility” (26.1% vs 10.7%, p value < 0.001) were more common among patients arriving by emergency medical services, while “pain” (71.3% vs 40.1%, p value < 0.001) and “risk factors for sepsis” (50.8% vs 30.8%, p value < 0.001) were more common among patients arriving by other means. Conclusions The distribution of most keywords related to sepsis presentation was similar irrespective of mode of arrival; however, some differences were present. This information may be useful in clinical decision tools or sepsis screening tools.

Keywords Reflecting Sepsis Presentation and Mode of Emergency Department Arrival: A Retrospective Cross-sectional Study

2020 ◽  
Author(s):  
Ulrika Margareta Wallgren ◽  
Eric Larsson ◽  
Anna Su ◽  
Jennifer Short ◽  
Hans Järnbert-Pettersson ◽  
...  
Keyword(s):  
Emergency Department ◽  
Clinical Presentation ◽  
Vital Signs ◽  
Cross Sectional Study ◽  
Screening Tools ◽  
P Value ◽  
Sectional Study ◽  
Cross Sectional ◽  
Emergency Department Arrival ◽  
Sepsis Screening

Abstract Background: Current sepsis screening tools rely predominantly on vital signs. Since patients with serious infections frequently present with normal vital signs there is a need for other variables to be included to detect sepsis. As a first step, it is essential to understand the clinical presentation of septic patients. The aim was to compare the prevalence of keywords reflecting the clinical presentation of sepsis and mode of arrival, among septic patients presenting to the emergency department. Methods: Retrospective cross-sectional study of 479 adult septic patients. Keywords reflecting sepsis presentation upon emergency department arrival were quantified and analyzed based on mode of arrival, i.e. by emergency medical services or by other means. We adjusted for multiple comparisons by applying Bonferroni-adjusted significance levels for all comparisons. Adjustments for age, gender and sepsis severity were performed by stratification. All patients were admitted to the emergency department of Södersjukhuset, Stockholm, and discharged with an ICD-10 code compatible with sepsis between January 1stand December 31st, 2013. Results: “Abnormal breathing” (51.8% vs 20.5%, p-value <0.001), “abnormal circulation” (38.4% vs 21.3%, p-value <0.001), “acute altered mental status” (31.1% vs 13.1%, p-value <0.001) and “decreased mobility” (26.1% vs 10.7%, p-value <0.001) were more common among patients arriving by emergency medical services, while “pain” (71.3% vs 40.1%, p-value <0.001) and “risk factors for sepsis” (50.8% vs 30.8%, p-value <0.001) were more common among patients arriving by other means.Conclusions: The distribution of most keywords related to sepsis presentation was similar irrespective of mode of arrival, however, some differences were present. This information may be useful in clinical decision tools or sepsis screening tools.

scholarly journals Stroke prediction in patients presenting with isolated dizziness in the emergency department

2021 ◽  
Vol 11 (1) ◽  
Author(s):  
June-sung Kim ◽  
Hong Jun Bae ◽  
Muyeol Kim ◽  
Shin Ahn ◽  
Chang Hwan Sohn ◽  
...  
Keyword(s):  
Risk Factors ◽  
Emergency Department ◽  
Multivariate Analysis ◽  
Acute Stroke ◽  
Neurological Deficits ◽  
Cerebrovascular Injury ◽  
Risk Patients ◽  
History Of ◽  
Independent Risk Factors ◽  
Record Review

AbstractDiagnosing stroke in patients experiencing dizziness without neurological deficits is challenging for physicians. The aim of this study was to evaluate the prevalence of acute stroke in patients who presented with isolated dizziness without neurological deficits at the emergency department (ED), and determine the relevant stroke predictors in this population. This was an observational, retrospective record review of consecutive 2215 adult patients presenting with dizziness at the ED between August 2019 and February 2020. Multivariate analysis was performed to identify risk factors for acute stroke. 1239 patients were enrolled and analyzed. Acute stroke was identified in 55 of 1239 patients (4.5%); most cases (96.3%) presented as ischemic stroke with frequent involvement (29.1%) of the cerebellum. In the multivariate analysis, the history of cerebrovascular injury (odds ratio [OR] 3.08 [95% confidence interval {CI} 1.24 to 7.67]) and an age of > 65 years (OR 3.01 [95% CI 1.33 to 6.83]) were the independent risk factors for predicting acute stroke. The combination of these two risks showed a higher specificity (94.26%) than that of each factor alone. High-risk patients, such as those aged over 65 years or with a history of cerebrovascular injury, may require further neuroimaging workup in the ED to rule out stroke.

Paramedic Documentation of Indicators for Cervical Spine Injury

1994 ◽  
Vol 9 (1) ◽  
pp. 40-43 ◽  
Author(s):  
Andre M. Pennardt ◽  
Wm. John Zehner
Keyword(s):  
Emergency Department ◽  
Cervical Spine ◽  
Motor Vehicle ◽  
Motor Vehicle Accident ◽  
Spinal Injury ◽  
Medical Center ◽  
Prehospital Care ◽  
Retrospective Chart Review ◽  
Spine Injury ◽  
Status Assessment

AbstractIntroduction:Current paramedic training mandates complete immobilization of all patients, symptomatic or not, whose mechanism of injury typically is viewed as conducive to spinal trauma. It is common to observe confrontations between paramedics and walking, asymptomatic accident victims who fail to understand why they should “wear that collar and be strapped to that board.” Immobilized, frustrated patients then may wait for hours in a busy emergency department until a physician declares them to be without spinal injury. Patients frequently refuse treatment and transport.Hypothesis:Algorithms exist for physicians to “clear” the cervical spine (C-spine) without radiography. It was hypothesized that paramedics routinely assess and document these indicators in their patient evaluations.Methods:A retrospective chart review was conducted on 161 patients (Group 1) admitted to a regional medical center with a diagnosis of C-spine injury over a 52-month period. The charts of 225 motor vehicle accident (MVA) victims (Group 2) transported by ambulance to the emergency department over a five-month period then were studied. Indicators for C-spine injury documented by emergency medical service (EMS) personnel were abstracted.Results:All patients underwent mental status assessment and full spinal immobilization (neck and back) by EMS crews prior to transport to the hospital. Two or more indicators of possible C-spine injury were documented on each prehospital care report (PCR).Conclusion:Paramedics already assess most, if not all, of the criteria standard to C-spine clearance algorithms, but are inconsistent in their documentation of the presence or absence of all of the relevant findings.

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