Role of Telemedicine in Prehospital Stroke Care

Emerging Adjuvant Thrombolytic Therapies for Acute Ischemic Stroke Reperfusion

Thrombolytic therapies for acute ischemic stroke are widely available but only result in recanalization early enough, to be therapeutically useful, in 10% to 30% of cases. This large gap in treatment effectiveness could be filled by novel therapies that can increase the effectiveness of thrombus clearance without significantly increasing the risk of harm. This focused update will describe the current state of emerging adjuvant treatments for acute ischemic stroke reperfusion. We focus on new treatments that are designed to (1) target different components that make up a stroke thrombus, (2) enhance endogenous fibrinolytic systems, (3) reduce stagnant blood flow, and (4) improve recanalization of distal thrombi and postendovascular thrombectomy.

Prehospital neurological emergencies- a survey on the state of prehospital neurological assessment by emergency medical professionals

BACKGROUND

Neurological emergencies are one of the major diagnosis groups in the Emergency Medical Services (EMS) with the highest rate of misdiagnosis. Despite the knowledge of time sensitivity and the importance of prehospital factors, prehospital delay is common. Although several stroke triage scales have been developed, a gold standard in the prehospital setting is lacking.

OBJECTIVES

Our aim was to evaluate the perception of neurological emergencies by EMS personnel and to identify current problems, difficulties and opportunities for improvement in the prehospital management of stroke, seizure, non-specific neurological symptoms, and paediatric neurological emergencies.

METHODS

The study was conducted as an online survey through SoSci Survey and was made available from March 1st to June 30th 2023 to all personnel working in emergency medical services. The access link was distributed through snowballing, social media, and through a QR code on a promotional poster. The survey was completed anonymously. The final survey consisted of 30 questions in German on the topics of neurological emergencies, general neurological assessment, specific neurological examination including paediatric assessment, stroke, and seizures, and finally suggestions for improvement.

RESULTS

The largest group of participants were paramedics, who estimated to encounter neurological emergencies at a general rate of 20-60%. When unease was felt, the main reasons were ambiguity of symptoms and insufficient admission capacity of hospitals. The biggest challenges were highly varied. Almost 80% of participants assumed that the neurological assessment would be omitted in difficult patient groups such as demented, intoxicated or children. 75% felt uncomfortable making a paediatric assessment, 50% were unfamiliar with the Paediatric Glasgow Coma Scale.

CONCLUSIONS

Support through more standardized practical training and defined, uniform guidelines is needed. There was also a clear need for peer collaboration, feedback and case sharing. Digitalization, the usage of telemedicine and updated versions of the documentation protocols including paediatric adaptations to current guidelines could further improve current neurological assessment in the prehospital setting.

Application of Telemedicine in the Ambulance for Stroke Patients: A Systematic Review

INTRODUCTION

The use of telemedicine for the prehospital management of emergency conditions, especially stroke, is increasing day by day. Few studies have investigated the applications of telemedicine in Emergency Medical Services (EMS). A comprehensive study of the applications of this technology in stroke patients in ambulances can help to build a better understanding. Therefore, this systematic review was conducted to investigate the use of telemedicine in ambulances for stroke patients in 2023.

METHODS

A systematic search was conducted in PubMed, Cochrane, Scopus, ProQuest, Science Direct, and Web of Science from 2013 through March 1, 2023. The authors selected the articles based on keywords and criteria and reviewed them in terms of title, abstract, and full text. Finally, the articles that were related to the study aim were evaluated.

RESULTS

The initial search resulted in the extraction of 2,795 articles. After review of the articles, and applying the inclusion and exclusion criteria, seven articles were selected for the final analysis. Three (42.85%) studies were on the feasibility and intervention types. Also, randomized trials, feasibility, feasibility and prospective-observational, and feasibility and retrospective-interventional studies were each one (14.28%). Six (85.71%) of the studies were conducted in the United States. The National Institutes of Health Stroke Scale (NIHSS) and RP-Xpress were the most commonly used tools for neurological evaluations and teleconsultations.

CONCLUSION

Remote prehospital consultations, triage, and sending patient data before they go to the emergency department can be provided through telemedicine in ambulances. Neurological evaluations via telemedicine are reliable and accurate, and they are almost equal to in-person evaluations by a neurologist.

Validity of the telematic Fugl Meyer assessment scale - upper extremity (TFMA-UE) Spanish version

Background

Telematic assistance has become indispensable in recent years. The increased prevalence of Acquired brain injury and the sequels it causes, requires long-lasting multidisciplinary treatments. Validated tools to assess the evolution of the disabilities and limitations of this pathology are essential to individualize and prescribe adapted treatments. The aim has been to create the telematic version of the Fugl Meyer Assessment-Upper Extremity Motor Function (TFMA-UE) Spanish scale and its adaptation to the remote assessment of neurologic patients.

Methods

An adapted scale was designed based on the Fugl Meyer Assessment scale-telematic version (FMA-TV): TFMA-UE. This scale is composed by 21 items which evaluate the upper extremity motor function. Physiotherapists trained in this tool, evaluate the results obtained from applying the two versions (on-site and telematic) to compare the results.

Results

TFMA-UE was administered to 30 patients with acquired brain injury. It was applied on site and through the web platform selected by the patients in two different days. Patients completed all the scale in an easily way without help. The exploratory and confirmatory factor analysis confirmed a factorial structure with a factor (76.08% of the variance). The Cronbach's internal consistency index obtained was 0.98 and the weight kappa index used to measure agreement between the two versions was 0.78 which represents substantial agreement.

Conclusion

The Telematic Fugl Meyer Assessment-Upper Extremity Motor Function (TFMA-UE) scale is a viable, useful and easy to apply tool that allows the upper extremity motor function assessment of Acquired Brain Injury patients.

Development of a prehospital lactic acidosis score for early-mortality. A prospective, multicenter, ambulance-based, cohort study

BACKGROUND

Lactic acidosis is a clinical status related to clinical worsening. Actually, higher levels of lactate is a well-established trigger of emergency situations. The aim of this work is to build-up a prehospital early warning score to predict 2-day mortality and intensive care unit (ICU) admission, constructed with other components of the lactic acidosis besides the lactate.

METHODS

Prospective, multicenter, observational, derivation-validation cohort study of adults evacuated by ambulance and admitted to emergency department with acute diseases, between January 1st, 2020 and December 31st, 2021. Including six advanced life support, thirty-eight basic life support units, referring to four hospitals (Spain). The primary and secondary outcome of the study were 2-day all-cause mortality and ICU-admission. The prehospital lactic acidosis (PLA) score was derived from the analysis of prehospital blood parameters associated with the outcome using a logistic regression. The calibration, clinical utility, and discrimination of PLA were determined and compared to the performance of each component of the score alone.

RESULTS

A total of 3334 patients were enrolled. The final PLA score included: lactate, pCO2, and pH. For 2-day mortality, the PLA showed an AUC of 0.941 (95%CI: 0.914-0.967), a better performance in calibration, and a higher net benefit as compared to the other score components alone. For the ICU admission, the PLA only showed a better performance for AUC: 0.75 (95%CI: 0.706-0.794).

CONCLUSIONS

Our results showed that PLA predicts 2-day mortality better than other lactic acidosis components alone. Including PLA score in prehospital setting could improve emergency services decision-making.

Fifteen Years of Sustainable Development in Emergency Medical Services under the Emergency Medicine Act of Thailand

BACKGROUND: Thailand’s emergency medical services (EMSs) are constantly evolving both in terms of personnel and technology in pre-hospital care. While sustainable development goals (SDGs) are used in part as a catalyst for development in all countries, there are currently no studies regarding the relationship between EMS research and SDGs in Thailand. AIM: This study aims to analyze how Thailand’s EMS research was affected after the National Institute for Emergency Medicine (NIEM) was established and how SDGs are related. METHODS: This was an analytical cross-sectional database study. Data were collected in the Scopus database with Thailand’s EMS records between 2008 and 2022. Three experienced emergency physicians were enrolled independently in this study for the purpose of giving opinions and feedback on the research. RESULTS: The three experts of this study are qualified emergency physicians in Thailand. The greatest number of the expert’s publications from the Scopus database was 117 articles. The greatest number of citations was 3994. The 175 documents were analyzed with three experts reviewing all documents and then narrowing it down to 25 documents. The most common SDG found in documents was Goal 3: GOOD HEALTH AND WELL-BEING. CONCLUSIONS: The development of Thailand’s EMS after the establishment of NIEM varied in aspects ranging from triage systems and care in ambulances to vehicle selection and technology. Goal 3: GOOD HEALTH AND WELL-BEING occurred most frequently in publications regarding SDGs in EMS studies.

Communication Requirements in 5G-Enabled Healthcare Applications: Review and Considerations

Fifth generation (5G) mobile communication technology can enable novel healthcare applications and augment existing ones. However, 5G-enabled healthcare applications demand diverse technical requirements for radio communication. Knowledge of these requirements is important for developers, network providers, and regulatory authorities in the healthcare sector to facilitate safe and effective healthcare. In this paper, we review, identify, describe, and compare the requirements for communication key performance indicators in relevant healthcare use cases, including remote robotic-assisted surgery, connected ambulance, wearable and implantable devices, and service robotics for assisted living, with a focus on quantitative requirements. We also compare 5G-healthcare requirements with the current state of 5G capabilities. Finally, we identify gaps in the existing literature and highlight considerations for this space.

[Time is Brain - Preclinical Emergency Care for Acute Ischemic Stroke]

Stroke is one of the most common neurological emergencies and requires rapid detection and treatment (time is brain). There is still insufficient knowledge about stroke warning signs. It is therefore of crucial importance that trained personnel in the preclinical setting recognize the relevant warning symptoms and collect the necessary information to quickly refer the patient to the appropriate additional care structure. For this purpose, training of the emergency medical services (EMS) and the correct triage are of particular importance. The on-site assessment of a patient with a suspected stroke by EMS should include airway, breathing, vital functions, a basic neurological examination, blood glucose testing and cardiac monitoring.Patients with suspected acute ischemic stroke should be brought to the nearest hospital with a stroke unit, ideally connected with a tertiary stroke centre. From there, once the primary diagnosis has been carried out and appropriate therapy initiated, the patient can be transferred to a thrombectomy center if necessary. To improve supply times, teleradiological networking plays a major role both between clinics of different levels of care and in communication between pre- and intra-hospital care providers. Also, the use of mobile stroke units can improve preclinical stroke care and reduce delays in access to intravenous thrombolytic therapy and mechanical thrombectomy. The identification of preclinical biomarkers could also save time.