Prehospital Advanced Diagnostics and Treatment of Acute Stroke: Protocol for a Controlled Intervention Study

Streamlining Acute Stroke Care by Introducing National Institutes of Health Stroke Scale in the Emergency Medical Services: A Prospective Cohort Study

National Institutes of Health Stroke Scale (NIHSS) is the most validated clinical scale for stroke recognition, severity grading, and symptom monitoring in acute care and hospital settings. Numerous modified prehospital stroke scales exist, but these scales contain less clinical information and lack compatibility with in-hospital stroke scales. In this real-life study, we aimed to investigate if NIHSS conducted by paramedics in the field is a feasible and accurate prehospital diagnostic tool.

Effects of alteplase on neurological deficits and expression of GFAP and GAP-43 in brain tissue of rats with acute cerebral infarction

OBJECTIVE

To investigate the effects of alteplase on neurological deficits, as well as on the expressions of glial fibrillary acidic protein (GFAP) and growth-associated protein-43 (GAP-43) in brain tissues of rats with acute cerebral infarction (ACI).

METHODS

Sprague Dawley (SD) rats (n = 50) were enrolled in a trial to establish a ACI rat model; of these, 48 rats were succeeefully modeled and were randomized into either the model or alteplase group, whereas another 24 SD rats were included in the sham-operated group.

FINDINGS

No significant difference in scores was observed between the model and alteplase groups at T1 (P > 0.05); however, rats in the alteplase group demonstrated lower scores than those in the model group at T2, T3, and T4 (P < 0.05). Rats in the model group showed a larger cerebral infarction volume than those in the alteplase group (P < 0.05), and the infarction volume on day 1, 3, 6, and 9 was higher in rats in the alteplase group than those in the sham-operated group (P < 0.05).

CONCLUSION

Treatment with alteplase can be effective in reducing cerebral infarction volume and moderating neurological deficits in ACI modeled rats within a 6-h time window, which may be correlated with the regulation of GFAP and GAP-43 expressions by alteplase.

Ultraearly thrombolysis by an anesthesiologist in a mobile stroke unit: A prospective, controlled intervention study

BACKGROUND

Acute stroke treatment in mobile stroke units (MSU) is feasible and reduces time-to-treatment, but the optimal staffing model is unknown. We wanted to explore if integrating thrombolysis of acute ischemic stroke (AIS) in an anesthesiologist-based emergency medical services (EMS) reduces time-to-treatment and is safe.

METHODS

A nonrandomized, prospective, controlled intervention study.

INCLUSION CRITERIA

age ≥18 years, nonpregnant, stroke symptoms with onset ≤4 h. The MSU staffing is inspired by the Norwegian Helicopter Emergency Medical Services crew with an anesthesiologist, a paramedic-nurse and a paramedic. Controls were included by conventional ambulances in the same catchment area. Primary outcome was onset-to-treatment time. Secondary outcomes were alarm-to-treatment time, thrombolytic rate and functional outcome. Safety outcomes were symptomatic intracranial hemorrhage and mortality.

RESULTS

We included 440 patients. MSU median (IQR) onset-to-treatment time was 101 (71-155) minutes versus 118 (90-176) minutes in controls, p = 0.007. MSU median (IQR) alarm-to-treatment time was 53 (44-65) minutes versus 74 (63-95) minutes in controls, p < 0.001. Golden hour treatment was achieved in 15.2% of the MSU patients versus 3.7% in the controls, p = 0.005. The thrombolytic rate was higher in the MSU (81% vs 59%, p = 0.001). MSU patients were more often discharged home (adjusted OR [95% CI]: 2.36 [1.11-5.03]). There were no other significant differences in outcomes.

CONCLUSIONS

Integrating thrombolysis of AIS in the anesthesiologist-based EMS reduces time-to-treatment without negatively affecting outcomes. An MSU based on the EMS enables prehospital assessment of acute stroke in addition to other medical and traumatic emergencies and may facilitate future implementation.

Diagnostic value of prehospital arterial blood gas measurements - a randomised controlled trial

Background

Arterial blood gas analysis is an important diagnostic tool in managing critically ill patients within the hospital. Whether prehospital application of this diagnostic modality contributes to more exact diagnoses and treatments in critically ill prehospital patients is unknown. The aim of this study was to establish whether access to arterial blood gas analysis increased the prehospital diagnostic accuracy of prehospital anaesthesiologists. Furthermore, we investigated whether prehospital blood gas analysis resulted in therapeutic interventions that would not have been carried out if the arterial blood gas analyser had not been available.

Methods

In a prospective randomised study, two groups of prehospital adult patients with acute critical illness were compared. All patients received standard prehospital care. In the intervention group, an arterial blood gas sample was analysed prehospitally. The primary outcome was the impact of blood gas analysis on the accuracy of prehospital diagnoses. Furthermore, we registered any therapeutic interventions that were carried out as a direct result of the blood gas analysis.

Results

A total of 310 patients were included in the study. Eighty-eight of these patients were subsequently excluded, primarily due to difficulties in obtaining post hoc consent or venous sampling or other technical difficulties. A total of 102 patients was analysed in the arterial blood gas group (ABG group), while 120 patients were analysed in the standard care group (noABG group). In 78 of the 102 patients in the ABG group, the prehospital physician reported that ABG analysis increased their perceived diagnostic precision. In 81 cases in the noABG group, the lack of arterial blood gas analysis was perceived to have decreased diagnostic accuracy. The claim that ABG analysis increased diagnostic accuracy could, however, not be substantiated as there was no difference in the number of un-specific diagnoses between the groups.

Blood gas analysis increased the probability of targeting specific prehospital therapeutic interventions and led to 159 interventions, including intubation, ventilation and/or upgrading the level of urgency, in 71 ABG-group patients (p < 0.001).

Conclusion

Although prehospital arterial blood gas analysis did not improve the accuracy of the prehospital diagnoses assigned to patients, it significantly increased the quality of treatment provided to patients with acute critical illness.

Trial registration

ClinicalTrials.gov, NCT03006692, retrospectively registered six months after first patient entry.