Prehospital Assessment Research Articles

Predicting in-hospital mortality among non-trauma patients based on vital sign changes between prehospital and in-hospital: An observational cohort study.

ObjectiveTo prevent misjudgment of the severity of patients in the emergency department who initially seem non-severe but are in a critical state, methods that differ from the conventional viewpoint are needed. We aimed to determine whether vital sign changes between prehospital and in-hospital could predict in-hospital mortality among non-trauma patients.MethodsThis observational cohort study was conducted in two tertiary care hospitals. Patients were included if they were transported by ambulance for non-trauma-related conditions but were excluded if they experienced prehospital cardiopulmonary arrest, were pregnant, were aged <15 years, had undergone inter-hospital transfer, or had complete missing data regarding prehospital or in-hospital vital signs. The main outcome was in-hospital mortality, and the study variables were changes in vital signs, pulse pressure, and/or shock index between the prehospital and in-hospital assessments. Logistic regression analyses were performed to obtain adjusted odds ratios for each variable. Receiver operating characteristic curve analyses were performed to identify cut-off values that produced a positive likelihood ratio of ≥2.ResultsAmong the 2,586 eligible patients, 170 died in the two hospitals. Significantly elevated risks of in-hospital mortality were associated with changes in the Glasgow Coma Scale (cut-off ≤–3), respiratory rate (no clinically significant cut-off), systolic blood pressure (cut-off ≥47 mmHg), pulse pressure (cut-off ≥55 mmHg), and shock index (cut-off ≥0.3).ConclusionsNon-trauma patients who exhibit changes in some vital signs between prehospital and in-hospital have an increased risk of in-hospital mortality. Therefore, it is useful to incorporate these changes in vital signs to improve triaging and predict the occurrence of in-hospital mortality.

Protocolo de sospecha de ictus y atención prehospitalaria

Prehospital assessment of patients with potential acute stroke immediately before on arrival to emergency department is a key factor. Prehospital evaluation a key role in both, symptoms recognition and clinical stabilization. Furthermore it is the first step in the acute stroke protocol. The knowledge of basic prehospital care and the stroke code activacion criteria is required to treat patients as soon as possible and in the best clinical conditions. At hospital arrival, patients will immediately be assessed by the stroke team and treated with revascularization therapies or/and admitted to the stroke unit.

Značaj RACE (Rapid Arterial Occlusion Evaluation) skale u akutnom ishemijskom moždanom udaru

Introduction: Endovascular mechanical thrombectomy performed within the first 6 hours after the start of symptoms, with or without thrombolytic therapy, significantly reduces disability in patients with acute ischemic stroke and large vessel occlusion (LVO). The effectiveness of therapeutic modalities decreases over time recording the period from the start of symptoms to the therapeutic application. Identification of patients with ischemic stroke and LVO at the prehospital level is crucial for expedited transport to comprehensive endovascular centers. Objectives: To indicate the advantages and benefits of RACE scale in detecting patients with stroke and LVO in the prehospital settings. Methodology: A systematic review of the professional literature was performed in the index databases and leading scientific journals. The findings were systematized based on results and commented in the discussion. Results: The neurological "gold standard" for stroke severity rating is the National Institutes of Health Stroke Scale (NIHSS). Due to its complexity and time consuming there is a modified version created for the prehospital assessment called the Rapid Arterial Occlusion Evaluation (RACE) scale. For Emergency Medical Services the RACE scale represents a simple and practical screening test for LVO prediction, assessing 5 variables from the NIHSS scale, including motor and cortical functions. Conclusion: With higher sensitivity and slightly less specificity, the RACE scale could be an almost ideal prehospital test for LVO prediction. In our environment the RACE scale should become an integral part of the prehospital algorithms and connection between emergency physicians and vascular neulogists.

Identification of thoracic injuries by emergency medical services providers among trauma patients

IntroductionSevere thoracic injuries are time sensitive and adequate triage to a facility with a high-level of trauma care is crucial. The emergency medical services (EMS) providers are required to identify patients with a severe thoracic injury to transport the patient to the right hospital. However, identifying these patients on-scene is difficult. The accuracy of prehospital assessment of potential thoracic injury by EMS providers of the ground ambulances is unknown. Therefore, the aim of this study is to evaluate the diagnostic accuracy of the assessment of the EMS provider in the identification of a thoracic injury and determine predictors of a severe thoracic injury. MethodsIn this multicentre cohort study, all trauma patients aged 16 and over, transported with a ground erence standard. Prehospital variables were analysed using logistic regression to explore prehospital ambulance to a trauma centre, were evaluated. The diagnostic value of EMS provider judgment was determined using the Abbreviated Injury Scale (AIS) of ≥ 1 in the thoracic region as ref predictors of a severe thoracic injury (AIS ≥ 3). ResultsIn total 2766 patients were included, of whom 465 (16.8%) sustained a thoracic injury and 210 (7.6%) a severe thoracic injury. The EMS providers’ judgment had a sensitivity of 54.8% and a specificity of 92.6% for the identification of a thoracic injury. Significant independent prehospital predictors were: age, oxygen saturation, Glasgow Coma Scale, fall > 2 m, and suspicion of inhalation trauma or a thoracic injury by the EMS provider. ConclusionEMS providers could identify little over half of the patients with a thoracic injury. A supplementary triage protocol to identify patients with a thoracic injury could improve prehospital triage of these patients. In this supplementary protocol, age, vital signs, and mechanism criteria could be included.

Emergency and acute care management of traumatic spinal cord injury: a survey of current practice among senior clinicians across Australia

BackgroundTo describe pre-hospital, emergency department and acute care assessment and management practices of senior clinicians for patients with acute traumatic spinal cord injury (TSCI) across Australia; and to describe clinical practice variation.MethodsWe used a descriptive, cross-sectional study design to survey senior clinicians (greater than 10 years practice in this field) caring for patients with acute TSCI. The assessment, management and referral practices of prehospital, emergency department/trauma and surgical expert clinicians, across prehospital, early hospital care, diagnostic imaging and haemodynamic management were surveyed.ResultsWe invited 95 eligible senior clinicians; the response rate was 75%. Survey findings demonstrated overall lack of awareness or consistent use of evidence based published guidelines; many clinicians following ‘locally written’ or ‘no particular’ guideline. Practitioners were conflicted across multiple areas including patient assessment and diagnosis, treatment and transport decisions. Reported spinal immobilisation practices differed substantially, as did target setting for blood pressure; the majority of clinicians actively monitored risk of respiratory deterioration. Specialist care consult and specialist service bed availability was reported as problematic by more than one third of clinicians.ConclusionsUnwarranted clinical practice variation is known to contribute to different health outcomes for patients with similar etiologies. Clinical practice guidelines offer evidence based, best practice standards, however are only effective if adopted throughout the healthcare system. Wide variability in acute care practices, pathways and timing to specialist centres for TSCI was evidenced by this survey despite seniority among clinicians. This devastating injury requires prompt, consistent, evidence based care from the moment of first responder. Improved outcomes for patients with TSCI would be more likely with standardised care across pre-hospital, emergency and acute care phases of care.KeywordsSpinal Cord Injuries, Multiple Trauma, Practice Guideline, Treatment Outcome, Surveys and Questionnaires, Expert Testimony

Association between the reported intensity of an acute symptom at first prehospital assessment and the subsequent outcome: a study on patients with acute chest pain and presumed acute coronary syndrome

BackgroundTo decrease the morbidity burden of cardiovascular disease and to avoid the development of potentially preventable complications, early assessment and treatment of acute coronary syndrome (ACS) are important. The aim of this study has therefore been to explore the possible association between patients’ estimated intensity of chest pain when first seen by the ambulance crew in suspected ACS, and the subsequent outcome before and after arrival in hospital.MethodsData was collected both prospectively and retrospectively. The inclusion criteria were chest pain raising suspicion of ACS and a reported intensity of pain ≥4 on the visual analogue scale.ResultsAll in all, 1603 patients were included in the study. Increased intensity of chest pain was related to: 1) more heart-related complications before hospital admission; 2) a higher proportion of heart failure, anxiety and chest pain after hospital admission; 3) a higher proportion of acute myocardial infarction and 4) a prolonged hospitalisation. However, there was no significant association with mortality neither in 30 days nor in three years. Adjustment for possible confounders including age, a history of smoking and heart failure showed similar results.ConclusionThe estimated intensity of chest pain reported by the patients on admission by the ambulance team was associated with the risk of complications prior to hospital admission, heart failure, anxiety and chest pain after hospital admission, the final diagnosis and the number of days in hospital.Trial registrationClinicalTrials.gov 151:2008/4564 Identifier: NCT00792181. Registred 17 November 2008 ‘retrospectively registered’.

Pre-hospital risk assessment in suspected non-ST-elevation acute coronary syndrome: A prospective observational study.

Pre-hospital risk stratification of non-ST-elevation acute coronary syndrome (NSTE-ACS) by the complete HEART score has not yet been assessed. We investigated whether pre-hospital risk stratification of patients with suspected NSTE-ACS using the HEART score is accurate in predicting major adverse cardiac events (MACE). This is a prospective observational study, including 700 patients with suspected NSTE-ACS. Risk stratification was performed by ambulance paramedics, using the HEART score; low risk was defined as HEART score ⩽ 3. Primary endpoint was occurrence of MACE within 45 days after inclusion. Secondary endpoint was myocardial infarction or death. A total of 172 patients (24.6%) were stratified as low risk and 528 patients (75.4%) as intermediate to high risk. Mean age was 53.9 years in the low risk group and 66.7 years in the intermediate to high risk group (p<0.001), 50% were male in the low risk group versus 60% in the intermediate to high risk group (p=0.026). MACE occurred in five patients in the low risk group (2.9%) and in 111 (21.0%) patients at intermediate or high risk (p<0.001). There were no deaths in the low risk group and the occurrence of acute myocardial infarction in this group was 1.2%. In the high risk group six patients died (1.1%) and 76 patients had myocardial infarction (14.4%). In suspected NSTE-ACS, pre-hospital risk stratification by ambulance paramedics, including troponin measurement, is accurate in differentiating between low and intermediate to high risk. Future studies should investigate whether transportation of low risk patients to a hospital can be avoided, and whether high risk patients benefit from immediate transfer to a hospital with early coronary angiography possibilities.

An Urban 9-1-1 System’s Experience with Left Ventricular Assist Device Patients

Background: Left ventricular assist devices (LVADs) are used with increasing frequency and left in place for longer periods of time. Prior publications have focused on the mechanics of troubleshooting the device itself. We aim to describe the epidemiology of LVAD patient presentations to emergency medical services (EMS), prehospital assessments and interventions, and hospital outcomes. Methods: This is a retrospective chart review of known LVAD patients that belong to a single academic center’s heart failure program who activated the 9-1-1 system and were transported by an urban EMS system to one of the center’s 2 emergency departments between January 2012 and December 2015. Identifying demographics were used to query the electronic medical record of the responding city fire agency and contracted transporting ambulance service. Two reviewers abstracted prehospital chief complaint, vital signs, assessments, and interventions. Emergency department and hospital outcomes were retrieved separately. Results: From January 2012 to December 2015, 15 LVAD patients were transported 16 times. The most common prehospital chief complaint was weakness (7/16), followed by chest pain (3/16). Of the 7 patients presenting with weakness, one was diagnosed with a stroke in the emergency department. Another patient was diagnosed with subarachnoid hemorrhage and expired during hospital admission. This was the only death in the cohort. The most common hospital diagnosis was GI bleed (3/16). The overall admission rate was 87.5% (14/16). Conclusions: EMS interactions with LVAD patients are infrequent but have high rates of admission and incidence of life-threatening diagnoses. The most common prehospital presenting symptoms were weakness and chest pain, and most prehospital interactions did not require LVAD-specific interventions. In addition to acquiring technical knowledge regarding LVADs, EMS providers should be aware of non-device-related complications including intracranial and GI bleeding and take this into account during their assessment.

Initial assessment, level of care and outcome among children who were seen by emergency medical services: a prospective observational study

BackgroundThe assessment of children in the Emergency Medical Service (EMS) is infrequent representing 5.4% of the patients in an urban area in the western part of Sweden. In Sweden, patients are assessed on scene by an EMS nurse whom independently decides on interventions and level of care. To aid the EMS nurse in the assessment a triage instrument, Rapid Emergency Triage and Treatment System-paediatrics (RETTS-p) developed for Emergency Department (ED) purpose has been in use the last 5 years. The aim of this study was to evaluate the EMS nurse assessment, management, the utilisation of RETTS-p and patient outcome.MethodsA prospective, observational study was performed on 651 children aged < 16 years from January to December 2016. Statistical tests used in the study were Mann-Whitney U test, Fisher’s exact test and Spearman’s rank statistics.ResultsThe dispatch centre indexed life-threatening priority in 69% of the missions but, of all children, only 6.1% were given a life threatening RETTS-p red colour by the EMS nurse. A total of 69.7% of the children were transported to the ED and, of these, 31.7% were discharged without any interventions. Among the non-conveyed patients, 16 of 197 (8.1%) visited the ED within 72 h but only two were hospitalised. Full triage, including five out of five vital signs measurements and an emergency severity index, was conducted in 37.6% of all children. A triage colour was not present in 146 children (22.4%), of which the majority were non-conveyed. The overall 30-day mortality rate was 0.8% (n = 5) in children 0–15 years.ConclusionsDespite the incomplete use of all vital signs according to the RETTS-p, the EMS nurse assessment of children appears to be adapted to the clinical situation in most cases and the patients appear to be assessed to the appropriate level of care but indicating an over triage. It seems that the RETTS-p with full triage is used selectively in the pre-hospital assessment of children with a risk of death during the first 30 days of less than 1%.

Does level of training predetermine the success rate of prehospital sepsis assessment? A prospective survey on early recognition

Introduction Sepsis is a challenge for health professionals. The increasing number of cases emphasizes the importance of early recognition resulting in better survival. Materials and methods Questionnaires were spread focusing on the prehospital recognition, treatment, and care pathway of septic patients. After presenting an initial scenario, other sepsis-like diseases were given as diagnosis of choice and the answers were registered. After redefining the situation, the same potential diagnoses were given and the difference in correct answers was detected. Results The number of responders was 120. Among them, 33% of responders chose hypovolaemia, 10% allergic reaction, 2.5% endocrine disease, 30.8% systemic inflammatory response syndrome/sepsis, 0.83% internal bleeding, 0.83% drug effect, 2.5% pulmonary embolism, and 19.17% metabolic disorder as primary diagnosis with a significantly higher number of trained paramedics highlighting the correct answer. After redefining the scenario, 63% changed the diagnosis, while 37% did not change (p &lt; .001). Further management was correctly chosen by the majority of responders. Discussion The small number of correct answers from non-paramedics highlights the need for more education in identifying the pitfalls of early recognition and therapy of those who attend patients first. Conclusion Trained paramedics recognize the sepsis better than other representatives, necessitating the introduction of new guidelines.

Prehospital idarucizumab prior to intravenous thrombolysis in a mobile stroke unit.

Administration of intravenous idarucizumab to reverse dabigatran anticoagulation prior to thrombolysis for patients with acute ischemic stroke has been previously described, but not in the prehospital setting. The speed and predictability of idarucizumab reversal is well suited to prehospital treatment in a mobile stroke unit and allows patients with recent dabigatran intake to access reperfusion therapy. To describe feasibility of prehospital idarucizumab administration prior to thrombolysis on the Melbourne mobile stroke unit. The Melbourne mobile stroke unit is a specialized stroke ambulance servicing central metropolitan Melbourne, Australia and provides prehospital assessment, scanning and treatment with an integrated CT scanner and multidisciplinary stroke team. All cases were identified through the mobile stroke unit treatment registry since launch in November 2017. Of a total of n = 20 thrombolysis cases in the first 4 months of operation, three patients (15%) received intravenous idarucizumab 5 g for dabigatran reversal prior to thrombolysis. Mean time between idarucizumab administration and thrombolysis was approximately 10 minutes. Two of the three patients were shown to have large vessel occlusion on CTA in the mobile stroke unit and proceeded to endovascular thrombectomy. At 24 hours, only one patient had a small amount of asymptomatic petechial hemorrhage on follow-up imaging. All patients demonstrated substantial neurological recovery and were discharged to inpatient rehabilitation. Rapid treatment with prehospital administration of idarucizumab prior to thrombolysis using a mobile stroke unit is feasible and facilitates hyperacute treatment.

Does an assessment aid improve Glasgow Coma Scale scoring by helicopter rescuers in Hong Kong: A randomised controlled trial

BackgroundGlasgow Coma Scale (GCS) is one of the most commonly used patient assessment tools. This study aimed to determine whether an assessment aid can improve the GCS scoring accuracy by helicopter rescuers in Hong Kong. MethodsIn this randomised controlled trial, Air Crewman Officers (ACMOs) of Government Flying Service in Hong Kong were randomised into two groups, with and without assessment aid. The group with the assessment aid was provided a printed copy of the GCS scoring table while watching the patient simulated videos. Ten videos with GCS scores ranging from 3 to 15 were used to test the performance of total GCS (tGCS) and motor component of GCS (mGCS) scoring. Results78% (n=25/32) of ACMOs participated in the study. By comparing the groups with and without an assessment aid, there was no significant difference in the accuracy of tGCS score (60% versus 60%; p=0.85) or mGCS score (80% versus 80%; p=0.75). Overall, mGCS has a higher accuracy than tGCS (p<0.001). The accuracy of mGCS was better than tGCS in mild and moderate brain injury scenarios. ConclusionThe use of an assessment aid did not improve GCS scoring by helicopter rescuers. The assessing of mGCS was more accurate than tGCS, further supporting the use of mGCS for prehospital conscious level assessment.

Innovation in Systems of Care in Acute Phase of Ischemic Stroke. The Experience of the Catalan Stroke Programme.

Stroke, and mainly ischemic stroke, is the second cause of death and disability. To confront the huge burden of this disease, innovative stroke systems of care are mandatory. This requires the development of national stroke plans to offer the best treatment to all patients eligible for reperfusion therapies. Key elements for success include a high level of organization, close cooperation with emergency medical services for prehospital assessment, an understanding of stroke singularity, the development of preassessment tools, a high level of commitment of all stroke teams at Stroke Centres, the availability of a disease-specific registry, and local government involvement to establish stroke care as a priority. In this mini review, we discuss recent evidence concerning different aspects of stroke systems of care and describe the success of the Catalan Stroke Programme as an example of innovation. In Catalonia, reperfusion treatment rates have increased in recent years and currently are among the highest in Europe (17.3% overall, 14.3% for IVT, and 6% for EVT in 2016).

Prehospital quick sequential organ failure assessment as a tool to predict in-hospital mortality

ObjectiveThis study aimed to evaluate the predictive ability of quick sequential organ failure assessment (qSOFA) score for in-hospital mortality among patients transported by physician-staffed helicopters. MethodsWe conducted a single-center, retrospective observational study using the physician-staffed helicopter registry data between 2003 and 2016. We calculated the qSOFA scores based on the patients' vital signs, which were measured on the scene. The tool's discriminatory ability was determined using the area under the curve of the receiver operating characteristic. ResultsA total of 1849 patients with a mean age of 63.0 (standard deviation [SD], 18.4) years were included in this study. The diagnostic categories included were trauma and nontrauma cases (1038 [56%] and 811 [44%], respectively). In-hospital mortality was documented in 169 (9%) patients. Meanwhile, the in-hospital mortality rates among patients with qSOFA scores of 0, 1, 2, and 3 were 5/411 (1%), 69/797 (9%), 71/541 (13%), and 24/100 (24%), respectively (P<0.0001 for trend). If the cutoff point is ≥1, the sensitivity and specificity of the qSOFA scores were 0.97 and 0.24, respectively. The area under the curve of the qSOFA scores was 0.67 for all patients, whereas that for trauma patients was 0.75. ConclusionAn increase in the qSOFA score is associated with a gradual increase in the in-hospital mortality rate among all patients. In particular, a very low mortality rate was observed among patients with a qSOFA score of 0. The qSOFA score predicted the in-hospital mortality of patients with trauma well.

Management of suspected paediatric meningitis: a multicentre prospective cohort study

ObjectiveTo quantify delays during management of children with suspected meningitis.DesignMulticentre prospective cohort study.SettingThree UK tertiary paediatric centres; June 2011–June 2012Patients388 children aged <16 years hospitalised with suspected meningitis or undergoing...

Abstract TP238: Accuracy of “Real-Life” Community Wide Prehospital Stroke Detection in San Diego County

Background: Recent studies have focused on improving prehospital stroke assessment tools, but specificity and sensitivity have been insufficient to reliably detect stroke in the prehospital setting. To assess the ability of emergency medical services (EMS) personnel to identify acute stroke in the field, we compared EMS stroke recognition with receiving medical center discharge diagnosis from a large community-based stroke dataset, the San Diego County Stroke Registry. The registry was founded in 2010 after San Diego County established 16 diverse stroke receiving centers. EMS uses the Cincinnati Prehospital Stroke Scale for screening. Methods: We captured all EMS transports in San Diego County from 2013 to 2015. Accuracy of stroke detection by the EMS providers was analyzed by: a) coding of stroke related provider impression (PI) by EMS; b) “stroke” recorded as the reason the transport destination was selected. All patients with diagnosis stroke on hospital discharge were considered confirmed stroke, and separated by: Acute Ischemic Stroke (AIS), Subarachnoid Hemorrhage (SAH), Transient Ischemic Attack (TIA) or Intracranial Hemorrhage (ICH). Results: Between 2013 and 2015, we identified 577,643 EMS transports, 7,425 (1.3%) were diagnosed as stroke by the treating facility (68.2% AIS, 14.4% TIA, 13.6% ICH, and 3.9% SAH). a) Of these 7,418 (99.9%) had a coded PI. Stroke related PI was positive in 53.8% (AIS: 55.9%; SAH: 18.1%; TIA: 60.5%; ICH 46.4%). b) A recorded reason for destination was found in 6,813 (91.8%) of all stroke patients. Stroke was the coded reason in 16.4% (AIS 16.4%; SAH 8.0%, TIA 18.0%, ICH 17.3%). Conclusion: In a large community EMS system, using routine stroke screening, 53.8% of all stroke patients were identified by EMS. Stroke was the coded reason for the selected destination in only 16.4% of EMS transported stroke cases. This emphasizes the need for better prehospital stroke detection to improve triage and direct patient care.

Cincinnati Prehospital Stroke Scale Can Identify Large Vessel Occlusion Stroke

Objective: Accurate prehospital identification of patients with acute ischemic stroke (AIS) from large vessel occlusion (LVO) facilitates direct transport to hospitals that perform endovascular thrombectomy. We hypothesize that a cut-off score of the Cincinnati Prehospital Stroke Scale (CPSS), a simple assessment tool currently used by emergency medical services (EMS) providers, can be used to identify LVO. Methods: Consecutively enrolled, confirmed AIS patients arriving via EMS between August 2012 and April 2014 at a high-volume stroke center in a large city with a single municipal EMS provider agency were identified in a prospective, single-center registry. Head and neck vessel imaging confirmed LVO. CPSS scores were abstracted from prehospital EMS records. Spearman's rank correlation, Wilcoxon rank-sum test, and Student's t-test were performed. Cohen's kappa was calculated between CPSS abstractors. The Youden index identified the optimal CPSS cut-off. Multivariate logistic regression controlling for age, sex, and race determined the odds ratio (OR) for LVO. Results: Of 144 eligible patients, 138 (95.8%) had CPSS scores in the EMS record and were included for analysis. The median age was 69 (IQR 58–81) years. Vessel imaging was performed in 97.9% of patients at a median of 5.9 (IQR 3.6–10.2) hours from hospital arrival, and 43.7% had an LVO. Intravenous tissue plasminogen activator was administered to 29 patients, in whom 12 had no LVO on subsequent vessel imaging. The optimal CPSS cut-off predicting LVO was 3, with a Youden index of 0.29, sensitivity of 0.41, and specificity of 0.88. The adjusted OR for LVO with CPSS = 3 was 5.7 (95% CI 2.3–14.1). Among patients with CPSS = 3, 72.7% had an LVO, compared with 34.3% of patients with CPSS ≤ 2 (p < 0.0001). Conclusions: A CPSS score of 3 reliably identifies LVO in AIS patients. EMS providers may be able to use the CPSS, a simple, widely adopted prehospital stroke assessment tool, with a cut-off score to screen for patients with suspected LVO.

Validation of the Cincinnati Prehospital Stroke Scale.

Background:Early recognition of Stroke is one of the key concepts in the “Chain of Survival” as described by the American Heart Association/American Stroke Association Stroke guidelines. The most commonly used tools for prehospital assessment of stroke are “The Cincinnati Prehospital Stroke Scale,” (CPSS) the “Face, Arm, Speech Test,” and “The Los Angeles Prehospital Stroke Screen.” The former two are used to identify stroke using physical findings while the latter is used to rule out other causes of altered consciousness.Aim:The aim of this study is to validate the CPSS in the prehospital setting by correlating with computed tomography scan findings. (1) To determine if these scores can be implemented in the Indian prehospital setting. (2) To determine if it is feasible for new emergency departments (EDs) to use these protocols for early detection of stroke.Methodology:A prospective, observational study from December, 2015 to March, 2016. Patients with suspected stroke were enrolled. Data were collected prehospital in patients that arrived to the ED in an ambulance. Sensitivity, specificity, positive predictive value, and negative predictive value of the score were calculated using standard formulae.Results:CPSS showed good sensitivity of 81% (confidence interval [CI] – 68.5%–97%) when combined and a positive predictive value (PPV) of 100% (CI: 91.9%–100%). Individually, they showed a sensitivity of 75.8%, 79%, and 74.1%, respectively, with a PPV of 100% and specificity of 95%–100%.Conclusion:As a prehospital screening tool, CPSS can be extremely useful as any diagnosis is only provisional until confirmed by an appropriate investigation in a hospital.

The impact of prehospital assessment and EMS transport of acute aortic syndrome patients

BackgroundThe quality of acute aortic syndrome (AAS) assessment by emergency medical service (EMS) and the incidence and prehospital factors associated with 1-month survival remain unclear. MethodsWe retrospectively analyzed the data collected for 94,468 patients with non-traumatic medical emergency excluding out-of-hospital cardiac arrest during the period of 2011–2014. ResultsOf these transported by EMS, 22,075 had any of the AAS-related symptoms, and 330 had an EMS-assessed risk for AAS; of these, 195 received an in-hospital AAS diagnosis. Of the remaining 21,745 patients without EMS-assessed risk, 166 were diagnosed with AAS. Therefore, the sensitivity and specificity of our EMS-risk assessment for AAS was 54.0% (195/361) and 99.4% (21,579/21,714), respectively. EMS assessed the risk less frequently when patients were elderly and presented with dyspnea and syncope/faintness. Sign of upper extremity ischemia was rarely detected (6.9%) and absence of this sign was associated with lack of EMS-assessed risk. The calculation of modified aortic dissection detection risk score revealed that rigorous assessment based on this score may increase the EMS sensitivity for AAS. The 1-month survival rate was significantly higher in patients admitted to core hospitals with surgical teams for AAS than in those admitted to all other hospitals [87.5% (210/240) vs 69.4% (84/121); P<0.01]. Multiple logistic regression analysis demonstrated that Stanford type A, Glasgow coma scale ≤14, and admission to core hospitals providing emergency cardiovascular surgery were associated with 1-month survival. ConclusionsImprovement of AAS survival is likely to be affected by rapid admission to appropriate hospitals providing cardiovascular surgery.

Patients with head trauma: A study on initial prehospital assessment and care

BackgroundBest evidence guidelines are intended to standardise assessment and treatment of patients with head trauma and improve outcomes for TBI patients. The primary aim was to explore pre-hospital emergency care nurses’ (PECNs’) documented assessment and care of patients with head trauma and the secondary aim to study gender differences in the documented care and interventions given by the PECNs. MethodsA retrospective observational study was conducted by evaluating 2750 prehospital medical records. ResultsThe results showed that 25.2% of the patients were assessed according to all four core-elements in the guidelines and 78.6% of the patients underwent at least one intervention by the PECNs. Male patients were to a higher extent assessed according to guidelines and were given higher transport priority while females were more often assessed for vital parameters and received significantly more analgesics. The assessment documented by the PECNs was not optimal concerning documentation using the Glasgow Coma Scale, but the documented assessment of circulation and, especially, respiratory rate was high (77.2%) compared to previous studies. ConclusionThe findings of this study showed a low degree of documented assessment of parameters related to head trauma and might also indicate some gender differences in the assessment and management.