Prehospital Diagnosis Research Articles

Abstract TP314: EEG Has High Precision for Diagnosing Stroke Hours After Onset

Background: Improvements are needed in prehospital diagnosis of stroke. The electroencephalogram (EEG) changes immediately after brain ischemia, and advances in EEG technology enable rapid acquisition in the acute care setting. We hypothesized that EEG data increase the accuracy with which patients are correctly classified as having acute stroke or not, and so performed a study in the Emergency Department (ED) as an initial step towards evaluating prehospital utility of EEG. Methods: Patients with suspected stroke in a comprehensive stroke center ED underwent a 3 min EEG using a wireless, dry-electrode system; data were analyzed offline. A model was developed to classify patients as stroke/TIA vs non-stroke using a training set of 60 randomly selected patients. The model was then tested in an independent validation cohort of 40 new patients. EEG variables were selected using Lasso regression. Four models were examined, the first three using logistic regression: [1] clinical data only; [2] EEG data only; [3] combined clinical and EEG data; [4] a deep learning neural network model using clinical and EEG data. Results: Of the 100 ED patients (mean age 64.5 ± 15.7), 63 were ultimately discharged with a diagnosis of stroke (43 ischemic, 7 hemorrhagic) or TIA (13). Median time from last known well (LKW) to EEG was 9.4 hours; from ED arrival to EEG, 3.7 hours. Median time to prepare/place EEG leads then initiate recording was 9 min, shortened during the study (p<0.0001), and was as brief as 36 seconds. To classify patients as stroke/TIA vs non-stroke: [1] The clinical data (including LKW and Rapid Arterial Occlusion Evaluation score) model had AUC=62.3. [2] The EEG data (Lasso selected 4 frontocentral leads, in higher frequencies) model had AUC=78.2. [3] The clinical+EEG data model had AUC=80.3. [4] The deep learning neural network model yielded AUC=87.8. Conclusions: The data support the feasibility of using a dry lead EEG system to rapidly acquire EEG in the acute stroke ED setting and suggest utility to improve prehospital stroke diagnosis once acquisition and analysis approaches are appropriately streamlined. EEG captures a signal that is diagnostically useful, independent from clinical measures, and improves the precision with which acute stroke can be diagnosed.

Abstract 168: Detection of Stroke Using Highly-Parallel Profiling of the Circulating Antibody Pool

Quick and accurate recognition of stroke during triage improves the probability of positive outcome, however the tools currently available to clinicians for prehospital and early in-hospital diagnosis of stroke are limited. The peripheral immune system is intricately involved in stroke pathology, and thus may be targetable for the development of immunodiagnostics. In this study, we sought to determine whether the circulating antibody pool is altered early in stroke, and whether such alterations could be leveraged for diagnosis. 100 uL of peripheral whole blood was sampled from 19 ischemic stroke patients, 17 hemorrhagic stroke patients, and 20 stroke mimics upon stroke team referral. A custom-fabricated high-density peptide array comprised of 125,000 unique probes was used to assess the binding characteristics of blood-borne antibodies, and a random forest-based approach was used to select a parsimonious set of probes with an optimal ability to discriminate between groups. The coordinate antibody binding intensities of the top 17 probes identified in our analysis displayed an ability to differentiate between stroke patients and stroke mimics with 92% sensitivity and 90% specificity, as well as detect hemorrhage with 88% sensitivity and 87% specificity, as determined using a same-set cross-validation. Our findings suggest that stroke-associated alterations in the circulating antibody pool may have clinical utility for diagnosis during triage, and that such a possibility warrants further investigation.

The ADAN scale: a proposed scale for pre‐hospital use to identify status epilepticus

The prognosis of status epilepticus (SE) depends on the time between onset and the diagnosis and start of treatment. Our aim was to design a scale with predictive value for pre-hospital diagnosis of SE. This was a retrospective study of 292 patients who attended the emergency department for an epileptic seizure. A total of 49 patients fulfilled the criteria for SE. We recorded the patients' history and clinical features. Variables independently associated with SE were combined to design a clinical scale. The performance of the scale was evaluated in a validation dataset of 197 patients. A total of 50.3% of the patients were male and the mean age was 55.9years. The following features were more prevalent in patients with SE: abnormal speech (79.6% vs. 18.9%, P<0.001), eye deviation (69.4% vs. 14.0%, P<0.001), automatism (22.4% vs. 6.3%, P<0.001), hemiparesis (24.5% vs. 10.9%, P=0.011), state of stupor/coma (46.9% vs. 4.2%, P<0.001) and number of pre-hospital seizures, i.e. two (34.7% vs. 4.5%, P<0.001) or more than two (51.0% vs. 0.4%, P<0.001). Based on these findings, we designed a scale that scored 1 point each for presence of abnormal speech, eye deviation, automatism and two seizures, and 2 points for more than two seizures. The predictive capacity of the scale for identifying SE in the validation dataset was 98.7% (95% confidence interval, 97.3%-100%) and 85.4% of patients with a score >1 had SE. A score >1 on the ADAN scale is a robust predictor of the diagnosis of SE in patients who experience an epileptic seizure. This scale may be a useful tool for clinical use and warrants further investigation.

Application of Telemedicine for the Control of Patients with Acute and Chronic Heart Diseases.

Introduction: Telemedicine (TM) has transformed the field of emergency cardiology, particularly the treatment of acute myocardial infarction (AMI). The ability to record an electrocardiogram (EKG) in the early prehospital phase, thus avoiding any delay in diagnosing myocardial infarction with direct transfer to the cath-lab for primary angioplasty, has proven to significantly reduce treatment times and mortality. Materials and Methods: We analyzed the available evidence and organizational models based on a support by TM in cardiology, including the applications of TM in cardiovascular disease based on a review of the literature. Results: The most important areas of application of TM in the field of cardiology are as follows: (1) Early prehospital diagnosis of AMI with EKG transmission; (2) Patient Remote control through wearable and devices; (3) Monitoring of patients with chronic heart failure; (4) Monitoring of patient's arrhythmias; and (5) Transmission of echo images to a III level center for a "second opinion". Conclusions: TM services should, therefore, be considered as a true diagnostic/therapeutic aspect of cardiovascular emergencies. It is necessary to educate medical staff and to provide a tempting environment for software engineers. Investing in infrastructure and equipment is imperative, as well as a positive climate for its implementation.

Prehospital dexamethasone administration in children with croup: a medical record review.

ObjectivesCroup is one of the most common childhood respiratory illnesses. Early dexamethasone administration in croup can improve patient outcomes. The objective of this study was to assess the clinical impact of prehospital administration of dexamethasone to children with croup.MethodsA medical record review that included children between 6 months and 6 years, who were brought via emergency medical services (EMS) to the emergency department (ED) with a final diagnosis of croup, between January 2010 and December 2012, was conducted. Data were collected regarding prehospital management and ED management, length of stay (LOS), final disposition, and patient demographics.ResultsA total of 188 patients with an ED diagnosis of croup were enrolled, 35.1% (66/188) of whom received a prehospital diagnosis of croup. The mean age of the participants was 32.96±17.18 months and 10.6% (20/188) were given dexamethasone in the prehospital setting by EMS, while 30.3% (57/188) were given epinephrine nebulizations. Out of the 66 patients with a prehospital diagnosis of croup, 10.6% (7/66) were given dexamethasone by EMS. In ED, dexamethasone was administered to 88.3% (166/188) while 29.8% of participants (56/188) received epinephrine nebulizations. There was no significant difference in ED LOS between those who received prehospital dexamethasone (2.6±1.6 hours, n=18) and those who did not (3.3±2.7 hours, n=159) (P=0.514). The number of in-hospital epinephrine doses per patient was significantly influenced by the administration of prehospital dexamethasone (P=0.010).ConclusionsPrehospital administration of dexamethasone results in less ED epinephrine use and may reflect dexamethasone’s positive influence on the severity and short-term persistence of croup symptoms.

Paramedic and physician perspectives on the potential use of remotely supported prehospital ultrasound.

During remotely supported prehospital ultrasound (RSPU), an ultrasound operator performs a scan and sends images to a remote expert for interpretation. This novel technology has been undergoing investigation in the randomised controlled SatCare trial, which seeks to assess the capability of RSPU to improve patient outcomes and standard of prehospital care in the Highlands of Scotland. This study aimed to explore the views of emergency medicine physicians and paramedics prior to starting the trial. An interview schedule was prepared a priori and was based upon normalisation process theory (NPT), which can be used to assess ways in which practitioners work to embed novel technologies in clinical practice. Semi-structured interviews were conducted with four consultant physicians and eight paramedics, who were recruited using purposive sampling until theoretical saturation. Analysis used open and hierarchical axial coding, and NPT as a framework to assist in the management and analysis of codes. The prospect of RSPU evoked significantly different responses from emergency care physicians and paramedics. Paramedics thought of RSPU as a logical progression of prehospital care, which addresses core prehospital challenges such as lack of decision-making support and a limited ability to identify life-threatening occult conditions. Paramedics saw RSPU as part of a trend to increase their skills and responsibilities, and viewed ultrasound as a validated tool within emergency medicine. Paramedics felt that ultrasound was simple to learn and would be practical for use within the prehospital arena. In contrast, physicians expressed a greater spectrum of views; most saw limited value to prehospital diagnosis and were concerned that RSPU would distract both paramedics and physicians from their existing roles (particularly in the context of the increasing demand and workload within Scotland's publicly funded National Health Service). Physicians were also concerned that ultrasound skills were poorly incorporated into training and practice in the British emergency medicine system. Furthermore, they believed that ultrasound was difficult to learn, prone to misinterpretation and easy to become deskilled in. Both sets of participants believed that the relational skills required between the two groups and the practical complexities of RSPU may pose challenges in its implementation. In particular, concerns were raised regarding the time that would be required to conduct the ultrasound scans and difficulties with transmission and communication in the Highlands. Both groups questioned the likelihood of measurable benefits from RSPU for patients. Furthermore, both groups were unsure how the technology would benefit those patients in urban areas close to the emergency department or whether RSPU would be effectively utilised in rural areas where serious emergencies are infrequent. There are substantial differences in emergency physician and paramedic perspectives on RSPU; however, both parties were willing to engage with the research process. Both groups have reservations, especially the emergency physicians who perceive significant barriers to the acquisition of skills, as well as the relational and contextual integration of RSPU. This study demonstrates the importance of conversations with physicians and paramedics throughout the research process, particularly as the role of prehospital care remains controversial.

Diagnostic accuracy of prehospital electrocardiograms interpreted remotely by emergency physicians in myocardial infarction patients

BackgroundPrehospital 12‑lead electrocardiogram (ECG) is the most widely used screening tool for recognition of ST-segment elevation myocardial infarction (STEMI). However, prehospital diagnosis of STEMI based solely on ECGs can be challenging. ObjectivesTo evaluate the ability of emergency department (ED) physicians to accurately interpret prehospital 12‑lead ECGs from a remote location. MethodsAll suspected prehospital STEMI patients who were transported by EMS and underwent angiography between 2006 and 2014 were included. We reviewed prehospital ECGs and grouped them based on: 1) presence or absence of a culprit artery lesion following angiography; and 2) whether they met the 3rd Universal Definition of Myocardial Infarction. We also described characteristics of ECGs that were misinterpreted by ED physicians. ResultsA total of 625 suspected STEMI cases were reviewed. Following angiography, 94% (590/625) of patients were found having a culprit artery lesion, while 6% (35/625) did not. Among these 35 patients, 24 had ECGs that mimicked STEMI criteria and 9 had non-ischemic signs. Upon ECG reinterpretation, 92% (577/625) had standard STEMI criteria while 8% (48/625) did not. Among these 48 patients, 35 had ischemic signs ECGs and 13 did not. Characteristics of misinterpreted ECGs included pericarditis, early repolarization, STE > 1 mm (1‑lead only), and negative T-wave. ConclusionsRemote interpretation of prehospital 12‑lead ECGs by ED physicians was a useful diagnostic tool in this EMS system. Even if the rate of ECG misinterpretation is low, there is still room for ED physicians operating from a remote location to improve their ability to accurately diagnose STEMI patients.

Трудности и ошибки диагностики внематочной беременности на догоспитальном этапе

Трудности и ошибки диагностики внематочной беременности на догоспитальном этапе

Mobile Stroke Units - Cost-Effective or Just an Expensive Hype?

Acute stroke is a treatable disease. Nevertheless, only a minority of patients obtain guideline-adjusted therapy. One major reason is the small time window in which therapies have to be administered in order to reverse or mitigate brain injury and prevent disability. The Mobile Stroke Unit (MSU) concept, available for a decade now, is spreading worldwide, comprising ambulances, fully equipped with computed tomography, laboratory unit and telemedicine connection to the stroke centre and staffed with a specialised stroke team. Besides its benefits, this concept adds a relevant amount of costs to health services. The feasibility of the MSU and its impact on reducing treatment times have been proven by several research trials. In addition, pre-hospital stroke diagnosis including computed tomographic angiography analysis facilitates correct triage of patients, needing mechanical recanalization, thereby reducing the number of secondary or inter-hospital transfers. Even so, the concept is not yet fully implemented on a broad scale. One reason is the still open question of cost-effectiveness. There are assumptions based on the randomised trials of MSUs hinting towards an acceptable amount of money per quality-adjusted life years and overall cost-effectiveness. Up to now, neither a prospective analysis nor a consideration of secondary transfer avoidance is available. The MSU concept is an innovative and impactful strategy to improve stroke management, especially in times of constraints in healthcare economics and health care professionals. Prospective information is needed to answer the cost-effectiveness question satisfactorily.

Express Immunochromatographic Detection of Rotavirus and Adenovirus Antigens in Pre-Hospital Differential Diagnosis of Acute Abdominal Pain in Children

Background.The assessment of the condition of a child with acute abdominal pain and a diagnostic search algorithm at the prehospital stage determine the further routing of the patient and the timeliness of healthcare delivery.Objective.Our aim was to evaluate the possibility of using immunochromatographic rapid tests (ICA) to determine the rota- and adenovirus infection in pre-hospital differential diagnosis of abdominal syndrome in children.Methods.In a retrospective cohort study, we analyzed the medical records of patients with a combination of abdominal and intestinal syndromes who applied for medical assistance to the emergency pediatric department of the FSAI “NMRC of Children’s Health” of the Ministry of Health of Russia from January 2015 to December 2017.Results.Outpatient medical records of 201 patients aged from 4 months to 17 years have been analyzed. In patients with a positive ICA, only 6% (5/88) of cases had doubtful or positive symptoms of peritoneal irritation, whereas in the case of a negative rapid test, almost all children needed a surgeon’s consultation. The frequency of leukocytosis detection in a clinical blood test was not different in patients with different results of ICA. The increase of C-reactive protein as a marker of bacterial inflammation was more common in patients with a negative rapid test. The volume of additional diagnostic care in the group of patients with a negative ICA result was significantly higher than in patients with confirmed viral gastroenteritis. None of the children with confirmed viral gastroenteritis required a surgical treatment. In the group with a negative ICA result, surgical treatment was performed in 11% (12/113) cases.Conclusion.Patients with confirmed viral gastroenteritis require significantly fewer diagnostic measures; they also have a minimal probability of acute surgical pathology. The use of laboratory rapid tests at the pre-hospital stage plays an important role in the timely diagnosis and the reduction in the frequency of non-specialized hospitalization.

Diagnostic Accuracy of Prehospital Tele-Electrocardiography in Acute Coronary Syndrome.

Tele-electrocardiography (tele-ECG) is a powerful ally in the screening of acute ischemic lesions. Evidence that confirms the correlation between the diagnosis of acute coronary syndrome (ACS) determined in the prehospital setting and the confirmation of the diagnosis in the hospital setting is scarce. This study compares the presumed diagnosis of ACS in the prehospital setting based on electrocardiographic changes, such as ST-segment deviation, with the diagnosis confirmed in a hospital setting. Retrospective, cross-sectional analysis of medical records of patients who sought emergency ambulance services of a distinguished public healthcare service in the city of Porto Alegre from September 2013 to August 2014. Data were collected from tele-ECG recordings and medical records available at the database of the Secretary of Health. The study was based on the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines. Among the 1,338 prehospital examinations performed, a total of 250 admissions in tertiary hospitals were registered. There was a significant agreement (p < 0.01) of 71% of the electrocardiographic changes identified in the prehospital setting with the diagnosis of ACS confirmed in the hospital setting. These changes were more prevalent in men (p = 0.048) and in patients aged 60 years or older (p = 0.006). The tele-ECG allows the early diagnosis of ACS, reducing the delay to definitive treatment, be it reperfusion, chemical, or mechanical therapy. Seventy-two percent of the prehospital diagnosis of ACS based on electrocardiographic changes was later confirmed in the hospital setting.

Acute coronary syndromes in the practice of the emergency medical team

An acute coronary syndrome (ACS) is described when myocardial ischemia occurs due to impeding blood flow through the coronary vessels, which in turn results in insufficient supply of oxygen. As a disease entity, it causes almost half of all deaths in Poland. The high mortality of ACS is primarily in the pre-hospital setting. The classification of acute coronary syndromes is based on criteria such as clinical symptoms, the nature and type of changes in the electrocardiogram, and indicators of myocardial necrosis. In the conditions of the emergency medical team, the division is based on the image of the ECG test. On this basis, ACS with elevation of the ST segment (STEMI) and without ST segment elevation (NSTEMI) are defined. Pre-hospital diagnosis of ACS includes an interview with the patient and a 12-lead ECG performed preferably in no more than 10 minutes since the first medical contact. The task of the emergency medical team is to quickly recognize, perform teletransmission to the interventional cardiology centre and implement pharmacological treatment, and then provide transport to the nearest centre of invasive cardiology, where the procedure should be performed to clear the blocked coronary artery. Therefore, it is important that the staff of medical emergency teams have appropriate knowledge and proper equipment for ambulances.

Prehospital point-of-care emergency ultrasound: a cohort study

BackgroundIn the prehospital situation, the diagnostic armamentarium available to the rescue physician is limited. Emergency ultrasound has proven to be a useful diagnostic tool, providing crucial information for the management of critically ill and injured patients. The proportion of performed ultrasound scans in all patients attended to by the rescue service team, the quality of the findings and the ultrasound-related changes in management approach and patient transport were evaluated.MethodsIn this prospective 18-month observational study, we documented all missions performed by rescue physicians with special training in emergency ultrasound (expert standard). These data were than analysed with regard to the ultrasound examinations. The ultrasound protocols used comprised Focussed Assessment with Sonography for Trauma (FAST), Prehospital Lung Ultrasound (PLUS) and Focused Echocardiography in Emergency Life support (FEEL). The quality of prehospital examinations was assessed by comparing the findings and diagnoses at the emergency site with those established in hospital. The changes in patient management and transport were documented using a standardized protocol.ResultsA total of 99 (18.1%) emergency ultrasound examinations were performed during 546 callouts. The most common indications for prehospital emergency ultrasound were dyspnoea (n = 38; 38.4%), during cardiac arrest (n = 17/17.2%), fall (n = 12/12.1%) and high-speed trauma (n = 11/11.1%). The combinations of ultrasound examination protocols in the trauma group (n = 31; 31.3%) were: 1. FAST+FEEL+PLUS (n = 17; 54.8%). 2. FAST+PLUS (n = 11; 35.5%) 3. FAST alone (n = 3; 9.7%). In the non-trauma group (n = 68; 68.7%), the following combinations were used: 1. FEEL+PLUS (n = 36; 52.9%), 2. FEEL alone (n = 21/30.9%). 3. PLUS alone (n = 6/8.8%) 4. FAST alone (n = 2; 2.9%) 5. FAST+FEEL+PLUS (n = 2; 2.9%). 6. FAST+FEEL (n = 1/1.5%). The emergency ultrasound findings impaired left ventricular contractile function (sensitivity 89.4%), right ventricular stress (85.7%), lung interstitial syndrome (100%), ruling out pneumothorax (specificity 100%), ruling out intraabdominal fluid (97,1%) were verified at the receiving hospital using ultrasonography, CT scan or x-rays; the prehospital diagnosis was confirmed in 90.8% of cases, the difference between the prehospital and in-hospital findings were not significant(p-values from p = 0.688 to p = 0,99). Ultrasound-related changes in patient management occurred in 49.5% of patients; in 33.3%, these were transported-related.ConclusionsEmergency ultrasound was as often used in the prehospital situation as it is in hospital. The ultrasound findings correlated well with in-hospital diagnostic results. Significant pathology changed patient-management, without prolonging the mission time.

Altered Mental Status: Current Evidence-based Recommendations for Prehospital Care.

IntroductionIn the United States emergency medical services (EMS) protocols vary widely across jurisdictions. We sought to develop evidence-based recommendations for the prehospital evaluation and treatment of a patient with an acute change in mental status and to compare these recommendations against the current protocols used by the 33 EMS agencies in the State of California.MethodsWe performed a literature review of the current evidence in the prehospital treatment of a patient with altered mental status (AMS) and augmented this review with guidelines from various national and international societies to create our evidence-based recommendations. We then compared the AMS protocols of each of the 33 EMS agencies for consistency with these recommendations. The specific protocol components that we analyzed were patient assessment, point-of-care tests, supplemental oxygen, use of standardized scoring, evaluating for causes of AMS, blood glucose evaluation, toxicological treatment, and pediatric evaluation and management.ResultsProtocols across 33 EMS agencies in California varied widely. All protocols call for a blood glucose check, 21 (64%) suggest treating adults at <60mg/dL, and half allow for the use of dextrose 10%. All the protocols recommend naloxone for signs of opioid overdose, but only 13 (39%) give specific parameters. Half the agencies (52%) recommend considering other toxicological causes of AMS, often by using the mnemonic AEIOU TIPS. Eight (24%) recommend a 12-lead electrocardiogram; others simply suggest cardiac monitoring. Fourteen (42%) advise supplemental oxygen as needed; only seven (21%) give specific parameters. In terms of considering various etiologies of AMS, 25 (76%) give instructions to consider trauma, 20 (61%) to consider stroke, and 18 (55%) to consider seizure. Twenty-three (70%) of the agencies have separate pediatric AMS protocols; others include pediatric considerations within the adult protocol.ConclusionProtocols for patients with AMS vary widely across the State of California. The evidence-based recommendations that we present for the prehospital diagnosis and treatment of this condition may be useful for EMS medical directors tasked with creating and revising these protocols.

Outpatient Experience of Human Caring Scale (OEHC-Scale): Improvement by Delphi Method.

Based on the outpatient interview and literature review, the initial framework of the outpatient experience of human caring scale was formed with 9 dimensions of outpatient process. The research aim was to improve the scale by Delphi method. Sixteen experts in medical management, human caring or medical education were invited to evaluate the importance of the dimensions and items of the scale and provided some expertise via filling out the Delphi consultation questionnaires twice in the consulting round. In the first round, the recovery rate showing the experts' positivity was 80%; the coefficient of reliability (Cr) ascertaining the authority of the evaluation was 0.92; the mean and full mark ratios responding the concentration of the evaluation were 2.88-4.94 and 6.25%-93.75% respectively; the coefficients of variation (CV) and the Kendall's W determining the concordance of the evaluation were 5.06%-52.15% and 0.21-0.24 respectively. In the second round, the recovery rate was 93.75%; the Cr was 0.93; the mean was 3.93-4.93; the full mark ratios were 26.67%-93.33%; the Kendall's W was 0.14-0.31, the CV was 5.25%-23.61%. Via the two-round Delphi study, the scale that included 10 dimensions and 61 items has been improved. Ten dimensions are pre-hospital medical service, guidance, registration, waiting, diagnosis & treatment, paying, inspection & assay, medicine receiving, therapy/injection/transfusion and global evaluation. It was concluded that Chinese scholars have paid high attention to human caring and outpatient experience. The experts have given high agreements about the dimensions which were established with Chinese outpatient process. The dimensions are different from the similar researches about outpatient experience study. In the future, it is necessary to survey the outpatients to test the construct validity, internal consistency reliability and others of the scale to improve the scale.

Clinical and Technological Approaches to the Prehospital Diagnosis of Large Vessel Occlusion.

Endovascular thrombectomy is highly effective for the treatment of acute ischemic stroke because of proximal large vessel occlusion,1 but the treatment effect falls rapidly with time.2 Almost all patients with severe stroke are transported by an emergency medical service (EMS), which is independently associated with reduced time to treatment.3 Nevertheless, delays are frequent in patients arriving for endovascular thrombectomy via secondary transport from another facility.1 To reduce time to treatment, some jurisdictions are exploring redirect policies, whereby patients bypass a closer primary stroke center and are instead transported directly to endovascular-capable facilities.4 Instituting a pathway for hospital bypass is a complex undertaking that involves the coordination of diverse stakeholders.4 Core components include patient selection criteria, interfacility agreements (eg, transfer and repatriation), paramedic training, and outcome evaluation. Approaches to patient selection have drawn recent interest, particularly in the use of simplified standardized clinical examinations for the diagnosis of proximal large vessel occlusion. In this review, we review current clinical and technological approaches to patient selection and discuss implementation in the context of jurisdictional features. The database search terms for this review article are provided in the online-only Data Supplement. Proximal large vessel occlusion is the substrate for endovascular thrombectomy—field diagnosis of large vessel occlusion is the sine qua non for hospital bypass. In this section, we discuss important caveats in prehospital diagnosis and follow with a review of specific clinical and technological approaches. ### Caveats Three caveats apply to the interpretation of studies of diagnostic tests for transport decision making: First, diagnosis is primarily a means to support transport decision making, not an end. If 2 diagnoses share the same transport destination, then it might not be so important to distinguish between them. For example, distinguishing between intracerebral hemorrhage (ICH) and large vessel occlusion may be …

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

BackgroundAcute ischemic stroke (AIS) is a medical emergency. The outcome is closely linked to the time elapsing from symptom onset to treatment, and seemingly small delays can mean the difference between full recovery and physical and cognitive dysfunction. Recanalization to allow blood to reenter the affected area is most efficient immediately after symptoms occur, and intravenous thrombolysis must be initiated no later than 4.5 hours after the symptom onset. A liable diagnosis is mandatory to administer the appropriate treatment. Prehospital diagnosis and, in cases where contraindications are ruled out, prehospital initiation of intravenous thrombolysis have been shown to significantly decrease the time from alarm to the treatment.ObjectiveThe objective of this paper is to investigate the effectiveness of prehospital thrombolysis as measured by (1) time spent from symptom onset to treatment and (2) the number of patients treated within 4.5 hours. In addition, we want to conduct explorative studies. These will include (1) the use of biomarkers for diagnostic and prognostic use where we will collect blood samples from various time points, including the hyperacute phase and (2) the study of magnetic resonance imaging (MRI) images at day 1 to determine the infarct volume and if the time to thrombolysis has an influence on this.MethodsThis is a prospective controlled intervention study. The intervention will involve a computed tomography (CT) and thrombolysis in a physician-manned ambulance called a mobile stroke unit (MSU). The control will be the conventional pathway where the patient is transported to the hospital for CT, and thrombolysis as per current procedure.ResultsPatient inclusion has started and a total of 37 patients are enrolled (control and intervention combined). The estimated time to completed inclusion is 36 months, starting from May 2017. The results of this study will be analyzed and published at the end of the trial.ConclusionsThis trial aims to document the feasibility of saving time for all stroke patients by providing prehospital diagnostics and treatment, as well as transport to appropriate level of care, in a safe environment provided by anesthesiologists trained in prehospital critical care.Trial RegistrationClinicalTrials.gov NCT03158259; https://clinicaltrials.gov/show/NCT03158259 (Archived by WebCite at http://www.webcitation.org/6wxNEUMUD)

Evidence-based guideline for the management of acute subaxial cervical spine injury

In order to provide the clinical guidelines of acute subaxial cervical spine injury for the Chinese orthopedic surgeons, the Spine Trauma Group of Chinese Association of Orthopedic Surgeons compiled this guidelines.The guidelines apply to adult patients with acute (less than 3 weeks) subaxial cervical spine and/(or) spinal cord or nerve root injuries. The Study Group wrote the guidelines by setting up questions, determining search words, screening literatures according to inclusion and exclusion criteria, analyzing the included literatures, confirming evidence levels and then providing recommendations. The guidelines include 141 literatures, 27 Chinese articles and 114 English articles. The guidelines set up 18 questions divided into 4 sections: pre-hospital care, diagnosis and evaluation, treatment and prevention of complications, which include 39 recommendations.

Predictive value of routine point-of-care cardiac troponin T measurement for prehospital diagnosis and risk-stratification in patients with suspected acute myocardial infarction.

The purpose of this study was to determine the predictive value of routine prehospital point-of-care cardiac troponin T measurement for diagnosis and risk stratification of patients with suspected acute myocardial infarction. All prehospital emergency medical service vehicles in the Central Denmark Region were equipped with a point-of-care cardiac troponin T device (Roche Cobas h232) for routine use in all patients with a suspected acute myocardial infarction. During the study period, 1 June 2012-30 November 2015, prehospital point-of-care cardiac troponin T measurements were performed in a total of 19,615 cases seen by the emergency medical service and 18,712 point-of-care cardiac troponin T measurements in 15,781 individuals were matched with an admission. A final diagnosis of acute myocardial infarction was confirmed in 2187 cases and a total of 2150 point-of-care cardiac troponin T measurements (11.0%) had a value ≥50 ng/l, including 966 with acute myocardial infarction (sensitivity: 44.2%, specificity: 92.8%). Patients presenting with a prehospital point-of-care cardiac troponin T value ≥50 ng/l had a one-year mortality of 24% compared with 4.8% in those with values <50 ng/l, log-rank: p<0.001. The following variables showed the strongest association with mortality in multivariable analysis: point-of-care cardiac troponin T≥50 ng/l (hazard ratio 2.10, 95% confidence interval: 1.90-2.33), congestive heart failure (hazard ratio 1.93, 95% confidence interval: 1.74-2.14), diabetes mellitus (hazard ratio 1.42, 95% confidence interval: 1.27-1.59) and age, one-year increase (hazard ratio 1.08, 95% confidence interval: 1.08-1.09). Patients with suspected acute myocardial infarction and a prehospital point-of-care cardiac troponin T ≥50 ng/l have a poor prognosis irrespective of the final diagnosis. Routine troponin measurement in the prehospital setting has a high predictive value and can be used to identify high-risk patients even before hospital arrival so that they may be re-routed directly for advanced care at an invasive centre.

Pre‐hospital thrombolysis in ST‐segment elevation myocardial infarction: a regional Australian experience

Objective The system of care in the Hunter New England Local Health District for patients with ST-segment elevation myocardial infarction (STEMI) foresees pre-hospital thrombolysis (PHT) administered by paramedics to patients more than 60 minutes from the cardiac catheterisation laboratory (CCL), and primary percutaneous coronary intervention (PCI) at the CCL for others. We assessed the safety and effectiveness of the pre-hospital diagnosis strategy, which allocates patients to PHT or primary PCI according to travel time to the CCL. Design, setting and participants Prospective, non-randomised, consecutive, single-centre case series of STEMI patients diagnosed on the basis of a pre-hospital electrocardiogram (ECG), from August 2008 to August 2013. All patients were treated at the tertiary referral hospital (John Hunter Hospital, Newcastle). Main outcome measures The primary efficacy endpoint was all-cause mortality at 12 months; the primary safety endpoint was bleeding. Results STEMI was diagnosed in 484 patients on the basis of pre-hospital ECG; 150 were administered PHT and 334 underwent primary PCI. The median time from first medical contact (FMC) to PHT was 35 minutes (IQR, 28-43 min) and to balloon inflation 130 minutes (IQR, 100-150 min). In the PHT group, 37 patients (27%) needed rescue PCI (median time, 4 h; IQR, 3-5 h). The 12-month all-cause mortality rate was 7.0% (PHT, 6.7%; PCI, 7.2%). The incidence of major bleeding (TIMI criteria) in the PHT group was 1.3%; no patients in the primary PCI group experienced major bleeding. Conclusion PHT can be delivered safely by paramedical staff in regional and rural Australia with good clinical outcomes.