Prehospital Phase Research Articles

Ionised calcium levels in major trauma patients who received blood en route to a military medical treatment facility

BackgroundHypocalcaemia is a common metabolic derangement in critically ill patients. Blood transfusion can also contribute to depleted calcium levels. The aims of this study were to identify the incidence of...

Hypothermia indices among severely injured trauma patients undergoing urgent surgery: A single-centred retrospective quality review and analysis

BackgroundHypothermia (<36°C) exacerbates trauma-induced coagulopathy and worsens morbidity and mortality among severely injured trauma patients; there is a paucity of published data describing how well trauma centres adhere to standards regarding measurement of temperature, and best practices for preventing and treating hypothermia. MethodsWe completed a retrospective quality audit of all severely injured trauma patients (Injury Severity Score (ISS≥20)) who had urgent surgery at Sunnybrook Health Sciences Centre (SHSC) between 2010 and 2014. Information regarding temperature monitoring was evaluated over the course of the initial resuscitation and admission. Independent risk factors for in-hospital mortality were elucidated through a multivariable regression analysis. ResultsOut of a total of 4492 trauma patients, 495 were severely-injured and went to the operating room (OPR) after being treated in the trauma bay (TB) at SHSC between 2010 and 2014. The majority of the patients were male (n=384, 77.6%) and had a blunt mechanism of injury (n=391, 79.0%). The median ISS score was 29 (interquartile range (IQR) 26, 35). Eighty-nine (17.9%) patients died; 26 (5.2%) of these patients died intra-operatively. Less than one fifth of patients (n=82,16.6%) received a temperature measurement during pre-hospital transport phase. Upon arrival to the TB, almost two-thirds (n=301, 60.8%) of patients had their temperature recorded and a similar proportion (n=175, 58.1%) of those patients were hypothermic (<36°C). In the OPR, close to 80% (n=389, 78.6%) of patients had their temperature measured on both arrival; almost 60% (n=223, 57.3%) were hypothermic on arrival. Almost all patients had their temperature measured upon arrival to the ICU or specialized ward (n=450, 98.3%). Warming initiatives were documented in only 36 (7.3%) patients in the TB, yet documented in almost all patients in OR (n=464, 93.7%). An increased risk of in-hospital mortality was correlated with not taking a temperature measurement in the TB (Odds Ratio (OR) 2.86 (95% Confidence Interval (CI) [1.64–4.99]) or OPR (OR 4.66 (95% CI [2.50–8.69]). ConclusionsA majority of severely injured trauma patients are hypothermic well into the perioperative period after initial admission. An absence of having temperature measurement during initial hospitalization is associated with increased in-hospital mortality amongst this patient group. Quality improvement initiatives should aim to strive for ongoing temperature measurement as a key performance indicator and early prevention and treatment of hypothermia during initial resuscitation.

Host responses to concurrent combined injuries in non-human primates

BackgroundMulti-organ failure (MOF) following trauma remains a significant cause of morbidity and mortality related to a poorly understood abnormal inflammatory response. We characterized the inflammatory response in a non-human primate soft tissue injury and closed abdomen hemorrhage and sepsis model developed to assess realistic injury patterns and induce MOF.MethodsAdult male Mauritan Cynomolgus Macaques underwent laparoscopy to create a cecal perforation and non-anatomic liver resection along with a full-thickness flank soft tissue injury. Treatment consisted of a pre-hospital phase followed by a hospital phase after 120 minutes. Blood counts, chemistries, and cytokines/chemokines were measured throughout the study. Lung tissue inflammation/apoptosis was confirmed by mRNA quantitative real-time PCR (qPCR), H&E, myeloperoxidase (MPO) and TUNEL staining was performed comparing age-matched uninjured controls to experimental animals.ResultsTwenty-one animals underwent the protocol. Mean percent hepatectomy was 64.4 ± 5.6; percent blood loss was 69.0 ± 12.1. Clinical evidence of end-organ damage was reflected by a significant elevation in creatinine (1.1 ± 0.03 vs. 1.9 ± 0.4, p=0.026). Significant increases in systemic levels of IL-10, IL-1ra, IL-6, G-CSF, and MCP-1 occurred (11-2986-fold) by 240 minutes. Excessive pulmonary inflammation was evidenced by alveolar edema, congestion, and wall thickening (H&E staining). Concordantly, amplified accumulation of MPO leukocytes and significant pulmonary inflammation and pneumocyte apoptosis (TUNEL) was confirmed using qRT-PCR.ConclusionWe created a clinically relevant large animal multi-trauma model using laparoscopy that resulted in a significant systemic inflammatory response and MOF. With this model, we anticipate studying systemic inflammation and testing innovative therapeutic options.

Prehospital hemostatic resuscitation to achieve zero preventable deaths after traumatic injury.

To describe how hemostatic resuscitation can be used in the prehospital phase of resuscitation to reduce preventable deaths after traumatic injury. Hemorrhagic shock is the leading cause of death that is preventable after injury. The National Academy of Sciences, recently, recommended that achievement of zero preventable deaths after traumatic injury should be the goal of a national trauma system. In the United States, there are an estimated 25 000 preventable deaths per year in the prehospital phase of resuscitation because of traumatic hemorrhagic shock. Therefore, to achieve the goal of zero preventable deaths after injury, both shock and hemostatic dysfunction need to be addressed rapidly in the prehospital phase of resuscitation. This review will highlight the epidemiology and outcomes of traumatic hemorrhagic shock, and explore potential solutions such as group O whole blood and platelets stored at 2-6°C. Trauma research receives the lowest funding relative to the burden of morbidity and mortality it creates when compared with all other diseases. Increased resources are required to achieve zero preventable deaths after injury. Prehospital hemostatic resuscitation has the potential to significantly reduce preventable death from hemorrhage.

Diagnostics and early treatment in prehospital and emergency-room phase in suspicious pelvic ring fractures

Testing for mechanical stability in pelvic ring fractures is advocated for the initial assessment and management of pelvic ring fractures. A survey among trauma surgeons showed that 91% agree with this recommendation. The aim of the present study was to describe the actual workup of patients with a high risk for unstable pelvic fractures in daily routine. We performed a prospective multicenter observational study on patients admitted to the emergency room with suspected pelvic ring fractures. Data were collected anonymously via a standardized case report. A total of 254 patients with suspected pelvic injuries from 12 different trauma centers were included in this study. In 95 out of 254 cases a per definition unstable pelvic fracture could be confirmed; 46 type B and 49 type C fractures was confirmed. Mechanical stability examination was carried out in 61% and revealed a sensitivity of 31.6% and a specificity of 92.2%. 11.5% (18 patients) actually showed a mechanical instability (6 B# 12 C#). Regardless, 166 patients (65.4%) received noninvasive external stabilization ahead of diagnostic imaging, as a result of clinical judgment. 72% (24×) showed signs of significant bleeding in the subsequent CT scans. 33 pelvic ring fractures (type B or C) had no prehospital stabilization. Testing of mechanical stability of the pelvic ring was carried out less often and with lower consequences for the actual management than expected. It seems worthwhile to rather put on a pelvic binder at earliest occasion based on trauma mechanism or clinical findings to reduce the risk of serious pelvic bleeding.

Determining Prognostic Value of Serum Levels of Lactate, Bicarbonate, Base Deficit and Glucose in Mortality Rate of Trauma Patients Admitted to Emergency Department

Background: Trauma is of the most important health problems in the world and major factor leading to mortality and morbidity, especially in the first four decades of life in injured people. So, we decided to examine in this study clinical symptoms and laboratory parameters in trauma patients and predictive value in determining prognosis and mortality of these patients.Methods: In this descriptive study, 150 cases of multi-trauma patients admitted to the emergency department of Tabriz Imam Reza hospital were enrolled in the study. Computerized block randomization method was applied to randomize the subjects The questionnaire containing basic information in the pre-hospital phase were recorded for selected patients. As well, injury severity score (ISS) and revised trauma score (RTS) were calculated. Then, blood samples were taken from patients for testing laboratory parameters, including serum lactate level, base deficit, blood glucose, serum bicarbonate levels, BUN and Cr. The data obtained were analyzed through descriptive statistics, frequency, percentage and mean difference test and chi-square test for qualitative variables examined using the software statistical SPSS v17. The P value&lt;0.05 was considered statistically significant.Results: mean age of patients was equal to 37.05±1.58 years. 130 patients (87.8%) were discharged after treatment and recovery and 18 patients (12.2%) died. predictive values of serum lactate cut of point was 27.65 pg/ml for serum lactate with sensitivity of 80% and specificity of 48% on admission.Conclusion: It seems that the mentioned markers alone are unable to be potent prognostic factors as predictors of mortality

PP25 Using a linked health dataset to identify what happens to patients following prehospital care

BackgroundUK prehospital services receive poor information about what happens to patients beyond the prehospital phase of care; this limits the opportunity to assess patient outcomes following non-conveyance. We aimed to...

Design and validation of a clinical scale for prehospital stroke recognition, severity grading and prediction of large vessel occlusion: the shortened NIH Stroke Scale for emergency medical services

ObjectiveTo develop an NIH Stroke Scale (NIHSS)-compatible, all-in-one scale for rapid and comprehensive prehospital stroke assessment including stroke recognition, severity grading and progression monitoring as well as prediction of large...

Transitional Home Care Program Utilizing the Integrated Practice Unit Concept (THC-IPU): Effectiveness in Improving Acute Hospital Utilization.

Background:Organizing care into integrated practice units (IPUs) around conditions and patient segments has been proposed to increase value. We organized transitional care into an IPU (THC-IPU) for a patient segment of functionally dependent patients with limited community ambulation.Methods:1,166 eligible patients were approached for enrolment into THC-IPU. THC-IPU patients received a comprehensive assessment within two weeks of discharge; medication reconciliation; education using standardized action plans and a dedicated nurse case manager for up to 90 days after discharge. Patients who rejected enrolment into THC-IPU received usual post-discharge care planned by their attending hospital physician, and formed the control group. The primary outcome was the proportion of patients with at least one unscheduled readmission within 30 days after discharge.Results:We found a statistically significant reduction in 30-day readmissions and emergency department visits in patients on THC-IPU care compared to usual care, even after adjusting for confounders.Conclusion:Delivering transitional care to patients with functional dependence in the form of home visits and organized into an IPU reduced acute hospital utilization in this patient segment. Extending the program into the pre-hospital discharge phase to include discharge planning can have incremental effectiveness in reducing avoidable hospital readmissions.

A comparison of Selective Aortic Arch Perfusion and Resuscitative Endovascular Balloon Occlusion of the Aorta for the management of hemorrhage-induced traumatic cardiac arrest: A translational model in large swine.

BackgroundSurvival rates remain low after hemorrhage-induced traumatic cardiac arrest (TCA). Noncompressible torso hemorrhage (NCTH) is a major cause of potentially survivable trauma death. Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) at the thoracic aorta (Zone 1) can limit subdiaphragmatic blood loss and allow for IV fluid resuscitation when intrinsic cardiac activity is still present. Selective Aortic Arch Perfusion (SAAP) combines thoracic aortic balloon hemorrhage control with intra-aortic oxygenated perfusion to achieve return of spontaneous circulation (ROSC) when cardiac arrest has occurred.Methods and findingsMale Yorkshire Landrace cross swine (80.0 ± 6.0 kg) underwent anesthesia, instrumentation for monitoring, and splenectomy. TCA was induced by laparoscopic liver lobe resection combined with arterial catheter blood withdrawal to achieve a sustained systolic blood pressure <10 mmHg, cardiac arrest. After 3 min of arrest, swine were allocated to one of three interventions: (1) REBOA plus 4 units of IV fresh whole blood (FWB), (2) SAAP with oxygenated lactated Ringer’s (LR), 1,600 mL/2 min, or (3) SAAP with oxygenated FWB 1,600 mL/2 min. Primary endpoint was survival to the end of 60 min of resuscitation, a simulated prehospital phase. Thirty animals were allocated to 3 groups (10 per group)—5 protocol exclusions resulted in a total of 35 animals being used. Baseline measurements and time to cardiac arrest were not different amongst groups. ROSC was achieved in 0/10 (0%, 95% CI 0.00–30.9) REBOA, 6/10 (60%, 95% CI 26.2–87.8) SAAP-LR and 10/10 (100%, 95% CI 69.2–100.0) SAAP-FWB animals, p < 0.001. Survival to end of simulated 60-minute prehospital resuscitation was 0/10 (0%, 95% CI 0.00–30.9) for REBOA, 1/10 (10%, 95% CI 0.25–44.5) for SAAP-LR and 9/10 (90%, 95% CI 55.5–99.7) for SAAP-FWB, p < 0.001. Total FWB infusion volume was similar for REBOA (2,452 ± 0 mL) and SAAP-FWB (2,250 ± 594 mL). This study was undertaken in laboratory conditions, and as such may have practical limitations when applied clinically. Cardiac arrest in this study was defined by intra-aortic pressure monitoring that is not feasible in clinical practice, and as such limits the generalizability of findings. Clinical trials are needed to determine if the beneficial effects of SAAP-FWB observed in this laboratory study will translate into improved survival in clinical practice.ConclusionsSAAP conferred a superior short-term survival over REBOA in this large animal model of hemorrhage-induced traumatic cardiac arrest with NCTH. SAAP using an oxygen-carrying perfusate was more effective in this study than non-oxygen carrying solutions in TCA. SAAP can effect ROSC from hemorrhage-induced electrocardiographic asystole in large swine.

ANMCO/SIT Consensus Document: telemedicine for cardiovascular emergency networks.

Telemedicine has deeply innovated the field of emergency cardiology, particularly the treatment of acute myocardial infarction. The ability to record an ECG 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. This consensus document aims to analyse the available evidence and organizational models based on a support by telemedicine, focusing on technical requirements, education, and legal aspects.

Major trauma from suspected child abuse: a profile of the patient pathway

BackgroundNetworked organised systems of care for patients with major trauma now exist in many countries, designed around the needs of the majority of patients (90% adults). Non-accidental injury is a...

Acute coronary syndrome in relation to the occurrence of associated symptoms: A quantitative study in prehospital emergency care

IntroductionAcute chest pain is a common symptom among prehospital emergency care patients. Therefore, it is crucial that ambulance nurses (ANs) have the ability to identify symptoms and assess patients suffering from acute coronary syndrome (ACS). The aim of this study is to explore the occurrence of dyspnoea and nausea and/or vomiting in the prehospital phase of a suspected ACS and the associations with patients’ outcome. MethodsThis study has a quantitative design based on data from hospital records and from a previous interventional study (randomised controlled trial) including five Emergency Medical Service (EMS) systems in western Sweden in the years 2008–2010. ResultsIn all, 1836 patients were included in the interventional study. Dyspnoea was reported in 38% and nausea and/or vomiting in 26% of patients. The risk of death within one year increased with the presence of dyspnoea. The presence of nausea and/or vomiting increased the likelihood of a final diagnosis of acute myocardial infarction (AMI). ConclusionThis study shows that dyspnoea, nausea and/or vomiting increase the risk of death and serious diagnosis among ACS patients. This means that dyspnoea, nausea and/or vomiting should influence the ANs’ assessment and that special education in cardiovascular nursing is required.

A Dedicated Spanish Language Line Increases Enrollment of Hispanics Into Prehospital Clinical Research.

Novel methods are needed to reduce the disparity of Hispanic enrollment in stroke clinical trials. Prehospital enrollment using a dedicated Spanish language line may help overcome this bias. Subjects or legally authorized representatives provided information on race and ethnicity for all cases enrolled in the FAST-MAG clinical trial (Field Administration of Stroke Therapy-Magnesium), a prehospital phase 3 randomized study of intravenous magnesium for neuroprotection. One of 2 in-ambulance cell phones (in English or Spanish) was used to obtain informed content in the field. We describe the yield and characteristics of subjects enrolled via Spanish line. There were 1700 subjects enrolled from 2005 to 2012, of which 402 (24%) identified as Hispanic ethnicity. Study racial makeup was 1325 (78%) white, 219 (13%) black, and 139 (8%) Asian. The dedicated Spanish line was used for 195 (12%) enrollments. Spanish-line enrollments were younger (65 versus 70 years old; P<0.001), more likely to identify as Hispanic (98% versus 14%; P<0.001), and more likely to present with intracerebral hemorrhage (36% versus 21%; P<0.001). The use of a dedicated Spanish language enrollment line allowed for greater enrollment of Hispanics, a population with significantly different baseline characteristics. URL: http://www.clinicaltrials.gov. Unique identifier: NCT00059332.

Pre-hospital lactate testing in the recognition and management of sepsis and septic shock

Sepsis a common condition, with a high mortality rate. Patients with this condition are routinely encountered by ambulance clinicians, but recognition of septic shock can be challenging. The pre-hospital phase of sepsis care provides the earliest opportunity for identification and treatment. Lactate measurement is a tool commonly used to stratify patient illness severity in sepsis, and is recommended as part of initial management in the acute hospital setting. A lack of evidence to inform the pre-hospital phase of care for patients with suspected sepsis prompted this pragmatic evaluation of point of care lactate measurement in an ambulance service. It is important to highlight that this study was carried out prior to the 2016 Sepsis-3 definitions and quickSOFA clinical criteria for recognising sepsis.

Current patterns of antithrombotic and revascularisation therapy in patients hospitalised for acute coronary syndromes. Data from the Polish subset of the EPICOR study.

Cardiovascular disease is the leading cause of mortality and morbidity in developed countries, including Poland. Antithrom-botic drugs play a crucial role in the management of acute coronary syndromes (ACS). Recent clinical trials have demonstrated the efficacy and safety profiles of new antiplatelet and anticoagulant agents, which may be used as add-on therapy or replacements for older drugs. The long-t E: rm follow-u P: of antithrombotic management patterns I: n acute COR: onary syndrome patients (EPICOR) is a prospective international observational study (NCT01171404) designed to describe the use of antithrombotic management strategies for the treatment of ACS during the acute phase and over a follow-up period of up to two years from the index event. A total of 608 patients from 26 hospitals in Poland were enrolled into the registry between September 2010 and March 2011. The aim of this work was to summarise data on pre-hospital and in-hospital and revascularisation therapy in 608 patients enrolled into the registry in Poland. The registry collected the records of patients who were hospitalised for ACS within 24 h of symptom onset and who had a final diagnosis of unstable angina (UA), non-ST-segment elevation myocardial infarction (NSTEMI), or ST-segment elevation myocardial infarction (STEMI), and survived to discharge. Among 608 enrolled patients, 291 had a final diagnosis of STEMI and 317 had a final diagnosis of NSTEMI/UA. Patients with NSTEMI/UA were generally at higher cardiovascular risk than patients with STEMI. Before admission to the hospital antiplatelet drugs (acetylsalicylic acid [ASA] and/or clopidogrel) were administered more frequently to STEMI than to NSTEMI/UA patients. Glycoprotein (GP) IIb/IIIa inhibitors were used in almost half of the STEMI patients and in nearly 10% of NSTEMI/UA patients. The combinations of antiplatelet drugs included ASA + clopidogrel (predominantly in NSTEMI/UA) or ASA + clopidogrel + GPIIb/IIIa inhibitor (predominantly in STEMI), while other possible combinations were not used. Almost all STEMI patients (96.2%) and the clear majority of NSTEMI/UA patients (73.8%) were subjected to percutaneous coronary intervention (PCI), while coronary artery bypass grafting was performed in only 2.5% of the NSTEMI/UA patients. At the time of discharge from hospital almost all patients with STEMI received ASA together with clopidogrel, but this strategy was used only in 91.5% of patients with NSTEMI/UA (p < 0.05). Unfractionated heparin was used in 62% of patients, low-molecular weight heparin in 35%, fondaparinux in 0.7%, and bivalirudin in none of the studied patients. Among patients with ACS enrolled to the EPICOR study in Poland, antiplatelet therapy was started in the pre-hospital phase in approximately one-third of the STEMI patients and in one out of ten of the NSTEMI/UA patients. The initial antiplatelet therapy was mostly based on ASA + clopidogrel and was followed by a combination of ASA + clopidogrel + GPIIb/IIIa inhibitor. Other drugs or combinations, as well as novel antiplatelet drugs, were only used exceptionally. Almost 10% of NSTEMI/UA patients did not receive dual antiplatelet therapy at discharge. PCI plays a dominating role in the first-line treatment for the patients enrolled to this registry in Poland.

Prehospital deaths from trauma: Are injuries survivable and do bystanders help?

Background and objectivesDeaths from trauma occurring in the prehospital phase of care are typically excluded from analysis in trauma registries. A direct historical comparison with Hussain and Redmond's study on preventable prehospital trauma deaths has shown that, two decades on, the number of potentially preventable deaths remains high. Using updated methodology, we aimed to determine the current nature, injury severity and survivability of traumatic prehospital deaths and to ascertain the presence of bystanders and their role following the point of injury including the frequency of first-aid delivery. MethodsWe examined the Coroners’ inquest files for deaths from trauma, occurring in the prehospital phase, over a three-year period in the Cheshire and Manchester (City), subsequently referred to as Manchester, Coronial jurisdictions. Injuries were scored using the Abbreviated-Injury-Scale (AIS-2008), Injury Severity Score (ISS) calculated and probability of survival estimated using the Trauma Audit and Research Network's outcome prediction model. ResultsOne hundred and seventy-eight deaths were included in the study (one hundred and thirty-four Cheshire, forty-four Manchester). The World Health Organisation's recommendations consider those with a probability of survival between 25–50% as potentially preventable and those above 50% as preventable. The median ISS was 29 (Cheshire) and 27.5 (Manchester) with sixty-two (46%) and twenty-six (59%) respectively having a probability of survival in the potentially preventable and preventable ranges. Bystander presence during or immediately after the point of injury was 45% (Cheshire) and 39% (Manchester). Bystander intervention of any kind was 25% and 30% respectively. Excluding those found dead and those with a probability of survival less than 25%, bystanders were present immediately after the point of injury or “within minutes” in thirty-three of thirty-five (94%) Cheshire and ten of twelve (83%) Manchester. First aid of any form was attempted in fourteen of thirty-five (40%) and nine of twelve (75%) respectively. ConclusionsA high number of prehospital deaths from trauma occur with injuries that are potentially survivable, yet first aid intervention is infrequent. Following injury there is a potential window of opportunity for the provision of bystander assistance, particularly in the context of head injury, for simple first-aid manoeuvres to save lives.

Pre-hospital transfusion of packed red blood cells in 147 patients from a UK helicopter emergency medical service

BackgroundEarly transfusion of packed red blood cells (PRBC) has been associated with improved survival in patients with haemorrhagic shock. This study aims to describe the characteristics of patients receiving pre-hospital blood transfusion and evaluate their subsequent need for in-hospital transfusion and surgery.MethodsThe decision to administer a pre-hospital PRBC transfusion was based on clinical judgment. All patients transfused pre-hospital PRBC between February 2013 and December 2014 were included. Pre-hospital and in-hospital records were retrospectively reviewed.ResultsOne hundred forty-seven patients were included. 142 patients had traumatic injuries and 5 patients had haemorrhagic shock from a medical origin. Median Injury Severity Score was 30. 90% of patients receiving PRBC had an ISS of >15. Patients received a mean of 2.4(±1.1) units of PRBC in the pre-hospital phase. Median time from initial emergency call to hospital arrival was 114 min (IQR 103–140). There was significant improvement in systolic (p < 0.001), diastolic (p < 0.001) and mean arterial pressures (p < 0.001) with PRBC transfusion but there was no difference in HR (p = 0.961). Patients received PRBC significantly faster in the field than waiting until hospital arrival. At the receiving hospital 57% required an urgent surgical or interventional radiology procedure. At hospital arrival, patients had a mean lactate of 5.4(±4.4) mmol/L, pH of 6.9(±1.3) and base deficit of −8.1(±6.7). Mean initial serum adjusted calcium was 2.26(±0.29) mmol/L. 89% received further blood products in hospital. No transfusion complications or significant incidents occurred and 100% traceability was achieved.DiscussionPre-hospital transfusion of packed red cells has the potential to improvde outcome for trauma patients with major haemorrhage. The pre-hospital time for trauma patients can be several hours, suggesting transfusion needs to start in the pre-hospital phase. Hospital transfusion research suggests a 1:1 ratio of packed red blood cells to plasma improves outcome and further research into pre-hospital adoption of this strategy is needed.ConclusionPre-hospital PRBC transfusion significantly reduces the time to transfusion for major trauma patients with suspected major haemorrhage. The majority of patients receiving pre-hospital PRBC were severely injured and required further transfusion in hospital. Further research is warranted to determine which patients are most likely to have outcome benefit from pre-hospital blood products and what triggers should be used for pre-hospital transfusion.

Abstract TP233: Patterns, Determinants and Outcomes of Ultra-Early Neurological Deterioration (U-END) in Acute Ischemic Stroke

Background: The patterns and outcomes of deterioration during prehospital transport and the first phase of ED care are important for planning for diversion of acute cerebral ischemia (ACI) patients to designated stroke centers and design of prehospital treatment trials. Methods: We analyzed patients enrolled in the NIH Phase 3 Field Administration of Stroke Therapy - Magnesium (FAST-MAG) trial within 2h of last known well (LKW). Deterioration was defined as worsening by ≥2 on the Glasgow Coma Scale (GCS), performed serially by paramedics in the field, upon ED arrival, and after the early ED course. Results: Among 713 acute cerebral ischemia patients, age was 65.4 (±13.4), 45% female. Times from LKW to GCS assessments were: paramedic, 25 mins (IQR 15-46); ED arrival, 60 mins (IQR 48-82); and after early ED course, 83 mins (IQR 60-106). Overall, 16.3% experienced neurological deterioration, including 9.0% in prehospital phase only, 7.3% in early ED phase only, and none in both phases. Granular patterns of deficit progression were: Prehospital Sustained - prehospital deterioration, then stable early ED phase, 2.2% (16); Dippers - prehospital deterioration, then early ED improvement, 6.7% (48); Delayed - stable prehospital, then ED deterioration, 3.0% (22); and Peakers - prehospital improvement, then early ED deterioration, 4.2% (30) (Figure). Ischemic stroke patients who experienced any U-END had higher age, 73.2 vs 69.8, p&lt;0.01; lower prehospital GCS scores, 14 (IQR 11-15) vs 15 (IQR 14-15), p&lt;0.001; and greater prehospital focal weakness, LAMS 4.2 vs 3.6, p&lt;0.001. U-END was associated with higher rates of disability or death (mRS 2-6) at 90 days, 77.8% vs 53.8%, p&lt;0.001. Conclusions: Ultra-early neurological deterioration occurs in one-sixth of EMS-transported acute cerebral ischemia patients, and is associated with less favorable outcome. Early identification and effective management strategies are needed to reduce its occurrence.

Abstract 149: Patterns, Determinants and Outcomes of Ultra-early Neurological Deterioration (U-END) in Intracranial Hemorrhage

Background: The patterns and outcomes of deterioration during prehospital transport and the first phase of ED care are important for planning for design of prehospital intracranial hemorrhage (ICH) treatment trials. Methods: Patients were enrolled in the NIH Phase 3 Field Administration of Stroke Therapy - Magnesium (FAST-MAG) prehospital trial within 2h of last known well (LKW). Deterioration was defined as worsening by ≥2 on the Glasgow Coma Scale (GCS), performed serially by paramedics in the field, upon ED arrival, and after the early ED course Results: Among 213 patients with ICH, age was 65.4 (±13.4), 33.3% female. Times from LKW to GCS assessments were: paramedic, 23 mins (IQR 14-39); ED arrival, 57 mins (IQR 45-75); and after early ED course, 89 mins (IQR 65-107). Overall, 38.5% experienced neurological deterioration, including 12.7% in prehospital phase only, 12.2% in early ED phase only, and 10.3% in both. Granular patterns of deficit progression were: Prehospital Sustained - prehospital deterioration, then stable early ED phase, 6.1% (13); Dippers - prehospital deterioration, then early ED improvement, 6.6% (14); Delayed - stable prehospital, then ED deterioration, 12.2% (26); and Continuous - prehospital deterioration, then further deterioration in ED, 10.3% (22) (Figure). ICH patients who experienced any U-END had lower prehospital GCS scores, 15 (IQR 12-15) vs 15 (IQR 15-15), p&lt;0.001, greater prehospital focal weakness, LAMS 4.4 vs 3.9, p&lt;0.001, history of hypertension, 87.4% vs 74.9%, p&lt;0.001, higher ED SBP, 186 vs 174, p&lt;0.001, and larger ICH volume, 45.8 vs 21.8 cm 3 , p&lt;0.001. U-END was associated with higher dependence or death (mRS 3-6) at 90d, 90.1% vs 61.6%, p&lt;0.001. Conclusions: Ultra-early neurological deterioration occurs in more than one-third of EMS-transported ICH patients, is associated with elevated BP, and leads to unfavorable outcome. Clinical trials testing prehospital initiation of BP-lowering therapy for ICH are desirable.