Jane H. Brice

Part 11: Adult Stroke 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care

Advances in stroke care will have the greatest effect on stroke outcome if care is delivered within a regional stroke system designed to improve both efficiency and effectiveness. The ultimate goal of stroke care is to minimize ongoing injury, emergently recanalize acute vascular occlusions, and begin secondary measures to maximize functional recovery. These efforts will provide stroke patients with the greatest opportunity for a return to previous quality of life and decrease the overall societal burden of stroke.

Calling emergency medical services for acute stroke: a study of 9-1-1 tapes.

Objective. To obtain a better understanding of how stroke events are communicated to 9-1-1 telecommunicators, andhow telecommunicators andemergency medical services (EMS) personnel respond to such calls. Methods. The authors identified 104 patients with a hospital discharge diagnosis of stroke or transient ischemic attack who were transported to hospital by ambulance in two North Carolina counties during 1999 and2000. Ambulance call reports were abstracted andlinked to 9-1-1 call center audiotapes, which were transcribed andverified. Results. Of the 104 calls, 44 were made by medical personnel, 38 by a family member, eight by a bystander or neighbor, five undetermined, andthree by other nonmedical personnel. In only six instances (6%) was the call placed by the patient. The most common symptoms reported were altered mental status (40%), trouble walking (32%), impaired speech (27%), andabnormal breathing (27%). Although the word “stroke” was often used (45%), 9-1-1 telecommunicators classified the calls as a stroke in only 31% of cases. However, in the majority of cases (79%), paramedics were dispatched at the highest priority. The median time from dispatch of EMS to patient arrival at the hospital was 41 minutes, approximately half of which was spent at the scene. Conclusion. Although typical stroke symptoms are commonly described, calls are often not classified as “strokes” by telecommunicators. Nevertheless, because of the symptoms reported during the calls, the majority of cases are treated as high priority by telecommunicators.

Study design and outcomes in out-of-hospital emergency medicine research: a ten-year analysis.

Objective. Lack of rigorous study design and failure to follow diverse patient outcomes have been identified as critical gaps in the medical research literature. This study sought to determine whether similar gaps exist in the literature for out-of-hospital interventions. Methods. A computerized MEDLINE search was conducted for the ten-year period 1985 through 1994 using the MeSH terms “emergency medical services,” “prehospital,” and “transportation of patients.” Using a standard abstraction form, two investigators independently analyzed articles meeting these inclusion criteria: original research evaluating an out-of-hospital intervention and measuring a patient outcome. Study design was categorized in order of scientific rigor, moving from case series to randomized trial. Measures of outcomes were classified into the six Ds: death, disease, discomfort, disability, dissatisfaction, and debt (cost). Results. Interobserver agreement was high (kappa = 0.80). For the ten-year period, 3,686 titles, 1,454 abstracts, and 373 articles were examined serially; all 285 studies meeting inclusion criteria were analyzed. Case series (44%) was the most frequently used design, while only 15% were randomized trials. The majority of the studies were retrospective (53%). A single outcome was assessed in 45% of the articles; 41% measured two outcomes, 13% three outcomes, and 1% four outcomes. Death and disease were the most common outcomes evaluated. Disability, debt, discomfort, and dissatisfaction were infrequently measured. Conclusion. Studies of out-of-hospital emergency medical interventions are limited in the scientific rigor of study design and the diversity of patient outcomes measured. To adequately assess the effectiveness of out-of-hospital care, efforts should be directed toward strengthening study designs and examining the full range of patient outcomes.

A simulation trial of traditional dispatcher-assisted CPR versus compressions - Only dispatcher-assisted CPR

Objectives. Growing evidence indicates that it may not be essential to deliver ventilations in the first few minutes of CPR. We compared time to delivery of first compression in traditional CPR with ventilations andcompressions to compression-only CPR performed by untrained laypersons assisted by a mock 911 dispatcher. Methods. This randomized-controlled simulation study included a convenience sample of English-speaking emergency department visitors during a 6-month period. Exclusion criteria were prior CPR training or physical incapacity. A cardiac arrest scenario was presented to subjects who were then provided with one of two sets of telephone CPR instructions by a mock 911 dispatcher. One group received traditional CPR instructions (TCPR) andthe second group received compression only CPR instructions (COCPR). Subjects performed CPR on a Laerdal Resusci-Anne CPR manikin andrecording strips were analyzed for frequency andquality measures. Pre-and post-test questionnaires assessed subject fatigue andtelephone instruction understanding. The primary outcome was the time interval from 911 call to initiation of chest compressions. Analysis included Student t-test, Chi-square, andWilcoxon Rank Sum. Results. Of 377 potential subjects, 54 consented to randomization. The data from 50 subjects were analyzed. Compared to group TCPR, group COCPR initiated chest compressions faster (72 vs 117 sec, p < 0.0001), completed four cycles of CPR faster (168 vs. 250 sec, p < 0.0001), andpaused for a smaller percentage of the resuscitation (13% vs. 36%, p < 0.0001). Only 9% of ventilation opportunities in the TCPR group yielded ventilations of the correct volume. There were no differences between groups in perceived understanding of CPR instruction or fatigue. Conclusions. We have identified the potential timesavings that may occur during compressions-only CPR. Bystander resuscitation may be more efficient when ventilations are excluded from the CPR sequence.

Management of the violent patient.

Emergency medical services (EMS) providers must often manage violent or combative patients. The data regarding violence against EMS personnel are poor, but according to studies conducted thus far, between 0.8% and 5.0% of incidents to which EMS personnel respond involve violence or the threat of violence. Physical or chemical restraint is usually the only option available to emergency care providers to control violent patients. Physical restraint, however, can lead to sudden death in otherwise healthy patients, possibly as a result of positional asphyxia, severe acidosis, or a patients excited delirium. Chemical restraint has traditionally consisted of either neuroleptics or benzodiazepines, but those drugs also have drawbacks. Haloperidol and droperidol, the neuroleptics most frequently used for restraint, can cause serious side effects such as extrapyramidal symptoms or QTc (QT interval corrected for heart rate) prolongation. The Food and Drug Administration recently issued a black box warning regarding the use of droperidol, because the QTc prolongation associated with the drug has led to fatal torsades de pointes in some patients. Benzodiazepines are also associated with adverse effects, such as sedation and respiratory depression, especially when the drugs are mixed with alcohol. The atypical antipsychotics, a new option that may be available soon, are less likely to cause such effects and therefore may be preferred over the neuroleptics. Liquid and injectable formulations of various atypical antipsychotics are currently in clinical trials. Because few options are currently available to EMS personnel for managing violent patients outside of the hospital, more research regarding violence against emergency care providers is necessary.

EMS Provider and Patient Safety during Response and Transport: Proceedings of an Ambulance Safety Conference

Abstract The out-of-hospital setting is unique to health care and presents many challenges to providing safe, high-quality medical care in emergency situations. The challenges of the prehospital environment require thoughtful design of systems and processes of care. The unique challenges of ambulance safety may be met by analyzing systems and incorporating process improvements. The purposes of this paper are to 1) outline the nature of this problem, 2) introduce a framework for this discussion, 3) provide expert opinion from a two-day ambulance safety conference, and 4) propose a plan of action to address the safety issues identified in the literature and expert opinion at the conference. Utilizing the Haddon Matrix as a framework, we present the safety issues and proposed solutions for factors contributing to an injury event in the emergency medical services (EMS) transport environment: host, agent, physical environment, and social environment. Host refers to the person or persons at risk, in this case, the EMS personnel or the patient. The agent of injury refers to the energy exerted during the course of an injury, and may be modified to include unrestrained equipment that contributes to the injury. The physical environment refers to the characteristics of the setting in which the injury takes place, such as the roadway or the physical design of the ambulance. Finally, the social environment refers to the social, legal, and cultural norms and practices in the society, such as peer pressure and a culture that discourages the use of safety equipment.

The North Carolina EMS Data System: A Comprehensive Integrated Emergency Medical Services Quality Improvement Program

Abstract Background. The EMS Agenda for the Future describes emergency medical services (EMS) as the intersection between public health, public safety, and health care. The most comprehensive method to describe, evaluate, and optimize these systems of care is using a state EMS data system. A centralized EMS data system can be a valuable tool to identify, evaluate, target, and improve EMS service delivery and patient care. Significant barriers, however, still exist to the standardization of EMS data systems and infrastructure nationally. Indeed, there is no comprehensive measurement of EMS service delivery or patient volume at the national level. Objective. In this article, we describe the successful development of a fully integrated, statewide EMS data system for quality improvement of EMS service delivery and patient care in North Carolina. The article also provides a platform for linking EMS with emergency physicians, other health care providers, and public health agencies responsible for planning, disease surveillance, and disaster preparedness. Results and Conclusion. The North Carolina EMS Data System represents the successful development of a large, fully integrated, comprehensive statewide EMS database and quality improvement effort. The North Carolina EMS Data System applications include the Prehospital Medical Information System (PreMIS), the Credentialing Information System (CIS), the State Medical Asset Resource Tracking Tool (SMARTT), and the EMS Performance Improvement Toolkits. The system provides a quality and performance improvement program consistent with the idealized EMS design described in the EMS Agenda for the Future. The program has already achieved significant improvements in the quality of EMS service delivery, patient care, and integrated systems of care. Consistent with the goals of the 2007 Institute of Medicines recommendations for EMS, the linkage of the North Carolina EMS Data System with other health care registries has created an environment that can evaluate larger systems of care and ultimate patient outcomes.

A comparison of emergency medical services times for stroke and myocardial infarction

Objective. Since stroke symptoms are often vague, and acute therapies for stroke are more recently available, it has been hypothesized that stroke patients may not be treated with the same urgency as myocardial infarction (MI) patients by emergency medical services (EMS). To examine this hypothesis, EMS transport times were examined for both stroke and MI patients who used a paramedic-level, county-based EMS system for transportation to a single hospital during 1999. Methods. Patients were first identified by their hospital discharge diagnosis as stroke (ICD-9 430–436, n = 50) or MI (ICD-9 410, n = 55). Trip sheets with corresponding transport times were retrospectively obtained from the 911 center. A separate analysis was performed on patients identified by dispatchers with a chief complaint of stroke (n = 85) or MI (n = 372). Results. Comparing stroke and MI patients identified by ICD-9 codes, mean EMS transport times in minutes did not meaningfully differ with respect to dispatch to scene arrival time (8.3 vs 8.9, p = 0.61), scene time (19.5 vs 21.4, p = 0.23), and transport time (13.7 vs 16.2, p = 0.10). Mean total call times in minutes from dispatch to hospital arrival were similar between stroke and MI patients (41.5 vs 46.4, p = 0.22). Results were similar when comparing patients identified by dispatchers with a chief complaint indicative of stroke or MI. Conclusion. In this single county, EMS response times were not different between stroke and MI patients. Replication in other EMS settings is needed to confirm these findings.

Out-of-Hospital Stroke Screen Accuracy in a State With an Emergency Medical Services Protocol for Routing Patients to Acute Stroke Centers

STUDY OBJECTIVE Emergency medical services (EMS) protocols, which route patients with suspected stroke to stroke centers, rely on the use of accurate stroke screening criteria. Our goal is to conduct a statewide EMS agency evaluation of the accuracies of the Cincinnati Prehospital Stroke Scale (CPSS) and the Los Angeles Prehospital Stroke Screen (LAPSS) for identifying acute stroke patients. METHODS We conducted a retrospective study in North Carolina by linking a statewide EMS database to a hospital database, using validated deterministic matching. We compared EMS CPSS or LAPSS results (positive or negative) to the emergency department diagnosis International Classification of Diseases, Ninth Revision codes. We calculated sensitivity, specificity, and positive and negative likelihood ratios for the EMS diagnosis of stroke, using each screening tool. RESULTS We included 1,217 CPSS patients and 1,225 LAPSS patients evaluated by 117 EMS agencies from 94 North Carolina counties. Most EMS agencies contributing data had high annual patient volumes and were governmental agencies with nonvolunteer, emergency medical technician-paramedic service level providers. The CPSS had a sensitivity of 80% (95% confidence interval [CI] 77% to 83%) versus 74% (95% CI 71% to 77%) for the LAPSS. Each had a specificity of 48% (CPSS 95% CI 44% to 52%; LAPSS 95% CI 43% to 53%). CONCLUSION The CPSS and LAPSS had similar test characteristics, with each having only limited specificity. Development of stroke screening scales that optimize both sensitivity and specificity is required if these are to be used to determine transport diversion to acute stroke centers.

Triage performance of first-year medical students using a multiple-casualty scenario, paper exercise.

INTRODUCTION Large-scale events may overwhelm the capacity of even the most advanced emergency medical systems. When patient volume outweighs the number of available emergency medical services (EMS) providers, a mass-casualty incident may require the aid of non-medical volunteers. These individuals may be utilized to perform field disaster triage, lessening the burden on EMS personnel. OBJECTIVE The purpose of this study was to evaluate the accuracy of triage decisions made by newly enrolled first-year medical students after receiving a brief educational intervention. METHODS A total of 315 first-year medical students from two successive classes participated in START triage training and completed a paper-based triage exercise as part of orientation. This questionnaire consisted of 15 clinical scenarios providing brief but sufficient details for prioritization. Subjects assigned each scenario a triage category of Red, Yellow, Green, or Black, based on the START protocol and were allowed four minutes to complete the exercise. Participants from the Class of 2009 were provided with printed START reference cards, while those from the Class of 2008 were not. Two test types varying in the order of patient age values were created to determine whether patient age was a factor in triage assessment. RESULTS The mean accuracy score of triage assignment by medical student volunteers after a brief START training session was 64.3%. The overall rate of over-triage was 17.8%, compared to an under-triage rate of 12.6%. There were no significant differences in triage accuracy between subjects with and without printed materials (63.9% vs. 64.6%, p = 0.729) or those completing the age-variant test types (64.4% vs. 64.1%, p = 0.889). CONCLUSIONS First-year medical students who received brief START training achieved triage accuracy scores similar to those of emergency physicians, registered nurses, and paramedics in previous studies. Observed rates of under and over-triage suggest that a need exists for improving the accuracy of triage decisions made by medical and non-medical personnel. This study did not find that printed materials significantly improved triage accuracy, nor did it find that patient age affected the ability of participants to correctly assign triage categories. Future research might further evaluate disaster triage by non-medical volunteers.