Todd J. Crocco

Guidelines for prehospital management of traumatic brain injury 2nd edition

The information contained in these Guidelines, which reflects the current state of knowledge at the time of completion of the literature search (July 2006), is intended to provide accurate and authoritative information about the subject matter covered. Because there will be future developments in scientific information and technology, it is anticipated that there will be periodic review and updating of these Guidelines. These Guidelines are distributed with the understanding that the Brain Trauma Foundation, the National Highway Traffic Safety Administration, and the other organizations that have collaborated in the development of these Guidelines are not engaged in rendering professional medical services. If medical advice or assistance is required, the services of a competent physician should be sought. The recommendations contained in these Guidelines may not be appropriate for use in all circumstances. The decision to adopt a particular recommendation contained in these Guidelines must be based on the judgment of medical personnel, who take into consideration the facts and circumstances in each case, and on the available resources.

Implementation Strategies for Emergency Medical Services Within Stroke Systems of Care A Policy Statement From the American Heart Association/ American Stroke Association Expert Panel on Emergency Medical Services Systems and the Stroke Council

Stroke remains the third leading cause of death and a leading cause of long-term disability among Americans, despite advances in stroke prevention, diagnosis, treatment, and rehabilitation. Approximately 700 000 individuals suffer a new or recurrent stroke each year.1 Advances over the past decade in acute stroke care, including the introduction of fibrinolytic and other short-term therapies, have highlighted the critical roles of emergency medical services (EMS) agencies and emergency medical services systems (EMSS) in optimizing stroke care.2–7 In this context, the term “EMS” refers to the full scope of prehospital services necessary for the acute care of patients with stroke, including 9-1-1 activation and dispatch, emergency medical response, triage and stabilization in the field, and transport by ground or air ambulance to a hospital or between facilities. The term “EMSS” refers to the delivery systems for EMS that may be organized on a local, regional, statewide, or nationwide basis.8 EMSS involves the organization of public and private resources for the delivery of emergency medical care. These systems include the community, emergency medical and healthcare personnel, public safety agencies, emergency facilities, and critical care units. The dissemination of public information and education, provision of professional training, and development of disaster planning and standardized record keeping also are key elements of EMSS. Additionally, EMSS must address issues related to communication, transportation, access to care, patient transfer, mutual aid (the sharing of resources across EMSS), and system review and evaluation.9 The successful integration of one (and often multiple) EMSS is critical to ensuring the effectiveness of a stroke system of care. The American Stroke Association (ASA), a division of the American Heart Association (AHA), is dedicated to improving stroke prevention, treatment, and rehabilitation through research, education, advocacy, and the development of scientifically based standards and guidelines. In 2004, the …

Interactions Within Stroke Systems of Care A Policy Statement From the American Heart Association/American Stroke Association

In the United States and other parts of the world, various cities, states, and regions are developing multitiered systems for the care of patients with acute stroke. These systems often involve a range of healthcare components supported by various rules and regulations. The present policy statement will put forth concepts and elements for stroke systems of care that are intended to optimize patient care and management processes and improve patient outcomes, are practical to implement, and are supported by existing clinical data or expert consensus opinion. We will also make policy recommendations for the key elements of a stroke system of care. The public health implications of stroke care in the United States and worldwide are profound. Stroke is currently the fourth-leading cause of death in the United States and a major cause of long-term disability. Advancing age is a major risk factor for stroke, and the demographics of the US population and elsewhere reflect a continued growth of the aging population, with a resulting increase in the absolute incidence and prevalence of stroke.1 Improved stroke systems of care can ensure proper treatment of these patients and a reduction in death and disability. This is consistent with current American Heart Association and Centers for Disease Control and Prevention Healthy People 2020 public health goals and initiatives.2 There are several new care paradigms and technologies that are emerging as important elements of a stroke system of care. These include the development and proliferation of various levels of stroke centers; the expanded use of telemedicine technologies; advanced medical, endovascular, and surgical interventions; and comprehensive rehabilitation strategies and programs. Prehospital care and triage and the efficient transfer of patients between hospitals are also key components of stroke systems. The present …

Selective MCA occlusion: a precise embolic stroke model.

The present study describes a method for improving the precision and accuracy of clot placement within the middle cerebral artery (MCA) of rats, utilizing a micro-catheter and laser Doppler flowmetry. This technique reduces the size of clot needed to achieve stable occlusion with no failed embolizations and a low percentage of early recanalizations. Infarctions were consistent in both size and distribution within the MCA perfusion territory. Selective embolization in aged animals (n = 10) resulted in substantially larger infarctions than those seen in aged animals (n = 10) following non-selective embolization (P < 0.05), or young animals (n = 10) subjected to filamentous occlusion (P < 0.001). Clots were localized to the MCA by direct examination at 0, 60 and 120 min post-embolization (n = 14). All aged animals surviving 24h exhibited moderate to severe functional deficits, with selectively occluded animals having a higher mean score on the modified neurologic severity scale (P = 0.002). This model provides a highly reproducible method for embolization of the MCA and reliable reperfusion with rt-PA.

EMS Management of Acute Stroke—Prehospital Triage (Resource Document to NAEMSP Position Statement)

PREHOSPITAL EMERGENCY CARE 2007;11:313–317

A nationwide prehospital stroke survey

OBJECTIVES To identify deficiencies in stroke knowledge among prehospital providers. METHODS A nationwide multiple-choice survey was sent to 689 paramedics (EMT-Ps) and 294 advanced EMTs (EMT-Is) from a random selection of the National Registry of Emergency Medical Technicians database. Of the 23 questions, five addressed demographic information, four quantity of training, five general knowledge, 6 and seven management, and two open-ended questions addressed the signs, symptoms, and risk factors of stroke. The EMT-P and EMT-I answers were compared using chi-square analysis or Fishers exact test. RESULTS Of the 355 (36%) respondents, 256 (72%) were EMT-Ps and 99 (28%) were EMT-Is. Virtually all the EMT-Ps (99%) and EMT-Is (98%) knew that a stroke injures the brain, but only 199 (78%) of the EMT-Ps and 47 (47%) of the EMT-Is correctly defined a transient ischemic attack (TIA) (p < 0.001). Slurred speech, weakness/ paralysis, and altered mental status were the three most commonly cited symptoms of stroke by both groups. The EMT-Ps were more likely to recognize that dextrose is potentially harmful to stroke patients [EMT-P = 216 (85%), EMT-I = 71 (72%), p = 0.005]; 169 (66%) of the EMT-Ps and 75 (76%) of the EMT-Is felt that elevated blood pressures should be lowered in the prehospital setting. Only 93 (36%) of the EMT-Ps and 22 (22%) of the EMT-Is knew that tissue plasminogen activator (tPA) must be given within three hours of symptom onset (p = 0.01). CONCLUSION Most EMS providers are knowledgeable about the symptoms of stroke but are unaware of the therapeutic window for thrombolysis and the recommended avoidance of prehospital blood pressure reduction. In addition, further education is needed regarding TIAs.

Feasibility of Neuroprotective Agent Administration by Prehospital Personnel in an Urban Setting

Background and Purpose— Studies have demonstrated the importance of early stroke treatment. If a neuroprotective agent (NA) clinical trial is successful, the greatest benefit might be attained with early prehospital administration. This study determined the potential reduction in time to treatment of stroke patients when NAs were administered in the prehospital setting. Methods— Twenty-three urban emergency medical services (EMS) agencies participated in this study. Prehospital personnel completed a stroke assessment checklist on any potential stroke victim. The checklist collected clinical inclusion/exclusion criteria for NA administration and event/decision times. Patients meeting the hypothetical clinical inclusion criteria were enrolled into this study. Time data included scene arrival/departure, emergency department (ED) arrival, and estimated time of theoretical NA administration. The reduction in time to stroke treatment was calculated as the difference between the time of ED arrival and the reported time of NA administration. The t test and simple linear regression were used to probe for differences in treatment time reduction between selected subgroups. EMS personnel’s ability to obtain informed consent for theoretical NA administration was calculated. Results— Two hundred twenty-two patients were enrolled in this study; of these, 75 were deemed eligible for hypothetical NA administration and had complete time data. On average, EMS personnel documented the theoretical time of NA administration at 12.04±2.07 minutes before arrival at the ED (17.06±1.74 minutes when the NA was given on scene [n=43]; 6.65±1.14 minutes when the NA was given en route [n=32]). Conclusions— Prehospital NA administration can potentially significantly reduce the time to first intervention in stroke patients.

Formation and Function of Acute Stroke–Ready Hospitals Within a Stroke System of Care Recommendations From the Brain Attack Coalition

Background and Purpose— Many patients with an acute stroke live in areas without ready access to a Primary or Comprehensive Stroke Center. The formation of care facilities that meet the needs of these patients might improve their care and outcomes and guide them and emergency responders to such centers within a stroke system of care. Methods— The Brain Attack Coalition conducted an electronic search of the English medical literature from January 2000 to December 2012 to identify care elements and processes shown to be beneficial for acute stroke care. We used evidence grading and consensus paradigms to synthesize recommendations for Acute Stroke–Ready Hospitals (ASRHs). Results— Several key elements for an ASRH were identified, including acute stroke teams, written care protocols, involvement of emergency medical services and emergency department, and rapid laboratory and neuroimaging testing. Unique aspects include the use of telemedicine, hospital transfer protocols, and drip and ship therapies. Emergent therapies include the use of intravenous tissue-type plasminogen activator and the reversal of coagulopathies. Although many of the care elements are similar to those of a Primary Stroke Center, compliance rates of ≥67% are suggested in recognition of the staffing, logistical, and financial challenges faced by rural facilities. Conclusions— ASRHs will form the foundation for acute stroke care in many settings. Recommended elements of an ASRH build on those proven to improve care and outcomes at Primary Stroke Centers. The ASRH will be a key component for patient care within an evolving stroke system of care.

Predictors of Stroke During 9-1-1 Calls: Opportunities for Improving EMS Response

Objective. Only 31%–52% of stroke calls are accurately identified by 9-1-1 dispatchers according to prior studies. Recognizing the time-dependent nature of acute stroke, better identification of stroke patients at the time of their 9-1-1 calls may allow an improved prehospital response. We sought to identify any words/phrases that 9-1-1 dispatchers could use to identify more stroke calls. Methods. Potential stroke calls were identified from emergency medical services run sheets, andthe discharge diagnosis for each of these patients was obtained. The emergency medical services tapes were independently reviewed by two listeners who were blinded to the final diagnosis. Words/phrases previously associated with 9-1-1 stroke calls mentioned by the caller were recorded. Other pertinent words/phrases were also recorded. Using the final diagnosis of stroke as the gold standard, the sensitivity, specificity, andpositive likelihood ratio of each word andphrase were calculated. Cohens κ was calculated to assess interrater agreement. Data were collected for runs from October 2003 to July 2004. Results. A total of 176 tapes were reviewed (40 strokes, 136 nonstrokes). The presence of at least one of four criteria predicted 80% of all stroke calls: the word “stroke,” facial droop, weakness/fall, andimpaired communication. All criterion elements had very good interrater agreement (κ > 0.7). The word “stroke” was highly predictive of actual stroke (positive likelihood ratio, 2.27). Conclusions. The majority of stroke patients in this study could be identified by 9-1-1 dispatchers if the caller reported any one of the following four complaints: stroke, facial droop, weakness/fall, or impaired communication.

Emergency Medical Services-Based Community Stroke Education Pilot Results From a Novel Approach

Background and Purpose— Although previous studies using mass media have demonstrated successful public stroke awareness campaigns, they may have been too costly for smaller communities to implement. The goal of this study was to investigate if a novel emergency medical services (EMS) -sponsored community awareness campaign could increase public stroke awareness. Methods— This was a pre- and postintervention study with 2 phases conducted between August 2005 and July 2007. During Phase I, strategic placement of stroke education media by EMS personnel was implemented in one county over a 2-year period. Five random-digit, standardized phone surveys measuring stroke awareness were conducted with county residents to assess the campaign’s impact. In Phase II, EMS interventions and random-digit measurements were conducted in 4 additional counties with 4 counties randomly selected as controls. Results— A pattern of increasing stroke knowledge after exposure to the EMS intervention followed by declines in the absence of the intervention was observed during Phase I. EMS interventions also demonstrated a positive effect on the stroke knowledge of residents who lived in counties exposed to the intervention during Phase II with a statistically significant (P<0.05) increase observed in the proportion of respondents that named 2 stroke risk factors and 3 symptoms in comparison to either no changes or declines in the control counties. No evidence of a positive impact on knowledge of calling 911 for stroke was observed. Conclusion— Results of this study suggest that the public’s knowledge of stroke signs and symptoms was increased using communitywide EMS-based programs. Additional studies are needed to determine optimal methods for educating the public regarding the need to call 911 for stroke and to confirm these results in other locales.