Fase Pre Hospitalaria

El Pre Hospitalario hace la Diferencia

Emergency stroke care depends on a 4-step chain

EMERGENCY EMERGENCY
GENERAL PUBLIC STROKE UNIT
CALL CENTRE MEDICAL SERVICES

RECOGNISE STROKE SYMPTOMS
REACT APPROPRIATELY
IDENTIFY STROKE SYMPTOMS PROMPT EVALUATION & IMMEDIATE TRIAGE,
STABILISATION ASSESSMENT AND IMAGING
PRIORITY DISPATCH OF EMS
PRIORITY TRANSFER TO STROKE MULTIDISCIPLINARY STROKE
FACILITIES TEAM
PRE-NOTIFICATION OF ACCURATE DIAGNOSIS
HOSPITAL
TREAT APPROPRIATELY

PRIORITY TRANSPORT & TREATMENT

1. Kothari R, et al. Stroke 1995;26:937-941.

2. Kothari R, et al. Stroke 1995;26:2238-2241.
3. Kaste M, et al. Cerebrovasc Dis 2000;10(Suppl 3):S1-S11.
The thrombolysis challenge
TIMELY ADMINISTRATION OF rt-PA IMPROVES OUTCOMES FOR ELIGIBLE PATIENTS WITH AIS
THROMBOLYSIS* IS UNDERUSED

ONLY 2-10% OF AIS PATIENTS RECEIVE IV THROMBOLYSIS* WITH rt-PA1

REASONS FOR PRE-HOSPITAL DELAYS INCLUDE

POOR RECOGNITION OF SIGNS AND SYMPTOMS2

INAPPROPRIATE OR DELAYED MEDICAL ASSISTANCE2

AVOIDANCE OR DELAYED DISPATCH OF EMS2

POOR TRIAGE AND INACCURATE EARLY ASSESSMENT3,4

LACK OF COMMUNICATION WITH THE RECEIVING HOSPITAL5

DELAYED ARRIVAL (OUTSIDE THE TIME WINDOW) AT A STROKE CENTRE1

1. Lahr MM, et al. Stroke 2012;43:1336-1340.

2. Fassbender K, et al. Lancet Neurol 2013;12:585-596.
3. Paul CL, et al. Implementation Sci 2014;9:38.
4. Yperzeele L, et al. Cerebrovasc Dis 2014;38:1-9.
5. Berglund A, et al. Stroke 2012;43:2666-2670.
*The ESO guidelines recommend the use of intravenous rt-PA for the thrombolysis of acute ischaemic stroke in eligible patients within 4.5 hours of the onset of stroke symptoms. (Class 1, Level A).
Please check your local regulations and prescribing information.
Public information campaigns - examples
CRITIAL MESSAGES

…AND THAT THIS

SYMPTOM EVERY CALL TO
COULD MAKE A
RECOGNITION SECOND COUNTS ACTION
DIFFERENCE
Call centre role

EMERGENCY CALL CENTRES AND DISPATCHERS HAVE AN IMPORTANT

ROLE IN RECOGNISING POTENTIAL STROKE PATIENTS AND DISPATCHING
AN EMERGENCY RESPONSE TEAM WITHOUT DELAY1

PROTOCOLS ARE AVAILABLE TO HELP IDENTIFY STROKE SYMPTOMS

DISPATCHERS CAN
*see notes
CORRECTLY IDENTIFY
UP TO 80% OF ALL
STROKE CALLS IF
SPECIFIC WORDS
ARE MENTIONED2*

1. Jauch EC, et al. Stroke 2013;44:870-947.

2. Acker JE, et al. Stroke 2007;38:3097-3115.
1. Diagnose stroke

1. Diagnóstico del ACV

 Stroke scales

100 93 STROKE ASSESSMENT TOOLS HELP EMS IDENTIFY STROKE

SYMPTOMS QUICKLY
% OF STROKE IDENTIFICATION

STROKE ASSESSMENT TRAINING RAISES THE ACCURACY OF

80
STROKE IDENTIFICATION

68 NO
EMS PERSONNEL DEMONSTRATED A SENSITIVITY OF 61-66%
SENSITIVITY

60 TRAINING IN WITHOUT STROKE ASSESSMENT TRAINING AND 86-97%

USE OF STROKE
ASSESSMENT WITH TRAINING
TOOL

40
TRAINING IN
USE OF STROKE
ASSESSMENT
20 TOOL

0
STROKE ASSESSMENT
TOOL TRAINING

Maggiore, W. A. (2012). 'Time is Brain' in Prehospital Stroke Treatment . Journal of Emergency Medical Services , 1- 9
Agreement between ambulance paramedic - and
physician - recorded neurological signs with FAST

100 96 95
79 77
80
70
STROKE PATIENTS (%)

68
60

PARAMEDIC
40

20

PHYSICIAN

0
FACIAL PARESIS ARM PARESIS SPEECH
DISTURBANCE

FAST = Face Arm Speech Test

Nor AM, et al. Stroke 2004;35:1355-1359.
Objetivo N° 1 del Pre Hospitalario

EMS ARE THE POINT OF FMC

THEIR PRIMARY GOAL IS TO IDENTIFY SUSPECTED STROKE
AND TRIGGER FAST TRACK FOR STROKE
1. Diagnose stroke

2. Selección del hospital

Choose hospital
Choose most appropriate hospital that can provide the patients with recanalization therapy, and
stroke unit care
1. Diagnose stroke

3. Transporte de Emergencia
Emergency Transport
Collect as much information as possible that
could be relevant to treatment decision for
example drugs taken and scene description

Do not waste unnecessary time at the scene,

transport patient emergently (< 15 Minutes)

Lin, C. B., Peterson, et al. (2012). Emergency Medical Service Hospital Pre-Notification is Associated with Improved Evaluation and Treatment of Acute Ischemic Stroke.
Journal of the American Heart Association , 1-9
AHA recommendations to EMS

DISPATCH TIME OF LESS EMS RESPONSE TIME LESS ON-SCENE TIME LESS
THAN 90 SECONDS THAN 8 MINUTES THAN 15 MINUTES

Jauch EC, Saver JL, Adams HP, Jr., et al. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/ American Stroke Association.
Stroke. 2013;44:870-947.
Fonarow GC, Zhao X, Smith EE, et al. Door-to-needle times for tissue plasminogen activator administration and clinical outcomes in acute ischemic stroke before and after a quality improvement initiative. JAMA. 2014;311:1632-40.
Berglund A, Svensson L, Sjostrand C, et al. Higher prehospital priority level of stroke improves thrombolysis frequency and time to stroke unit: the Hyper Acute Stroke Alarm (HASTA) study. Stroke. 2012;43:2666-70.
Mosley I, Nicol M, Donnan G, et al. The impact of ambulance practice on acute stroke care. Stroke. 2007;38:2765-70.
Patel MD, Brice JH, Moss C, et al. An evaluation of emergency medical services stroke protocols and scene times. Prehosp Emerg Care. 2014;18:15-21.
Nancy K. Glober et AlAcute Stroke: Current Evidence-based Recommendations for Prehospital Care Western Journal of Emergency Medicine 104 Volume XVII, no. 2 : March 2016
 Do as much as possible before hospital arrival
Oxygen saturation Blood pressure IV access Glucose test Pre-admit patient

Leaving as little as
possible to be done
after hospital arrival

Deliver directly to CT scanner

ABC’s - Establish an IV access
Start 2 large bore IV access (One could be used for
thrombolytic therapy and the second to give
contrast to identify patients for thrombectomy).
However, transport should not be delayed for this.
No strong evidence supports or refutes routinely
giving fluid boluses to stroke patients. Patients with
low systolic blood pressure and no contraindications
should be given a bolus of IV fluids.

Stoll M, Treib J, Seltmann A, et al. Hemodynamics of stroke patients under therapy with low molecular weight hydroxyethyl starch. Neurol Res. 1998;20:231-4.
ABC’s - Oxygen saturation
Assess airway compromise. Occurs more frequently
in older patients, those with a severe stroke, or
those with symptoms of dysphagia.
Use of supplementary oxygen to maintain oxygen
saturation above 95%. Beyond 95%, oxyhemoglobin
is saturated and no further physiologic benefit is
derived.

Sulter G, Elting JW, Stewart R, et al. Continuous pulse oximetry in acute hemiparetic stroke. J Neurol Sci. 2000;179:65-9.
Branson RD and Johannigman JA. Pre-hospital oxygen therapy. Resp Care. 2013;58:86-97.
ABC’s - Blood sugar test
Hypoglycemia could mimic stroke.
Measuring glucose levels can help differentiate
between stroke and hypoglycemia.
Symptoms such as hemiparesis hemiplegia, speech
or visual disturbances, confusion, and poor
coordination can all present in patients with
hypoglycemia and can be corrected with
administration of dextrose.
Provide dextrose to those patients with glucose
below 60 mg/dL.
Pre-existing hyperglycaemia worsens the clinical
outcome of acute stroke.

Jauch EC, Saver JL, Adams HP, Jr., et al. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/ American Stroke Association. Stroke. 2013;44:870-947.
Abarbanell NR. Is prehospital blood glucose measurement necessary in suspected cerebrovascular accident patients? Am J Emerg Med. 2005;23:823-7.
Terakawa Y, Tsuyuguchi N, Nunomura K, et al. Reversible diffusion weighted imaging changes in the splenium of the corpus callosum and internal capsule associated with hypoglycemia case report. Neurol Med Chir. 2007;47:486-8.
Capes SE, Hunt D, Malmberg K, Pathak P, Gerstein HC. Stress hyperglycemia and prognosis of stroke in nondiabetic and diabetic patients: a systematic overview. Stroke. 2001 Oct. 32(10):2426-32.
ABC’s - Blood pressure
Abrupt blood pressure lowering should be avoided.
Cautious blood pressure lowering is recommended in
patients with extremely high blood pressures
(>220/120 mmHg) on repeated measurements, or
with severe cardiac failure, aortic dissection, or
hypertensive encephalopathy.
Patients with the highest and lowest levels of blood
pressure in the first 24 hours after stroke are more
likely to have early neurological decline and poorer
Outcomes.
Blood pressure can usually be raised by adequate
rehydration with crystalloid (saline) solutions.

ESO Guidelines for Management of Ischaemic Stroke and Transient Ischaemic Attack 2008. Castillo J, Leira R, Garcia MM, Serena J, Blanco M, Davalos A: Blood pressure
decrease during the acute phase of ischemic stroke is associated with brain injury and poor stroke outcome. Stroke 2004;35:520-526.
Patient position
Head injuries: bed at 30 degrees alleviates elevated
intracranial pressure.
Stroke patients typically do not have elevated
intracranial pressure.
Cerebral blood flow and cerebral perfusion
pressure improved with the patient in a supine
position.
Patients should be laid flat as tolerated, unless
precluded by clinical issues such as compromised
respiratory status, secretions, or aspiration risk.

Feldman Z, Kanter MJ, Robertson CS, et al. Effect of head elevation on intracranial pressure, cerebral perfusion pressure, and cerebral blood flow in head-injured patients. J Neurosurg. 1992;76:207-11.
Ng I, Lim J, Wong HB. Effects of head posture on cerebral hemodynamics: its influences on intracranial pressure, cerebral perfusion pressure, and cerebral oxygenation. Neurosurgery. 2004;54:593-7.
Favilla CG, Mesquita RC, Mullen M, et al. Optical bedside monitoring of cerebral blood flow in acute ischemic stroke patients during headof-bed manipulation. Stroke. 2014;45:1269-74.
Schwarz S, Georgiadis D, Aschoff A, et al. Effects of body position on intracranial pressure and cerebral perfusion in patients with large hemispheric stroke. Stroke. 2002;33:497-501.
Medical history
Responders must document:
Patient last seen normal time
Current medication list, pay special attention to
medication to treat coagulation disorders
Use of specific language, facilitates clear
communication
1. Diagnose stroke

4. Pre Notificación del Hospital

 Pre-notification
BENEFITS HOW?

ALLOWS HOSPITALS TO PREPARE AND MOBILIZE RESOURCES STROKE PHONE IN HOSPITAL

SUCH AS IMAGING BEFORE THE PATIENT ARRIVES HOSPITAL BUSINESS CARD IN AMBULANCES

REDUCES IN-HOSPITAL DELAY

STROKE TEAM PRESENT ON PATIENT
ARRIVAL AT THE DOOR
COLLECT RELEVANT INFO
(EMERGENCY RESPONSE TEAM FORM)

APPROPRIATE INFORMATION ALLOWS PATIENT TO BE REGISTERED IN

HOSPITAL SYSTEMS BEFORE ARRIVAL
(INFORMATION NEEDED INCLUDE: NAME, DATE OF BIRTH, INSURANCE NUMBER)

PRENOTIFICATION IS THE KEY THAT ALLOWS PATIENTS TO BE TREATED FASTER

Pre-notification
STUDIES HAVE SHOWN:

SHORTER SYMPTOM ONSET TO

HOSPITAL ARRIVAL

INCREASE IN THE AMOUNT OF

PATIENTS WITH DOOR-TO-
IMAGING TIMES WITHIN 25 MIN

LOWER ONSET TO DOOR TIMES

OBSERVED (113 MIN VS. 150 MIN)

Lin, C. B., Peterson, et al. (2012). Emergency Medical Service Hospital Pre-Notification is Associated with Improved Evaluation and Treatment of Acute Ischemic Stroke.
Journal of the American Heart Association , 1-9