NINDS: Stroke Proceedings: Prehospital

Proceedings of a National Symposium on
Rapid Identification and Treatment of Acute Stroke
December 12-13, 1996

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RECOMMENDATIONS:
Prehospital Emergency Medical Care Systems Panel

The Prehospital Emergency Medical Care Systems Panel addressed the early needs of the stroke patient in theprehospital setting. The panel, consisting of invitedacknowledged specialists in emergency medical services (EMS) systems, took commentary from invited organizations and audience members at large. The assimilated summary recommendations are as follows:

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• Overall Recommendations
• Specific Subpanel Recommendations
• Conclusions

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Overall Recommendations

1. Stroke management should be re-prioritized in EMS systems as a time-dependent, urgent medical emergency, just as is currently stressed for major trauma and acute myocardial infarction.

2. A Chain of Recovery ( Figure 1 ) should be ensured in each community and emphasized with educational initiatives in order to optimize the chances of recovery for stroke patients.

3. New educational initiatives should be developed and widely promulgated, as applicable, for each of the various persons constituting the respective links in the Chain of Recovery: (a) the public at large; (b) EMS dispatchers; (c) first-responder crews; (d) basic and advanced life-support ambulance/response crews; and (e) receiving facility personnel, including emergency department (ED) staff members and neurological disease specialists.

4. Task forces should be created to: (a) help develop model educational initiatives for each of the respective links; and (b) develop standardized data sets to help ensure more effective research and outcomes analyses.

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Specific Subpanel Recommendations

Three subpanels were organized to specifically address issues related to: (a) EMS dispatch activities; (b) procedures and medical care that should be performed on the scene and en route to the hospital; and (c) special considerations in terms of access to care. The specific subpanel recommendations are detailed in separate sections, but can be summarized as follows:

• Dispatch Issues
• Prehospital Medical Care Issues
• Special Considerations in Access to Care
• Research Recommendations

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Dispatch Issues

1. The public at large should be educated about how to "make the right call."

2. Enhanced 911 systems (that automatically display the caller's address and telephone number) are strongly encouraged.

3. Dispatchers and dispatching systems should have medical (as well as administrative) supervision that provides medical oversight and continuing medical education.

4. New educational initiatives for dispatchers should emphasize stroke as a time-dependent, urgent medical emergency.

5. Even with the emphasis on re-prioritizing stroke patients, dispatch protocols should still consider sending the closest available transport unit, basic or advanced, in tiered ambulance systems.

6. Additional information should be elicited from the callers regarding relevant medical conditions (such as history of diabetes and current medications) and, also, certain basic medical care instructions should be provided prior to arrival of the EMS crews (i.e., "prearrival instructions").

7. Like all other rescuers in the Chain of Recovery, dispatchers should receive feedback and additional reinforcement regarding their actions in stroke cases.

8. Policies regarding stroke patients should be re-evaluated by managed care organizations to ensure that stroke patients receive timely and appropriate care.

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Prehospital Medical Care Issues

1. It should be recognized that most texts currently utilized by EMS personnel are lacking in terms of stroke management.

2. Simple, directed assessments should be emphasized in training of EMS personnel regarding stroke management.

3. Except for patients with respiratory distress or insufficiency, low-flow oxygen (1-2 liters/minute) should be administered and, if the tools are readily available, serum glucose levels should be measured.

4. Respiratory efforts and airway patency should be continuously monitored.

5. Although intravenous catheter placement and 12-lead electrocardiographic tracings are preferable, performing these procedures in the prehospital setting should not significantly delay transport to definitive care facilities. Therefore their performance may be venue-dependent (e.g., there is more help available in the prehospital setting than in the ED).

6. In general, hypertension should not be treated in the prehospital setting; hypotension should be treated aggressively (in accordance with the underlying etiology for the hypotension).

7. More data on neuroprotective agents are needed and future prehospital research is recommended.

8. EMS personnel should gather applicable onset information, including telephone access to witnesses/bystanders, and they should collect and/or document all medications (particularly aspirin, warfarin, insulin, and antihypertensives).

9. Systems for prealerting receiving facilities should be established so that ED staff members, imaging technicians, and stroke specialists can be readied for the arriving stroke patient.

10. As in the case of dispatchers, EMS crews should receive more feedback and training opportunities that emphasize the urgency of both stroke and transient ischemic attacks (TIAs).

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Special Considerations in Access to Care

1. In those venues with multiple medical facilities, it is advised to bypass those facilities not capable of providing appropriate care for the stroke patient.

2. In those venues without nearby definitive stroke care capabilities, it is advised, in general, that EMS providers immediately transport patients to the closest appropriate emergency facility where rapid evaluation and transfer (if appropriate) can be performed.

3. In remote areas without nearby facilities, direct on-scene rescue by air medical services can be considered if: (a) the closest emergency facility is more than an hour away; (b) the closest facility is not capable of providing definitive diagnosis and care; and (c) the patient can reach the definitive care facility within the agreed upon therapeutic time window for stroke.

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Research Recommendations

Several recurring questions were asked during the panel sessions. These questions include the following potential research issues:

1. What are the sensitivities and specificities of various dispatch triage algorithms for stroke patients, particularly those evaluating "hot" and "cold" responses or advanced versus basic life-support ambulance dispatches in tiered systems?

2. What are optimal inspired oxygen fractions for stroke patients?

3. Are 12-lead electrocardiographs or glucose measurements of discernible value in any given stroke patient?

4. Is the prehospital administration of any neuroprotective agent of value?

5. Are designated stroke centers demonstrably efficacious in altering outcome?

6. What is the safety of air medical transport after treatment (e.g., thrombolytic therapy for stroke)?

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Conclusions

The Prehospital Emergency Medical Care Systems Panel delineated a roadmap for improving stroke management through an intensive and well-represented consensus process. It is anticipated that this plan will need further refinements, but, for now, the document provides a significant advance in terms of the educational awareness needs as well as a global strategy for improving the Chain of Recovery for stroke patients.

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Figure 1. The Chain of Recovery for Acute Ischemic Stroke Patients.

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Last Edited: February 10, 2000

National Institute of Neurological Disorders and Stroke
National Institutes of Health
Bethesda, MD 20892