Role of EMS in Acute Strokes - Printable Version

Friday, December 28, 2007

Review of: National Association of EMS Physicians. "The Role of EMS in the Management of Acute Stroke: Triage, Treatment and Stroke Systems." Prehospital Emergency Care. 11:312, 2007.

The Science

This week I present to you a position paper from the National Association of EMS Physicians (NAEMSP) that addresses the role of EMS in the treatment of stroke victims. The position paper is followed by two resource documents that provide the scientific foundation for the position paper. The position paper states the following;

The NAEMSP believes that:

Patients with acute stroke symptoms should receive expeditious EMS dispatch and response.
EMS personnel should be knowledgeable in the assessment, management and triage of suspected stroke patients. Personnel should be skilled in the performance of prehospital stroke screening and in determining the timing, onset and nature of symptoms.
Because some acute stroke treatments require the provision of definitive care within a specific time frame, EMS personnel should communicate with the receiving facilities as soon as possible.
EMS protocols should be consistent with evidence-based treatment practices for stroke patients and should be consistent with local/regional resources.
EMS systems and medical directors should develop local/regional strategies for treating, triaging and transporting patients with acute stroke symptoms -- including the identification of centers that are capable of treating acute stroke patients and the criteria for identifying the patients who should be transported to such centers.

Resources:

Crocco TJ, Grotta JC, Jauch EC, et al: "EMS Management of Acute Stroke- Prehospital triage." Prehospital Emergency Care. 11:313-317, 2007.

Millin MG, Gullett T, Daya MR: "EMS Management of Acute Stroke-Out-of-hospital treatment and stroke system development." Prehospital Emergency Care. 11:318-325, 2007.

The Street

The American Heart Association (AHA) has made us all acutely aware of the need to expand our evaluation of patients to include detecting the signs and symptoms of stroke. The 2005 AHA Guidelines have provided extensive information on this topic but stopped short of providing specific information on how to implement a stroke detection and treatment program integrating the EMS and available medical resources.

The NAEMSP position clearly states what all of us already appreciate, but the accompanying resource documents provide us specific steps to develop a realistic prehospital stroke care system. This must include proper training of 9-1-1 dispatchers to detect the signs and symptoms of stroke and quickly mobilize EMS. Because the treatment window of strokes is relatively small, it's vital stroke patient be transported rapidly to a facility capable of performing a CT scan and determining whether the patient is a candidate for fibrinolytics.

This reminds me of what we went through when we first began to treat heart attacks. However, the treatment window and options are significantly greater for myocardial infarction than for stroke. Debate continues as to whether fibrionolytics are sufficient, but we will only know if we give our patients a chance to receive them. Future neuroscience research will more than likely mirror that of cardiology with the proliferation of new and better treatments.

The biggest controversy facing EMS in the development of a stroke care system is creating policies and protocols to bypass closer hospitals in preference of hospitals with immediate availability to CT scans and medication. The role of air medical transport to facilitate such a program will also offer additional challenges.