Accuracy and Implications of Hemorrhagic Stroke Recognition by Emergency Medical Services.

Background Hemorrhagic stroke is a medical emergency that requires rapid identification and treatment. Despite playing a critical role in the emergency response to hemorrhagic stroke patients, a minimal amount is known about the quality of emergency medical services (EMS) care for this condition. The objectives of this study were to quantify EMS hemorrhagic stroke recognition, identify predictors of accurate EMS recognition, and examine associations between EMS recognition, quality of prehospital care, and patient outcomes. Methods: Consecutive EMS-transported hemorrhagic strokes were identified from medical records at 4 primary stroke centers. Data regarding prehospital care were abstracted from EMS records and linked to in-hospital data. Clinical predictors of accurate EMS recognition were examined using logistic regression. EMS performance measure compliance and hospital outcomes were also compared among EMS recognized and unrecognized hemorrhagic strokes. Results: Over 24 months, EMS-transported 188 hemorrhagic stroke patients; 108 (57.4%) were recognized by EMS. Recognized cases had higher rates of stroke scale documentation (84.3% vs. 20.0%, p < 0.001); multivariable logistic regression confirmed a strong independent relationship between stroke scale documentation and recognition (adjusted OR 15.1 [5.6 to 40.7]). Recognized cases also had shorter on-scene times (15.5 vs. 21 min, p < 0.001) and door-to-computed tomography (DTCT) acquisition times (20 vs. 47 min, p < 0.001). Conclusions: Among EMS-transported hemorrhagic stroke cases, stroke screen documentation was strongly associated with EMS stroke recognition, which was in turn associated with higher quality of EMS care and faster computed tomography (CT) scans upon emergency department arrival.

Educating Paramedics on the Finger-to-Nose Test Improves Recognition of Posterior Stroke.

Background and Purpose- Emergency medical services (EMS) stroke recognition facilitates rapid care, however, prehospital stroke screening tools rely on signs that are often absent in posterior circulation strokes. We hypothesized that addition of the finger-to-nose (FTN) test to the Cincinnati Prehospital Stroke Scale would improve EMS posterior stroke recognition. Methods- In this controlled before and after study of consecutive EMS transported posterior ischemic strokes, paramedics in a single EMS agency received in-person training in the use of the FTN test. Paramedics at 2 other local EMS agencies served as controls. We compared the change in posterior stroke recognition, door-to-CT times, and alteplase delivery between the FTN (intervention) and control agencies. Results- Over 21 months, 51 posterior circulation strokes were transported by the FTN agency and 88 in the control agencies. Following training, posterior stroke recognition improved from 46% to 74% (P=0.039) in the FTN agency, whereas there was no change in the control agencies (32% before versus 39% after, P=0.467). Mean door-to-CT time in the FTN agency also improved following training (62-41 minutes, P=0.037) but not in the control agencies (58-61 minutes, P=0.771). There was no difference in alteplase delivery. Conclusions- Paramedics trained in the FTN test were more likely to identify posterior stroke. If future studies confirm these findings, such training may expedite the care of posterior stroke patients transported by EMS.

Brief Educational Intervention Improves Emergency Medical Services Stroke Recognition.

Background and Purpose- Recognition of stroke symptoms and hospital prenotification by emergency medical services (EMS) facilitate rapid stroke treatment; however, one-third of patients with stroke are unrecognized by EMS. To promote stroke recognition and quality measure compliant prehospital stroke care, we deployed a 30-minute online EMS educational module coupled with a performance feedback system in a single Michigan county. Methods- During a 24-month study period, a registry of consecutive EMS-transported suspected or unrecognized stroke cases was utilized to perform an interrupted time series analysis of the impact of the EMS education and feedback intervention. For each agency, we compared EMS stroke recognition and quality measure compliance rates, as well as emergency department performance and hospital outcomes during 12 preintervention months with performance in the remaining study months. Results- A total of 1805 EMS-transported cases met inclusion criteria; 1235 (68.4%) of these had ischemic or hemorrhagic strokes or transient ischemic attacks. There were no trends toward improvement in any outcome before the intervention. After the intervention, the EMS stroke recognition rate increased from 63.8% to 69.5% ( P=0.037). Prenotification increased from 60.9% to 77.3% ( P<0.001). Among patients with ischemic stroke/transient ischemic attack, there was a trend toward higher rates of tPA (tissue-type plasminogen activator) delivery (13.9%-17.7%; P=0.096) and a significant increase in tPA delivery within 45 minutes (5.7%-8.9%; P=0.042) after intervention. However, improvements in EMS recognition were limited to the first 3 months following intervention. Conclusions- A brief educational intervention was associated with improved EMS stroke recognition, hospital prenotification, and faster tPA delivery. Gains were primarily observed immediately following education and were not sustained through provision of performance feedback to paramedics.

Toxic traveler? Latrodectus species envenomation in Michigan with refractory symptoms after antivenin administration.

A 17-year-old male was envenomated on the right forearm by a black widow spider that had presumably traveled in a packaged dishwasher and been shipped from Mexico to Michigan. The patient experienced vomiting and severe pain in his abdomen and chest approximately 30 min after being bitten. He received 6000 units (1 vial) of Latrodectus antivenin intravenously about 7 h after he was envenomated. He did not experience significant improvement in his symptoms after the administration of antivenin and additional antivenin was not given. The patient was hospitalized for 7 days and still was complaining of intermittent episodes of pain in his chest and lower back 3 weeks after envenomation. To avoid prolonged symptomatology and hospitalization, additional Latrodectus antivenin should be given promptly to those individuals whose symptoms are not ameliorated after 1 vial.