RESUMO
Systems of care for acute ischemic stroke are being challenged to implement processes that ensure rapid access to endovascular thrombectomy. Optimizing existing regionalized stroke thrombolysis programs for endovascular thrombectomy will require accurate field recognition of treatment candidates. We begin with a review of the development of early clinical tests for ischemic stroke, illustrating challenges relevant to future field tests for large vessel occlusion. Second, we discuss aspects of diagnosis, eligibility, feasibility, and system organization that are potentially relevant to the development and implementation of field tests and diversion criteria. These considerations may influence the choice and parametrization of field tests in individual jurisdictions. Third, we review the literature evaluating eight clinical tests for the field identification of probable large vessel occlusion. All candidate tests include evaluations for focal weakness, and six evaluate for cortical signs such as aphasia or gaze deviation. Most appear roughly comparable to the NIH Stroke Scale, but direct comparison between studies is inappropriate because of major methodological differences. Finally, we discuss our jurisdiction's approach to the field recognition of thrombectomy candidates. We contextualize diagnostic, eligibility, and system considerations within distinct metro and rural environments and propose a screen-and-consult model for the rural setting.
Assuntos
Isquemia Encefálica/diagnóstico , Seleção de Pacientes , Acidente Vascular Cerebral/diagnóstico , Trombectomia , Doença Aguda , Afasia , Isquemia Encefálica/epidemiologia , Isquemia Encefálica/cirurgia , Canadá/epidemiologia , Testes Diagnósticos de Rotina/métodos , Humanos , Atenção Primária à Saúde , Regionalização da Saúde , Classe Social , Acidente Vascular Cerebral/epidemiologia , Acidente Vascular Cerebral/cirurgiaRESUMO
This report describes the development of an evidence-based guideline for external hemorrhage control in the prehospital setting. This project included a systematic review of the literature regarding the use of tourniquets and hemostatic agents for management of life-threatening extremity and junctional hemorrhage. Using the GRADE methodology to define the key clinical questions, an expert panel then reviewed the results of the literature review, established the quality of the evidence and made recommendations for EMS care. A clinical care guideline is proposed for adoption by EMS systems. Key words: tourniquet; hemostatic agents; external hemorrhage.
