Embedded Files
subsequent ED assessment.. Guidelines for EMS Management of Patients With Oxygen (as required O2 saturation <92%)Critical elements of the patient’s history must include information on time of symptom onset This may require obtaining information from bystanders or, preferably, transporting witnesses with the patient. Similarly, next of kin, if available, may be needed for information or consent and should travel to the receiving hospital concurrently. Telephone numbers, including cellular telephone numbers, of witnesses or relatives may help the ED to clarify the history or seek consent for treatment. A list of the patient’s medications, or the medication containers themselves, should be sought, with particular attention paid to identifying anticoagulant (both oral and injectable), antiplatelet, and antihypertensive drug use.. Key Components of History After the patient’s airway, breathing, and circulation (ABCs) are assessed and stabilized, common presenting signs of stroke should be sought and a focused examination completed. Prehospital stroke assessment tools have proved effective in identifying stroke patients in the field. The Los Angeles Prehospital Stroke Screen uses patient history, physical findings, and finger stick glucose determination to identify stroke patients.26 The Cincinnati Prehospital Stroke Scale is an alternative instrument with fewer data elements requiring only 30 to 60 seconds to complete.27 Other prehospital stroke evaluation tools exist, although data on their validity are limited. 5. Prehospital Stroke Identification Instruments B. EMS Management Guidelines for EMS management are presented in After initial stabilization, it is recommended that patient transport commence as soon as possible, with cardiac monitoring and intravenous access established during transport, if possible. Isotonic crystalloids (most commonly normal saline solution) are recommended for resuscitation, if needed. Dextrose-containing fluids should be avoided unless hypoglycemia is present or strongly suspected because excessive glucose may be injurious to stroke patients. No recommendations can be offered on the prehospital management of hypertension in patients with suspected stroke, and intervention is best accomplished after hospital arrival. It is well recognized that hypoglycemic patients may have symptoms that mimic an acute stroke, manifesting focal symptoms, altered speech, and/or cognitive changes, and therefore EMS assessment of blood glucose has been a routine practice for many years. A single report suggests that a more selective approach may be possible, with blood glucose measurement advocated only in the presence of a history suspicious for hypoglycemia or inability to obtain adequate patient information.29 That study is limited, however, by its retrospective methodology and an upper confidence interval of 2.4% for the likelihood of failing to identify a hypoglycemic patient. At present, checking blood glucose concentrations in most patients with stroke is a prudent step, even among patients without a history of diabetes mellitus or use of insulin.The availability of resources to care for patients with acute stroke varies widely both among and within communities. The National Institutes of Health (NIH) Task Force report, “Improving the Chain of Recovery for Acute Stroke in Your Community,” recommends identifying hospitals capable of providing acute stroke care and creating a transport system to these centers based on patient location. Such systems require advanced planning and frequent updating and should incorporate EMS representatives, community leaders, hospitals, and physicians to ensure clear guidance for EMS providers with regard to patient destination. Identification of an effective neuroprotective therapy may further expand the role of EMS in the treatment of acute stroke. The feasibility of initiation of hypothermia has also been demonstrated in the prehospital setting.30 Of importance for future research is the fact that it appears possible to incorporate EMS into the research process, with EMS personnel having demonstrated success in facilitating physician cell phone elicitation of consent from
Report abuse