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Stroke Severity as Well as Time Should Determine Stroke Patient Triage

2013; Lippincott Williams & Wilkins; Volume: 44; Issue: 2 Linguagem: Inglês

10.1161/strokeaha.112.669721

1524-4628

James C. Grotta, Sean I. Savitz, David Persse,

Venous Thromboembolism Diagnosis and Management

HomeStrokeVol. 44, No. 2Stroke Severity as Well as Time Should Determine Stroke Patient Triage Free AccessResearch ArticlePDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessResearch ArticlePDF/EPUBStroke Severity as Well as Time Should Determine Stroke Patient Triage James C. Grotta, MD, Sean I. Savitz, MD and David Persse, MD James C. GrottaJames C. Grotta From the Departments of Neurology (J.C.G., S.I.S.) and Emergency Medicine (D.P.), University of Texas Medical School, Houston, TX; Department of Surgery (D.P.), Baylor College of Medicine, Houston, TX; and City of Houston, Emergency Medical Services (D.P.), Houston, TX. , Sean I. SavitzSean I. Savitz From the Departments of Neurology (J.C.G., S.I.S.) and Emergency Medicine (D.P.), University of Texas Medical School, Houston, TX; Department of Surgery (D.P.), Baylor College of Medicine, Houston, TX; and City of Houston, Emergency Medical Services (D.P.), Houston, TX. and David PersseDavid Persse From the Departments of Neurology (J.C.G., S.I.S.) and Emergency Medicine (D.P.), University of Texas Medical School, Houston, TX; Department of Surgery (D.P.), Baylor College of Medicine, Houston, TX; and City of Houston, Emergency Medical Services (D.P.), Houston, TX. Originally published3 Jan 2013https://doi.org/10.1161/STROKEAHA.112.669721Stroke. 2013;44:555–557Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: January 1, 2013: Previous Version 1 Tissue Plasminogen Activator and Time to TreatmentThe National Institute of Neurological Disorders and Stroke studies,1 published in 1995, demonstrated for the first time that in patients selected by clinical and noncontrast computed tomography criteria, intravenous TPA (IV tissue plasminogen activator) resulted in improved outcomes compared with standard treatment. Since that time, safe and quick delivery of IV TPA has become the primary focus of acute stroke management and forever changed the way that acute stroke care is delivered.The most important variable that predicts response to treatment is time from symptom onset to treatment initiation.2,3 On the basis of European Cooperative Acute Stroke Study III (ECASS III),4 treatment with IV TPA in Europe is approved out to 4.5 hours, but the benefit of treatment if started >3 hours is marginal if any. IV TPA is not approved >3 hours in the United States and best results occur if treatment is started within 2 hours. The number needed to treat of 3.1 within 3 hours5 is probablyμ2 if treatment is started within 2 hours. Recently, this lesson has been reinforced by the International Stroke Trial (IST),6 which once again confirmed that time is the most important determination of IV TPA benefit, and that other criteria, such as advanced age and increased stroke severity, commonly used to exclude patients from treatment, do not in fact preclude benefit.7 Although such a narrow time window necessarily limits treatment to only a subset of stroke patients, such is the reality of reperfusion therapy at least with IV TPA as demonstrated now by abundant human clinical trial data.Because IV TPA was approved in 1996, this critical importance of time to treatment has generated a massive change in the way stroke is managed by prehospital emergency medical services (EMS) and emergency departments (EDs). Guidelines have promoted triage of all acute stroke patients to the nearest primary stroke center (PSC).8 More than 800 PSCs have been certified throughout the country.9 PSCs often enlarge their ability to treat more patients by promoting treatment at outlying support hospitals using either telemedicine or drip and ship transfer agreements. These important developments have resulted in a gradual increase in the percent of patients treated with IV TPA. Although it is difficult to be certain of this proportion, it is probably still <10% nationwide.10 In Houston, Texas where strong community and EMS education programs have existed since the development of IV TPA treatment for stroke, and where there is a citywide collaboration to report treatment rates and complications, in the last quarter of 2011, the treatment rate was 9% of all strokes directly taken to citywide stroke center EDs (81% of those patients eligible were treated).Need for Better Treatments, Especially for Severe StrokesAs if the narrow time window were not enough of a problem, the other deficiency of IV TPA therapy is that it does not work well enough, particularly for larger arterial occlusions. Only 1 in 3 of all patients treated with IV TPA within 3 hours of symptom onset will return to a modified Rankin score of 0 to 1 (ie, no disability).1 Of patients with proximal middle cerebral artery occlusions, only 15% to 20% will recanalize by 2 hours after TPA bolus, and this number is lower for proximal or distal carotid or basilar occlusions.11 On the other hand, 70% to 75% of patients with less severe strokes (National Institutes of Health Stroke Scale 4.17 This 3-item score, consisting only of face, arm, and grip strength has been used successfully by paramedics to convey stroke severity information in the Field Administration of Stroke Therapy-Magnesium trial (FAST-MAG; ClinicalTrials.gov NCT00059332).Proposed Severity-adjusted EMS Triage AlgorithmWe propose a severity-adjusted EMS triage algorithm that takes into account stroke severity and the likelihood of a patient harboring a large artery occlusion (or large intracerebral hemorrhage) that would benefit from urgent CSC care, while at the same time preserving the urgency to treat patients as fast as possible (Figure 1). Although a prospective study comparing various triage schemes would be ideal, regional variability in stroke care logistics probably requires a system tailored to local needs. For instance, in small communities with limited EMS resources, long transport times, such as our proposed cutoff of 40 minutes for specific patients, would limit the availability of an ambulance for other patients in need. The Centers for Disease Control and Prevention Field Triage "Guidelines for the Field Triage of Injured Patients" recommends transport (of severely injured patients) to a facility that provides the highest level of care within the defined trauma system. For Houston, ground transport to the nearest level 1 trauma center from anywhere within our defined trauma system covered by EMS could take up to 40 minutes. This time might differ for defined systems in other locations. We urge adoption of this or a similar algorithm, along with reporting of treatment rates, EMS and door to needle times, and complication rates for all PSCs and CSCs alike. This should be part of a broader regional planning scheme that not only includes criteria for patients to be triaged directly to CSCs versus PSCs (or not to be, eg, moribund or minimally affected patients) but also addresses criteria for transfer from PSCs to CSCs. We welcome comments.Download figureDownload PowerPointFigure. Proposed sample severity-adjusted EMS triage algorithm. CSC indicates comprehensive stroke center; EMS emergency medical services; LAMS, Los Angeles motor scale; and tPA, tissue plasminogen activator.DisclosuresDrs Grotta and Savitz report a conflict of interest with a National Institute of Health research grant >$10 000. The other authors have no conflicts to report.FootnotesRalph L. Sacco, MD, MS, was the guest editor for this article.Correspondence to James C. 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February 2013Vol 44, Issue 2 Advertisement Article InformationMetrics © 2013 American Heart Association, Inc.https://doi.org/10.1161/STROKEAHA.112.669721PMID: 23287779 Manuscript receivedJuly 11, 2012Manuscript acceptedOctober 10, 2012Originally publishedJanuary 3, 2013 Keywordsacute careTPAorganized stroke carePDF download Advertisement SubjectsCardiopulmonary Resuscitation and Emergency Cardiac CareEthics and Policy