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Kim JT, Chung PW, Starkman S, Sanossian N, Stratton SJ, Eckstein M, Pratt FD, Conwit R, Liebeskind DS, Sharma L, Restrepo L, Tenser MK, Valdes-Sueiras M, Gornbein J, Hamilton S, Saver JL. Field Validation of the Los Angeles Motor Scale as a Tool for Paramedic Assessment of Stroke Severity. Stroke 2017; 48:298-306. [DOI: 10.1161/strokeaha.116.015247] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2016] [Revised: 11/21/2016] [Accepted: 12/02/2016] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
The Los Angeles Motor Scale (LAMS) is a 3-item, 0- to 10-point motor stroke-deficit scale developed for prehospital use. We assessed the convergent, divergent, and predictive validity of the LAMS when performed by paramedics in the field at multiple sites in a large and diverse geographic region.
Methods—
We analyzed early assessment and outcome data prospectively gathered in the FAST-MAG trial (Field Administration of Stroke Therapy–Magnesium phase 3) among patients with acute cerebrovascular disease (cerebral ischemia and intracranial hemorrhage) within 2 hours of onset, transported by 315 ambulances to 60 receiving hospitals.
Results—
Among 1632 acute cerebrovascular disease patients (age 70±13 years, male 57.5%), time from onset to prehospital LAMS was median 30 minutes (interquartile range 20–50), onset to early postarrival (EPA) LAMS was 145 minutes (interquartile range 119–180), and onset to EPA National Institutes of Health Stroke Scale was 150 minutes (interquartile range 120–180). Between the prehospital and EPA assessments, LAMS scores were stable in 40.5%, improved in 37.6%, and worsened in 21.9%. In tests of convergent validity, against the EPA National Institutes of Health Stroke Scale, correlations were
r
=0.49 for the prehospital LAMS and
r
=0.89 for the EPA LAMS. Prehospital LAMS scores did diverge from the prehospital Glasgow Coma Scale,
r
=−0.22. Predictive accuracy (adjusted C statistics) for nondisabled 3-month outcome was as follows: prehospital LAMS, 0.76 (95% confidence interval 0.74–0.78); EPA LAMS, 0.85 (95% confidence interval 0.83–0.87); and EPA National Institutes of Health Stroke Scale, 0.87 (95% confidence interval 0.85–0.88).
Conclusions—
In this multicenter, prospective, prehospital study, the LAMS showed good to excellent convergent, divergent, and predictive validity, further establishing it as a validated instrument to characterize stroke severity in the field.
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Affiliation(s)
- Joon-Tae Kim
- From the Department of Neurology, Chonnam National University Hospital, Gwangju, Korea (J.-T.K.); Department of Neurology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea (P.-W.C.); Department of Emergency Medicine and Neurology (S.S.), Department of Emergency (F.D.P.), Department of Neurology and Comprehensive Stroke Center (D.S.L., L.S., L.R., M.V.-S., J.L.S.), Neurovascular Imaging Research Core (D.S.L.), and Department of Biomathematics (J.G.), David Geffen
| | - Pil-Wook Chung
- From the Department of Neurology, Chonnam National University Hospital, Gwangju, Korea (J.-T.K.); Department of Neurology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea (P.-W.C.); Department of Emergency Medicine and Neurology (S.S.), Department of Emergency (F.D.P.), Department of Neurology and Comprehensive Stroke Center (D.S.L., L.S., L.R., M.V.-S., J.L.S.), Neurovascular Imaging Research Core (D.S.L.), and Department of Biomathematics (J.G.), David Geffen
| | - Sidney Starkman
- From the Department of Neurology, Chonnam National University Hospital, Gwangju, Korea (J.-T.K.); Department of Neurology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea (P.-W.C.); Department of Emergency Medicine and Neurology (S.S.), Department of Emergency (F.D.P.), Department of Neurology and Comprehensive Stroke Center (D.S.L., L.S., L.R., M.V.-S., J.L.S.), Neurovascular Imaging Research Core (D.S.L.), and Department of Biomathematics (J.G.), David Geffen
| | - Nerses Sanossian
- From the Department of Neurology, Chonnam National University Hospital, Gwangju, Korea (J.-T.K.); Department of Neurology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea (P.-W.C.); Department of Emergency Medicine and Neurology (S.S.), Department of Emergency (F.D.P.), Department of Neurology and Comprehensive Stroke Center (D.S.L., L.S., L.R., M.V.-S., J.L.S.), Neurovascular Imaging Research Core (D.S.L.), and Department of Biomathematics (J.G.), David Geffen
| | - Samuel J. Stratton
- From the Department of Neurology, Chonnam National University Hospital, Gwangju, Korea (J.-T.K.); Department of Neurology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea (P.-W.C.); Department of Emergency Medicine and Neurology (S.S.), Department of Emergency (F.D.P.), Department of Neurology and Comprehensive Stroke Center (D.S.L., L.S., L.R., M.V.-S., J.L.S.), Neurovascular Imaging Research Core (D.S.L.), and Department of Biomathematics (J.G.), David Geffen
| | - Marc Eckstein
- From the Department of Neurology, Chonnam National University Hospital, Gwangju, Korea (J.-T.K.); Department of Neurology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea (P.-W.C.); Department of Emergency Medicine and Neurology (S.S.), Department of Emergency (F.D.P.), Department of Neurology and Comprehensive Stroke Center (D.S.L., L.S., L.R., M.V.-S., J.L.S.), Neurovascular Imaging Research Core (D.S.L.), and Department of Biomathematics (J.G.), David Geffen
| | - Frank D. Pratt
- From the Department of Neurology, Chonnam National University Hospital, Gwangju, Korea (J.-T.K.); Department of Neurology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea (P.-W.C.); Department of Emergency Medicine and Neurology (S.S.), Department of Emergency (F.D.P.), Department of Neurology and Comprehensive Stroke Center (D.S.L., L.S., L.R., M.V.-S., J.L.S.), Neurovascular Imaging Research Core (D.S.L.), and Department of Biomathematics (J.G.), David Geffen
| | - Robin Conwit
- From the Department of Neurology, Chonnam National University Hospital, Gwangju, Korea (J.-T.K.); Department of Neurology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea (P.-W.C.); Department of Emergency Medicine and Neurology (S.S.), Department of Emergency (F.D.P.), Department of Neurology and Comprehensive Stroke Center (D.S.L., L.S., L.R., M.V.-S., J.L.S.), Neurovascular Imaging Research Core (D.S.L.), and Department of Biomathematics (J.G.), David Geffen
| | - David S. Liebeskind
- From the Department of Neurology, Chonnam National University Hospital, Gwangju, Korea (J.-T.K.); Department of Neurology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea (P.-W.C.); Department of Emergency Medicine and Neurology (S.S.), Department of Emergency (F.D.P.), Department of Neurology and Comprehensive Stroke Center (D.S.L., L.S., L.R., M.V.-S., J.L.S.), Neurovascular Imaging Research Core (D.S.L.), and Department of Biomathematics (J.G.), David Geffen
| | - Latisha Sharma
- From the Department of Neurology, Chonnam National University Hospital, Gwangju, Korea (J.-T.K.); Department of Neurology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea (P.-W.C.); Department of Emergency Medicine and Neurology (S.S.), Department of Emergency (F.D.P.), Department of Neurology and Comprehensive Stroke Center (D.S.L., L.S., L.R., M.V.-S., J.L.S.), Neurovascular Imaging Research Core (D.S.L.), and Department of Biomathematics (J.G.), David Geffen
| | - Lucas Restrepo
- From the Department of Neurology, Chonnam National University Hospital, Gwangju, Korea (J.-T.K.); Department of Neurology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea (P.-W.C.); Department of Emergency Medicine and Neurology (S.S.), Department of Emergency (F.D.P.), Department of Neurology and Comprehensive Stroke Center (D.S.L., L.S., L.R., M.V.-S., J.L.S.), Neurovascular Imaging Research Core (D.S.L.), and Department of Biomathematics (J.G.), David Geffen
| | - May-Kim Tenser
- From the Department of Neurology, Chonnam National University Hospital, Gwangju, Korea (J.-T.K.); Department of Neurology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea (P.-W.C.); Department of Emergency Medicine and Neurology (S.S.), Department of Emergency (F.D.P.), Department of Neurology and Comprehensive Stroke Center (D.S.L., L.S., L.R., M.V.-S., J.L.S.), Neurovascular Imaging Research Core (D.S.L.), and Department of Biomathematics (J.G.), David Geffen
| | - Miguel Valdes-Sueiras
- From the Department of Neurology, Chonnam National University Hospital, Gwangju, Korea (J.-T.K.); Department of Neurology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea (P.-W.C.); Department of Emergency Medicine and Neurology (S.S.), Department of Emergency (F.D.P.), Department of Neurology and Comprehensive Stroke Center (D.S.L., L.S., L.R., M.V.-S., J.L.S.), Neurovascular Imaging Research Core (D.S.L.), and Department of Biomathematics (J.G.), David Geffen
| | - Jeffrey Gornbein
- From the Department of Neurology, Chonnam National University Hospital, Gwangju, Korea (J.-T.K.); Department of Neurology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea (P.-W.C.); Department of Emergency Medicine and Neurology (S.S.), Department of Emergency (F.D.P.), Department of Neurology and Comprehensive Stroke Center (D.S.L., L.S., L.R., M.V.-S., J.L.S.), Neurovascular Imaging Research Core (D.S.L.), and Department of Biomathematics (J.G.), David Geffen
| | - Scott Hamilton
- From the Department of Neurology, Chonnam National University Hospital, Gwangju, Korea (J.-T.K.); Department of Neurology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea (P.-W.C.); Department of Emergency Medicine and Neurology (S.S.), Department of Emergency (F.D.P.), Department of Neurology and Comprehensive Stroke Center (D.S.L., L.S., L.R., M.V.-S., J.L.S.), Neurovascular Imaging Research Core (D.S.L.), and Department of Biomathematics (J.G.), David Geffen
| | - Jeffrey L. Saver
- From the Department of Neurology, Chonnam National University Hospital, Gwangju, Korea (J.-T.K.); Department of Neurology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, Korea (P.-W.C.); Department of Emergency Medicine and Neurology (S.S.), Department of Emergency (F.D.P.), Department of Neurology and Comprehensive Stroke Center (D.S.L., L.S., L.R., M.V.-S., J.L.S.), Neurovascular Imaging Research Core (D.S.L.), and Department of Biomathematics (J.G.), David Geffen
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Glober NK, Sporer KA, Guluma KZ, Serra JP, Barger JA, Brown JF, Gilbert GH, Koenig KL, Rudnick EM, Salvucci AA. Acute Stroke: Current Evidence-based Recommendations for Prehospital Care. West J Emerg Med 2016; 17:104-28. [PMID: 26973735 PMCID: PMC4786229 DOI: 10.5811/westjem.2015.12.28995] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Revised: 12/07/2015] [Accepted: 12/08/2015] [Indexed: 12/20/2022] Open
Abstract
Introduction In the United States, emergency medical services (EMS) protocols vary widely across jurisdictions. We sought to develop evidence-based recommendations for the prehospital evaluation and treatment of a patient with a suspected stroke and to compare these recommendations against the current protocols used by the 33 EMS agencies in the state of California. Methods We performed a literature review of the current evidence in the prehospital treatment of a patient with a suspected stroke and augmented this review with guidelines from various national and international societies to create our evidence-based recommendations. We then compared the stroke protocols of each of the 33 EMS agencies for consistency with these recommendations. The specific protocol components that we analyzed were the use of a stroke scale, blood glucose evaluation, use of supplemental oxygen, patient positioning, 12-lead electrocardiogram (ECG) and cardiac monitoring, fluid assessment and intravenous access, and stroke regionalization. Results Protocols across EMS agencies in California varied widely. Most used some sort of stroke scale with the majority using the Cincinnati Prehospital Stroke Scale (CPSS). All recommended the evaluation of blood glucose with the level for action ranging from 60 to 80mg/dL. Cardiac monitoring was recommended in 58% and 33% recommended an ECG. More than half required the direct transport to a primary stroke center and 88% recommended hospital notification. Conclusion Protocols for a patient with a suspected stroke vary widely across the state of California. The evidence-based recommendations that we present for the prehospital diagnosis and treatment of this condition may be useful for EMS medical directors tasked with creating and revising these protocols.
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Affiliation(s)
- Nancy K Glober
- University of California San Diego, Department of Emergency Medicine, San Diego, California
| | - Karl A Sporer
- EMS Medical Directors Association of California, California; University of California San Francisco, Department of Emergency Medicine, San Francisco, California
| | - Kama Z Guluma
- University of California San Diego, Department of Emergency Medicine, San Diego, California
| | - John P Serra
- University of California San Diego, Department of Emergency Medicine, San Diego, California
| | - Joe A Barger
- EMS Medical Directors Association of California, California
| | - John F Brown
- EMS Medical Directors Association of California, California; University of California San Francisco, Department of Emergency Medicine, San Francisco, California
| | - Gregory H Gilbert
- EMS Medical Directors Association of California, California; Stanford University, Department of Emergency Medicine, Stanford, California
| | - Kristi L Koenig
- EMS Medical Directors Association of California, California; University of California Irvine, Center for Disaster Medical Sciences, Orange, California
| | - Eric M Rudnick
- EMS Medical Directors Association of California, California
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