Assessment of Emergency Medical Services in the Ashanti Region of Ghana

BACKGROUND

We aimed to assess the structure, function and performance of Ashanti Region's emergency medical services system in the context of the regional need for prehospital emergency care.

DESIGN

A mixed-methods approach was employed, using retrospective collection of quantitative data and prospectively gathered qualitative data. Setting - pertinent data were collected from Ghanaian and international sources; interviews and technical assessments were performed primarily in the Ashanti Region of Ghana.

PARTICIPANTS

All stakeholders relevant to emergency medical services in the Ashanti Region of Ghana were assessed; there was a special focus on National Ambulance Service (NAS) and Ashanti Region healthcare personnel.

INTERVENTION

This was an observational study using qualitative and quantitative assessment techniques.

MAIN OUTCOME MEASURES

The structure, function and performance of the Ashanti emergency medical services system, guided by a relevant technical assessment framework.

RESULTS

NAS is the premier and only true prehospital agency in the Ashanti Region. NAS has developed almost every essential aspect of an EMS system necessary to achieve its mission within a low-resource setting. NAS continues to increase its number of response units to address the overwhelming Ashanti region demand, especially primary calls. Deficient areas in need of development are governance, reliable revenue, public access, community integration, clinical care guidelines, research and quality assurance processes.

CONCLUSIONS

The Ashanti Region has a growing and thriving emergency medical services system. Although many essential areas for development were identified, NAS is well poised to meet the regional demand for prehospital emergency care and transport.

Treatment of acute ischemic stroke

Acute ischemic stroke is the third leading cause of death in the United States and the leading cause of adult disability. The direct and indirect costs of stroke care exceed $51 billion annually. In 1996, the US Food and Drug Administration approved the first treatment for acute ischemic stroke, intravenous tissue plasminogen activator. Later that year, the National Institute of Neurologic Disorders and Stroke (a branch of the National Institutes of Health) convened a consensus conference on the Rapid Identification and Treatment of Acute Ischemic Stroke, setting goals for stroke care in the United States. Since then, it has become imperative that emergency physicians understand the pathophysiology of stroke, the basis and rationale for treatment, and the therapeutic approaches. This article reviews the state of the art of acute stroke treatment, its foundation, as well as its future.

Early hemorrhage growth in patients with intracerebral hemorrhage

BACKGROUND AND PURPOSE

The goal of the present study was to prospectively determine how frequently early growth of intracerebral hemorrhage occurs and whether this early growth is related to early neurological deterioration.

METHODS

We performed a prospective observational study of patients with intracerebral hemorrhage within 3 hours of onset. Patients had a neurological evaluation and CT scan performed at baseline, 1 hour after baseline, and 20 hours after baseline.

RESULTS

Substantial growth in the volume of parenchymal hemorrhage occurred in 26% of the 103 study patients between the baseline and 1-hour CT scans. An additional 12% of patients had substantial growth between the 1- and 20-hour CT scans. Hemorrhage growth between the baseline and 1-hour CT scans was significantly associated with clinical deterioration, as measured by the change between the baseline and 1-hour Glasgow Coma Scale and National Institutes of Health Stroke Scale scores. No baseline clinical or CT prediction of hemorrhage growth was identified.

CONCLUSIONS

Substantial early hemorrhage growth in patients with intracerebral hemorrhage is common and is associated with neurological deterioration. Randomized treatment trials are needed to determine whether this early natural history of ongoing bleeding and frequent neurological deterioration can be improved.

Prognostic value of the hyperdense middle cerebral artery sign and stroke scale score before ultraearly thrombolytic therapy

PURPOSE

To determine the relationship between the hyperdense middle cerebral artery sign (HMCAS) and neurologic deficit, as evidenced by the National Institutes of Health (NIH) stroke scale score, and to determine the relationship of the HMCAS and the NIH stroke scale score to arteriographic findings after thrombolytic therapy.

METHODS

Fifty-five patients with acute ischemic stroke were rated on the NIH stroke scale, were examined with CT, and were treated with intravenous alteplase within 90 minutes of symptom onset. Presence of the HMCAS was determined on the baseline CT scan by a neuroradiologist blinded to the patient's neurologic deficit. Patients with the HMCAS were compared with those without HMCAS with regard to baseline NIH stroke scale score, 2-hour NIH stroke scale score, findings at posttreatment arteriography, 3-month residual neurologic deficit, and 3-month ischemia volumes as evidenced on CT scans.

RESULTS

Eighteen patients (33%) had the HMCAS. These patients had a median baseline NIH stroke scale score of 19.5 compared with a median score of 10 for the patients lacking the HMCAS sign. At 3 months, one (6%) of the HMCAS-positive patients was completely improved neurologically compared with 17 (47%) of the HMCAS-negative patients. Restricting analysis to those patients with a stroke scale score of 10 or greater (n = 37), 18 HMCAS-positive patients showed less early neurologic improvement, were less likely to be completely improved at 3 months, and had larger infarcts compared with the 19 HMCAS-negative patients. Compared with the HMCAS-positive and HMCAS-negative patients with a stroke scale score of 10 or greater, patients with a stroke scale score of less than 10 had fewer occlusive changes of the internal carotid and middle cerebral arteries on posttreatment arteriograms and had a better neurologic recovery at 3 months.

CONCLUSION

The presence of the HMCAS on CT scans obtained within 90 minutes of stroke onset is associated with a major neurologic deficit, and in this study it predicted a poor clinical and radiologic outcome after intravenous thrombolytic therapy. However, a major neurologic deficit, defined as a stroke scale score of 10 or more, was better than a positive HMCAS as a predictor of poor neurologic outcome after thrombolytic therapy. Patients with a low stroke scale score (< 10) may benefit from ultraearly intravenous alteplase therapy.

Frequency and accuracy of prehospital diagnosis of acute stroke

BACKGROUND AND PURPOSE

This pilot study evaluated the frequency and accuracy of diagnosis of stroke made by prehospital care system dispatchers, emergency medical technicians (EMTs), and paramedics in one emergency medical services (EMS) system. In addition, the study determined patient prehospital triage and time intervals in the transport and examination of patients given a diagnosis of stroke by this EMS system.

METHODS

We reviewed records of 4413 consecutive prehospital records of a two-tiered EMS system for patients with potential stroke. Hospital records were obtained for patients given a diagnosis of stroke or transient ischemic attack (TIA) by an EMS dispatcher, EMT, or paramedic. The EMS system studied serves a community of 13,000 within the greater Cincinnati area.

RESULTS

Of 4413 EMS on-scene evaluations, the diagnosis of stroke or TIA was made by an EMT or paramedic for 96 patients (2%). Of the study population (n = 86), a final hospital discharge diagnosis of stroke or TIA was made for 62 patients (72%). EMS dispatchers correctly identified 52% and paramedics 72% of these 86 patients as having sustained a stroke or TIA. Twenty-two of the 86 patients required paramedic-level interventions, which included three intubations. Of the 24 patients whose symptoms were misdiagnosed as stroke or TIA by the paramedics, 16 (19%) had acute conditions for which effective therapies are available. Prehospital personnel arrived at the scene to examine potential stroke patients in a mean of 3 minutes after the emergency 911 call was received by the dispatcher. Patients transported by basic life support units (EMTs) arrived earlier at the hospital than did those transported by advanced life support units (paramedics) (40 +/- 1 versus 45 +/- 1 minutes, P = .004). However, patients transported by advanced life support units were seen by a physician sooner after arrival at the emergency department (10 +/- 2 versus 20 +/- 4 minutes, P = .02) and underwent computed tomography of the brain sooner (47 +/- 5 versus 69 +/- 10 minutes, P = .04).

CONCLUSIONS

Prehospital evaluation of potential stroke patients can be accomplished promptly after the EMS system is activated. Urgent evaluation and transport of potential stroke patients is justified because paramedic-level interventions are frequently required and because almost 20% of patients with potential stroke have acute medical conditions for which effective specific therapies are available.

Factors related to intracranial hematoma formation in patients receiving tissue-type plasminogen activator for acute ischemic stroke

BACKGROUND AND PURPOSE

Several studies are currently evaluating tissue-type plasminogen activator (TPA) as a potential therapy in acute ischemic stroke. The possibility of inducing intracranial hematomas, however, introduces an important concern into ultimate evaluation of risk and benefit. This retrospective analysis sought to identify factors associated with intracranial hematoma formation in a pilot phase 1 study of TPA for stroke.

METHODS

Ninety-four patients received TPA within 3 hours of the onset of an acute ischemic stroke. Five of these patients developed a symptomatic intracerebral hematoma: 3 of 74 (4%) among patients treated within 90 minutes of stroke onset and 2 of 20 (10%) among those treated at 91 to 180 minutes. Three of the 5 died within 2 weeks. The analysis investigated associations between clinical factors and intracerebral hematomas.

RESULTS

Factors significantly related to the development of an intracerebral hematoma were TPA dose and diastolic hypertension. Intracerebral hematomas developed in 4 (18%) of 22 patients given a TPA dose of at least 0.90 mg/kg versus only 1 hematoma in the remaining 72 patients (1%; P < .02, Fisher's exact test). Four (18%) of 22 patients who had initial diastolic blood pressures of at least 100 mm Hg suffered an intracerebral hematoma versus only 1 (1%) of 72 patients (P < .02) with lower initial diastolic pressures.

CONCLUSIONS

Since the study was not designed to test specific safety hypotheses, results must not be overinterpreted. Nonetheless, these data emphasize the need for caution in both patient and dose selection for further studies of thrombolytic agents in stroke.

Blood pressure during the first minutes of focal cerebral ischemia

STUDY OBJECTIVE

To determine whether blood pressure declines spontaneously during the first minutes and hours of focal cerebral ischemia.

DESIGN

Multiple blood pressure measurements as part of an urgent stroke therapy trial (treatment within 90 minutes of stroke onset).

SETTING

Thirteen hospitals in three metropolitan communities.

PARTICIPANTS

Sixty-nine patients (mean age, 65 +/- 9 years) with acute ischemic stroke who were participants in a phase I urgent stroke therapy trial of recombinant tissue plasminogen activator.

MAIN OUTCOME MEASURE

Blood pressures recorded at the scene of stroke by life-squad personnel, in the emergency department, and in the ICU.

RESULTS

The mean time from stroke onset to the time of first blood pressure measurement was 19 +/- 13 minutes. Twenty-four of the 69 patients in the urgent stroke therapy trial had an initial systolic blood pressure of at least 160 mm Hg. Of these, 23 had a significant decline in systolic and diastolic blood pressure during the first 90 minutes after the onset of stroke (mean change in systolic pressure, -29 +/- 22 mm Hg, P < .001; mean change in diastolic pressure, -10 +/- 14 mm Hg, P < .01). No patients received antihypertensive therapy during the time in which the decline in blood pressure was noted.

CONCLUSION

Mildly or moderately elevated blood pressure frequently declines spontaneously during the first minutes and hours of focal cerebral ischemia and generally does not require urgent pharmacologic treatment.

Pilot randomized trial of tissue plasminogen activator in acute ischemic stroke. The TPA Bridging Study Group

BACKGROUND AND PURPOSE

Early thrombolytic therapy with recombinant tissue-type plasminogen activator is a theoretically attractive approach to the treatment of acute focal cerebral ischemia. In preparation for a larger multicenter trial, three centers piloted a protocol for a randomized, double-blind, placebo-controlled trial of intravenous recombinant tissue-type plasminogen activator begun within 3 hours of the onset of symptoms of acute stroke to test its feasibility and to explore trends.

METHODS

Eligible patients had pretreatment computed tomographic scanning, gave informed consent, and began treatment with either 0.85 mg/kg recombinant tissue-type plasminogen activator or placebo as soon as possible, but no later than 180 minutes after stroke onset. Patients were stratified by whether treatment was begun within 90 minutes or 91 to 180 minutes from onset. The primary end point was the proportion of patients in each group who improved by 4 or more points on the National Institutes of Health Stroke Scale at 24 hours, as determined by a separate blinded evaluator.

RESULTS

Twenty-seven patients were randomized: 20 (10 recombinant tissue-type plasminogen activator, 10 placebo) within 90 minutes, and 7 (4 recombinant tissue-type plasminogen activator, 3 placebo) from 91 to 180 minutes. Median baseline Stroke Scale scores were 16 (minimum = 5, maximum = 26) for the recombinant tissue-type plasminogen activator-treated group and 11 (minimum = 3, maximum = 21) for the control subjects in the group treated within 90 minutes. Six patients treated with recombinant tissue-type plasminogen activator within 90 minutes improved by 4 or more points at 24 hours compared with 1 patient in the placebo group (P < .05, Fisher's Exact Test). Two patients in each group in the 91- to 180-minute arm improved. One fatal intracerebral hemorrhage occurred in the placebo group.

CONCLUSIONS

A randomized, double-blind, placebo-controlled trial of recombinant tissue-type plasminogen activator very early in acute stroke is feasible. Preliminary observations suggest that recombinant tissue-type plasminogen activator treatment within 90 minutes may be associated with early neurological improvement. Larger studies are needed so that the potentially serious short-term risks of this treatment can be assessed in relation to meaningful long-term benefit.

Urgent therapy for stroke. Part I. Pilot study of tissue plasminogen activator administered within 90 minutes

BACKGROUND AND PURPOSE

Thrombolytic agents hold theoretical promise as therapy for cerebral infarction. This study was designed to evaluate the safety of tissue plasminogen activator, to accomplish urgent patient treatment, and to estimate potential efficacy of tissue plasminogen activator.

METHODS

Following neurological evaluation and computed tomography of the brain, patients with acute ischemic stroke were evaluated and treated with intravenous tissue plasminogen activator under an open-label, dose-escalation design within 90 minutes from symptom onset. End points examined included symptomatic and asymptomatic intracranial hematoma, systemic hemorrhage, and neurological outcome at 2 hours, 24 hours, and 3 months.

RESULTS

Seventy-four patients were treated within 90 minutes of symptom onset over seven dose tiers of tissue plasminogen activator, ranging from 0.35 mg/kg to 1.08 mg/kg. Intracranial hematoma with associated neurological deterioration occurred in three patients and was related to increasing doses of tissue plasminogen activator (p = 0.045). Intracranial hematoma did not occur in any of the 58 patients treated with less than or equal to 0.85 mg/kg. Major neurological improvement occurred in 22 patients (30%) at 2 hours from the initiation of tissue plasminogen activator and in a total of 34 patients (46%) at 24 hours, but major neurological improvement was not related to increasing doses of tissue plasminogen activator or to stroke type.

CONCLUSIONS

Patients with acute stroke can be evaluated and treated within 90 minutes. Tissue plasminogen activator for acute ischemic infarction is not without risk, but the potential for clinical benefit justifies a randomized clinical trial. To date, differences in hemorrhagic risk or neurological benefit of tissue plasminogen activator for particular ischemic stroke types are not apparent.

Thrombus localization with emergency cerebral CT

PURPOSE

To determine the prevalence of the hyperdense middle cerebral artery sign (HMCAS) in an acute stroke population (treated with intravenous tissue plasminogen activator (tPA) within 90 minutes of stroke onset); to correlate the presence/absence of the sign with arteriographic findings; and to correlate the HMCAS with the volume of subsequent infarction.

PATIENTS AND METHODS

55 patients with acute ischemic stroke underwent CT to exclude cerebral hemorrhage and were then treated with intravenous tPA. The neuroradiologist, blinded to the clinical and arteriographic data, sought the HMCAS on the initial and subsequent scans.

RESULTS

The HMCAS was detected by CT in 19 of 55 (34.5%) patients (one false positive). Arteriograms in 14 of the 18 true positive patients confirmed the CT-predicted middle cerebral artery segment in 12. The 18 patients developed infarcts larger than patients not exhibiting the sign (132 cc vs 52 cc, P less than .002).

CONCLUSION

The HMCAS does predict middle cerebral artery occlusion and subsequent development of a large infarct.

Ultra-early evaluation of intracerebral hemorrhage

The authors evaluate eight patients with intracerebral hemorrhage (ICH) who underwent computerized tomography (CT) within 2 1/2 hours after symptom onset and then again several hours later. The second CT scan was performed within 12 hours after onset for seven of the patients and 100 hours after onset for the eighth patient. In four patients, the second CT scan was obtained prospectively. The mean percentage of increase in the volume of hemorrhage between the first and second CT scans was 107% (range 1% to 338%). In each of the six patients with a greater than 40% increase in hemorrhage volume, neurological deterioration occurred soon after the first CT. A systolic blood pressure of 195 mm Hg or greater was recorded during the first 6 hours in five of the same six patients. The data from this study indicate that, in ICH, bleeding may continue after the 1st hour post-hemorrhage, particularly in patients with early clinical deterioration.

Hyperdense middle cerebral artery: incidence and quantitative significance

The hyperdense middle cerebral artery sign (HMCAS) is recognized as a CT finding that indicates thrombus or embolus within the middle cerebral artery. The incidence and significance of this sign are quantitatively evaluated in 50 patients entered into experimental drug studies for treatment of cerebral infarction.