Prehospital CT for early diagnosis and treatment of suspected acute stroke or severe head injury. A health technology assessment
Sari Susanna OrmstadUlrikke Højslev LundKishan ChudasamaKatrine FrønsdalMaren Ranhoff HovIda OrmbergElisabet HafstadAnna Stoinska‐SchneiderBjarne RobberstadVigdis LauvrakLene Kristine Juvet
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Keywords:
Stroke
Acute stroke
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Stroke
Neurointensive care
Acute stroke
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Background:
In this feasibility study, we tested whether prehospital diagnostic stroke workup enables rational decision-making regarding treatment and the target hospital in persons with suspected stroke.Methods:
A mobile stroke unit that delivers imaging (including multimodal brain imaging with CT angiography and CT perfusion), point-of-care-laboratory analysis, and neurologic expertise directly at the emergency site was analyzed for its use in prehospital diagnosis-based triage of suspected stroke patients.Results:
We present 4 complementary cases with suspected stroke who underwent prehospital diagnostic workup that enabled direct diagnosis-based treatment decisions and reliable triage regarding the most appropriate medical facility for that individual, e.g., a primary hospital vs specialized centers of a tertiary hospital.Conclusions:
This preliminary report demonstrates the feasibility of prehospital diagnostic stroke workup for immediate etiology-specific decision-making regarding the necessary time-sensitive stroke treatment and the most appropriate target hospital.Triage
Stroke
Etiology
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Torrents, V. Sanchez; Negro, M. De Miguel; Soler, M. Colomina; Alemany, R. Monforte; Solé, J. Roigé Author Information
Severe trauma
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Polytrauma
Interventional radiology
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Background Dysphagia is associated with aspiration pneumonia after stroke. Data are limited on the influences of dysphagia screen and assessment in clinical practice. Aims To determine associations between a “brief” screen and “detailed” assessment of dysphagia on clinical outcomes in acute stroke patients. Methods A prospective cohort study analyzed retrospectively using data from a multicenter, cluster cross-over, randomized controlled trial (Head Positioning in Acute Stroke Trial [HeadPoST]) from 114 hospitals in nine countries. HeadPoST included 11,093 acute stroke patients randomized to lying-flat or sitting-up head positioning. Herein, we report predefined secondary analyses of the association of dysphagia screening and assessment and clinical outcomes of pneumonia and death or disability (modified Rankin scale 3–6) at 90 days. Results Overall, 8784 (79.2%) and 3917 (35.3%) patients were screened and assessed for dysphagia, respectively, but the frequency and timing for each varied widely across regions. Neither use of a screen nor an assessment for dysphagia was associated with the outcomes, but their results were compared to “screen-pass” patients, those who failed had higher risks of pneumonia (adjusted odds ratio [aOR] = 3.00, 95% confidence interval [CI] = 2.18–4.10) and death or disability (aOR = 1.66, 95% CI = 1.41–1.95). Similar results were evidence for the results of an assessment for dysphagia. Subsequent feeding restrictions were related to higher risk of pneumonia in patients failed dysphagia screen or assessment (aOR = 4.06, 95% CI = 1.72–9.54). Conclusions Failing a dysphagia screen is associated with increased risks of pneumonia and poor clinical outcome after acute stroke. Further studies concentrate on determining the effective subsequent feeding actions are needed to improve patient outcomes.
Stroke
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Approximately 20 million strokes occur in the world each year and over one-quarter of these are fatal. This makes stroke the second most common cause of death, after ischaemic heart disease, and strokes are responsible for 6 million deaths (almost 10% of all deaths) annually. Stroke has major consequences in terms of residual physical disability, depression, dementia, epilepsy, and carer burden. Moreover, around 20% of survivors experience a further stroke or serious vascular event within a few years of the index event. Ischaemic stroke contributes the greatest share of the impact of stroke, with a rate of approximately 1 in 1000 person-years and accounting for between 60% (in Asia) and 90% (in Western ‘white’ populations) of all strokes around the world. Diagnosis and assessment are essentially clinical and confirmed by CT or MRI scanning. Prognostication is difficult in the early phase of haemorrhagic stroke and in ischaemic stroke is affected by the availability and timely use of treatments to recanalize the occluded vessel.
Stroke
Depression
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Guideline
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Introduction Outcome measures are used in clinical trials to determine efficacy of interventions. We aimed to determine which outcome measures in prehospital major trauma trials have been reported in the literature, and which of these are most patient-centred. Methods A systematic review identified outcomes reported in prehospital clinical trials of major trauma patients. A search was undertaken using Medline, Embase, clinicaltrials.gov, Web of Science and Google Scholar. Data were summarised by dividing outcomes into common themes which were presented to a Patient and Public Involvement group consisting of trauma survivors and their relatives. This group ranked the categories of outcomes in order of most importance, and agreed consensus statements regarding these outcome measures. Results There were 27 eligible studies, including 9,537 patients. Outcome measures were divided into nine categories: quality of life; length of stay; mortality/survival; physiological parameters; fluid/blood product requirements; complications; health economics; safety and feasibility; and intervention success. Of these, mortality/survival was the most commonly reported category, but over multiple timescales. The Patient and Public Involvement group agreed that the most important category was quality of life, and that mortality/survival should only be reported if concurrently reported with longer term quality of life. Length of stay and health economics were not considered important. Conclusions Outcome measures in prehospital clinical trials in major trauma have been heterogeneous, inconsistent, and not necessarily patient-centred. Trauma survivors considered quality of life and mortality most important when combined. Consensus is required for consistent, patient-centred, outcome measures in order to investigate interventions of meaningful impact to patients.
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Abstract Introduction: Traumatic brain injury is one of the leading causes of death and sources of heavy societal burden. Hypoxemia and hypercapnia are the 2 common complications of brain injury. Intubation seems to be an effective intervention for preventing the 2 complications in pre-hospital setting. But the results of the existing studies on the effect of pre-hospital intubation on prognosis of patients (aged less than 18) with severe traumatic brain injury are conflict. Thus, in this study, we aim to conduct a systematic review and meta-analysis to evaluate whether pre-hospital intubation is benefit for the prognosis in infants, children and adolescents with severe traumatic brain injury. Methods: We will develop a systematic search strategy which includes MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Chinese Biomedical Literature Database, WanFang Data and China National Knowledge Infrastructure. The WHO International Clinical Trials Registry Platform will be searched for the ongoing studies as well. The cohort studies which aim to evaluate the effect of pre-hospital intubation for infants, children and adolescents with severe traumatic brain injury will be selected. The Newcastle-Ottawa Scale will be used for assessing the risk of bias of the included studies. Results: The results of this study will be presented in the full-text of the systematic review. Conclusion: This is the first systematic review and meta-analysis about evaluation of the effect of pre-hospital intubation on prognosis in infants, children and adolescents with traumatic brain injury. PRESPERO registration number: CRD42019121214
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