Early identification and delay to treatment in myocardial infarction and stroke: differences and similarities

<p>Abstract</p> <p>Background</p> <p>The two major complications of atherosclerosis are acute myocardial infarction (AMI) and acute ischemic stroke. Both are life-threatening conditions characterised by the abrupt cessation of blood flow to respective organs, resulting in an infarction. Depending on the extent of the infarction, loss of organ function varies considerably.</p> <p>In both conditions, it is possible to limit the extent of infarction with early intervention. In both conditions, minutes count.</p> <p>This article aims to describe differences and similarities with regard to the way patients, bystanders and health care providers act in the acute phase of the two diseases with the emphasis on the pre-hospital phase.</p> <p>Method</p> <p>A literature search was performed on the PubMed, Embase (Ovid SP) and Cochrane Library databases.</p> <p>Results</p> <p>In both conditions, symptoms vary considerably. Patients appear to suspect AMI more frequently than stroke and, in the former, there is a gender gap (men suspect AMI more frequently than women).</p> <p>With regard to detection of AMI and stroke at dispatch centre and in Emergency Medical Service (EMS) there is room for improvement in both conditions. The use of EMS appears to be higher in stroke but the overall delay to hospital admission is shorter in AMI. In both conditions, the fast track concept has been shown to influence the delay to treatment considerably.</p> <p>In terms of diagnostic evaluation by the EMS, more supported instruments are available in AMI than in stroke. Knowledge of the importance of early treatment has been reported to influence delays in both AMI and stroke.</p> <p>Conclusion</p> <p>Both in AMI and stroke minutes count and therefore the fast track concept has been introduced. Time to treatment still appears to be longer in stroke than in AMI. In the future improvement in the early detection as well as further shortening to start of treatment will be in focus in both conditions. A collaboration between cardiologists and neurologists and also between pre-hospital and in-hospital care might be fruitful.</p

Suspicion and treatment of severe sepsis. An overview of the prehospital chain of care

Sepsis is a life-threatening condition where the risk of death has been reported to be even higher than that associated with the major complications of atherosclerosis, i.e. myocardial infarction and stroke. In all three conditions, early treatment could limit organ dysfunction and thereby improve the prognosis

Emergency medical dispatch. The first medical response for life-threatening conditions. Assessment and invention of patients with chest pain and/or suspected cardiac arrest

Aims: To describe the Emergency Medical Dispatcher's (EMDs) possibility of assessment and intervention of patients reported having chest pain and/or cardiac arrest, with regard to identification of the problem, priority-decision, provision of instructions in dispatcher-assisted bystander cardiopulmonary resuscitation (CPR), and the subsequent outcome in terms of final diagnosis and survival. Methods: Prospective and retrospective observational studies based on registrations made by EMDs in case record forms (during two months, 1993), and in the dispatch protocol (27 months, 1994-1996) and subsequent follow-up in ambulance and hospital files. Evaluations of tape recordings of emergency calls to the EMS dispatch centre, concerning patients treated for out-of-hospital cardiac arrest (99 calls/1986, 100 calls/2000-2001). A qualitative study was used to describe the EMDs perceptions of identifying cardiac arrest, offer and provide instructions in CPR to callers. Ten EMDs were approached for face-to-face interviews in 1997. Results: Among 503 patients reporting chest pain, 68% were judged as having severe chest pain, of which 26% developed acute myocardial infarction (AMI) as compared with 13% among patients judged as having only vague chest pain (p = 0.0004). The EMDs had a strong suspicion of AMI in 36%, a moderate suspicion of AMI in 34%, and a vague or no suspicion in 30%. Among patients with a strong suspicion of AMI, 29% subsequently developed AMI compared with 18% among patients with a moderate suspicion, and 15% among patients with only a vague or no suspicion of AMI (p< 0.001). The study sample size was too small to evaluate the predictive value of various associated symptoms accompanying chest pain. The priority level was similar in patients with and without a life-threatening condition (81% vs. 73% receiving the highest priority). In patients with cardiac arrest outside hospital, more attention should be paid to the detection of these patients by the EMDs, however, when the EMDs had a suspicion, their accuracy was high. Half of witnesses accepted an offer of instructions in CPR, and one-third completed dispatcher-assisted bystander CPR. The comparison between no performance and performance of dispatcher-assisted bystander CPR, suggests an increase in survival from 6% to 9%. Among suspected cardiac arrest cases, EMDs offer CPR instruction to only a small fraction of callers, with an accomplishment in all, of ~8%. However, 30-50% of suspected cardiac arrest cases seemed eligible to be approached with such an offer. A major obstacle was the presentation of suspected agonal breathing, which was estimated to occur in about 30%, and was described as: difficulties breathing, poorly, gasping, wheezing, impaired and occasional breathing. The EMDs have a belief that they are being an empathic authority that relieves the caller of the burden of responsibility, and by meeting the witness mentally, this may enable the caller to act at the scene. The EMDs are dependent on the callers knowledge and trustworthiness, and convincing answers from the caller prompt a more secure feeling in the EMDs, just as caller's lack of knowledge having a negative effect on the EMDs efforts. Conclusion: There was a strong relationship between the EMDs suspicion of AMI and subsequent development of AMI. One-third, however, developed AMI among those where the EMD had had a moderate, vague or no suspicion of AMI. Patients judged to have severe chest pain, developed AMI twice as often as patients judged to have vague pain. Caller's reporting patients with a combination of unconsciousness and agonal breathing or respiratory arrest should be offered dispatcher-assisted CPR instruction. This may improve survival in out-of hospital cardiac arrest

Prehospital suspicion and identification of adult septic patients:Experiences of a screening tool

Introduction:  Sepsis  is life threatening  and  requires  urgent healthcare  to reduce  suffering  and death. Therefore it is important that septic patients are identified early to enable treatment.   Aim: To investigate to what extent EMS personnel identified patients with sepsis using the "BAS 90-30-90"  model, and to describe assessments and medical procedures that were  undertaken by the personnel.   Methods: This was a retrospective study where  185 EMS medical records were  reviewed. The inclusion was based on patients who were later diagnosed with sepsis in the hospital.   Results: A physician assessed the patients  in 74 of the EMS cases, which lead to exclusion  of these  records  in  regard  to  the  EMS  personnel's  ability  to  identify  sepsis.  The  personnel documented  suspicion  of severe sepsis in eight (n=8) of the remaining 111 records (7.2%). The proportion  of patients  065 years  of age was 73% (n=135)  of which  37% (n=50) were over 80 years  old. Thirty-nine percent  (39%,  n=72)  were  females. The  personnel  documented blood pressure   in  91%  (n=168),  respiratory   rate  in  76%  (n=140),   saturation   in  100%  (n=185), temperature  in 76%  (n=141),  and  heart  rate  in  94%  (n=174)  of  the  records.  Systolic  blood pressure  &lt;90 mmHg  was  documented  in 14,2%  (n=24),  respiratory  rate  030 in 36%  (n=50), saturation &lt;90 in 49%   (n=91). temperature &gt;38°C in 37.6% (n=53), and heart rate 090 in 70% (n=121) of the records. Documented medical procedures and treatments were intravenous  lines (70%, n=130), intravenous  fluids (10%, n=19) and administration  of oxygen (72%, n=133).   Conclusion:  The EMS personnel identified  only a few septic patients  with the help of the BAS 90-30-90  model when  all three criteria  would  be met for severe  sepsis. Either  advanced age (&gt;65  years),   fever   (&gt;38°C)   or  tachypnea (020  breaths/min)   appeared   to   increase  the personnel's suspicion  of sepsis. Oxygen, but not intravenous  fluids, was given in an adequate way

Clinical presentation in EMS patients with acute chest pain in relation to sex, age and medical history: prospective cohort study

OBJECTIVE: To assess symptom presentation related to age, sex and previous medical history in patients with chest pain. DESIGN: Prospective observational cohort study. SETTING: Two-centre study in a Swedish county emergency medical service (EMS) organisation. PARTICIPANTS: Unselected inclusion of 2917 patients with chest pain cared for by the EMS during 2018. DATA ANALYSIS: Multivariate analysis on the association between symptom characteristics, patients' sex, age, previous acute coronary syndrome (ACS) or diabetes and the final outcome of acute myocardial infarction (AMI). RESULTS: Symptomology in patients assessed by the EMS due to acute chest pain varied with sex and age and also with previous ACS or diabetes. Women suffered more often from nausea (OR 1.6) and pain in throat (OR 2.1) or back (OR 2.1). Their pain was more often affected by palpation (1.7) or movement (OR 1.4). Older patients more often described pain onset while sleeping (OR 1.5) and that the onset of symptoms was slow, over hours rather than minutes (OR 1.4). They were less likely to report pain in other parts of their body than their chest (OR 1.4). They were to a lesser extent clammy (OR 0.6) or nauseous (OR 0.6). These differences were present regardless of whether the symptoms were caused by AMI or not. CONCLUSIONS: A number of aspects of the symptom of chest pain appear to differ in unselected prehospital patients with chest pain in relation to age, sex and medical history, regardless of whether the chest pain was caused by a myocardial infarction or not. This complicates the possibility in prehospital care of using symptoms to predict the underlying aetiology of acute chest pain

Suspicion and treatment of severe sepsis. An overview of the prehospital chain of care

Abstract Background Sepsis is a life-threatening condition where the risk of death has been reported to be even higher than that associated with the major complications of atherosclerosis, i.e. myocardial infarction and stroke. In all three conditions, early treatment could limit organ dysfunction and thereby improve the prognosis. Aim To describe what has been published in the literature a/ with regard to the association between delay until start of treatment and outcome in sepsis with the emphasis on the pre-hospital phase and b/ to present published data and the opportunity to improve various links in the pre-hospital chain of care in sepsis. Methods A literature search was performed on the PubMed, Embase (Ovid SP) and Cochrane Library databases. Results In overall terms, we found a small number of articles (n = 12 of 1,162 unique hits) which addressed the prehospital phase. For each hour of delay until the start of antibiotics, the prognosis appeared to become worse. However, there was no evidence that prehospital treatment improved the prognosis. Studies indicated that about half of the patients with severe sepsis used the emergency medical service (EMS) for transport to hospital. Patients who used the EMS experienced a shorter delay to treatment with antibiotics and the start of early goal-directed therapy (EGDT). Among EMS-transported patients, those in whom the EMS staff already suspected sepsis at the scene had a shorter delay to treatment with antibiotics and the start of EGDT. There are insufficient data on other links in the prehospital chain of care, i.e. patients, bystanders and dispatchers. Conclusion Severe sepsis is a life-threatening condition. Previous studies suggest that, with every hour of delay until the start of antibiotics, the prognosis deteriorates. About half of the patients use the EMS. We need to know more about the present situation with regard to the different links in the prehospital chain of care in sepsis.</p

Ambulanssjukvården måste bli jämlik

Skiftande vårdkvalité hotar patientsäkerheten inom ambulanssjukvården. Nu måste regeringen och Socialstyrelsen skapa nationella riktlinjer, skriver Nätverket för utbildning av ambulanssjuksköterskor