Health Policy Analysis

Acute Stroke: Current Evidence-based Recommendations for Prehospital Care

Volume 17, Issue 2, March 2016.
Nancy K. Glober, MD, et al.

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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Prehospital Care

Chest Pain of Suspected Cardiac Origin: Current Evidence-based Recommendations for Prehospital Care

Volume 16, Issue 7, December 2015.
P. Brian Savino, MD

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 chest pain of suspected cardiac origin 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 chest pain and augmented this review with guidelines from various national and international
societies to create our evidence-based recommendations. We then compared the chest pain
protocols of each of the 33 EMS agencies for consistency with these recommendations. The
specific protocol components that we analyzed were use of supplemental oxygen, aspirin, nitrates,
opiates, 12-lead electrocardiogram (ECG), ST segment elevation myocardial infarction (STEMI)
regionalization systems, prehospital fibrinolysis and β-blockers.

Results: The protocols varied widely in terms of medication and dosing choices, as well as listed
contraindications to treatments. Every agency uses oxygen with 54% recommending titrated
dosing. All agencies use aspirin (64% recommending 325mg, 24% recommending 162mg and 15%
recommending either), as well as nitroglycerin and opiates (58% choosing morphine). Prehospital 12-
Lead ECGs are used in 97% of agencies, and all but one agency has some form of regionalized care
for their STEMI patients. No agency is currently employing prehospital fibrinolysis or β-blocker use.

Conclusion: Protocols for chest pain of suspected cardiac origin vary widely across 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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Contact Information

WestJEM/ Department of Emergency Medicine
UC Irvine Health

333 The City Blvd. West, Rt 128-01
Suite 640
Orange, CA 92868, USA
Phone: 1-714-456-6389
Email: westjem@gmail.com

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WestJEM
ISSN: 1936-900X
e-ISSN: 1936-9018

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ISSN: 2474-252X

Our Philosophy

Emergency Medicine is a specialty which closely reflects societal challenges and consequences of public policy decisions. The emergency department specifically deals with social injustice, health and economic disparities, violence, substance abuse, and disaster preparedness and response. This journal focuses on how emergency care affects the health of the community and population, and conversely, how these societal challenges affect the composition of the patient population who seek care in the emergency department. The development of better systems to provide emergency care, including technology solutions, is critical to enhancing population health.