Name: Prehospital Thrombolysis: A Manual from Berlin (Video) | JoVE Journal
Uploaded: 2013-11-26T19:30:00.000+00:00
Duration: 5 min 52 s
Description: Learn pre-hospital thrombolysis for acute ischemic stroke using a mobile stroke unit equipped with CT scanner and point-of-care laboratory. This protocol reduces treatment time by 36 minutes and enables earlier intervention.

ai_agent_IP

ai_agent

maintenance

instantTrialDurationMinutes

isBiopharma

enableNewMyJoveSectionDesign

educationFeatures

seoMetaApi

ai_copilot_institution_blacklist

ai_chat_institution_blacklist

freeAccessWindow

ssoRoleCapture

scheduledMaintenanceBanner

joveLabsFeatures

disable_autoplay_for_bots

extended_trial_duration

5 minutes

We wish to acknowledge all of the funding organizations, the &#34;Technology Foundation Berlin&#34; (TSB) via the &#34;Zukunftsfonds Berlin&#34;, the Federal Ministry of Education and Research via the grant CSB (01 EO 0801), the Volkswagen Foundation (Lichtenberg program to Matthias Endres), the EU (EuStroke, ARISE) and the German Research Foundation (NeuroCure, SFB-TR 43).

1. Emergency Response at the Dispatch Center of the Berlin Fire Brigade
<ol>
	<li>Answer an incoming &#34;112&#34; emergency call.</li>
	<li>Gather information about the emergency site, such as address, floor, name on the doorbell and phone number. Type the data directly into the worksheet of the computer-controlled emergency dispatch system (called Ignis)</li>
	<li>Identify the medical emergency as a stroke emergency, using the newly developed Dispatcher Identification Algorithm for Stroke Emergencies (DIASE).</li>
	<li>Verify that the emergency site is within the operating area of STEMO via Ignis.</li>
	<li>Communicate alarm to STEMO via a radio-based alarm system. (In Berlin, currently, a regular care ambulance is alarmed simultaneously.) Available information concerning the emergency is automatically transmitted via fax.</li>
</ol>
2. Receipt of the Alarm Transmission at the Fire Station
<ol>
	<li>A personal pager signals the alert by audible tone. Go immediately to the fax machine and take the fax containing the detailed emergency information.</li>
	<li>Go to the STEMO vehicle, press the status button 3 on the on-board radio, thus confirming a receipt for alert to the dispatch center. The GPS-based navigation system has automatically received a routing to the patient&#39;s location.</li>
	<li>When complete crew is on board (Paramedic, Neurologist and Radiology technician) drive the STEMO vehicle to the emergency site. CAUTION: Approach with blue lights flashing and siren to the scene. Therefore, pay particular attention to other road users and observe the regulations of the German traffic law concerning the use of blue lights and siren.</li>
	<li>Upon arrival at the emergency site, press the status button 4 on the on-board radio, thus giving a confirmation to the dispatch center.</li>
	<li>Pay extra attention to safety before leaving the STEMO vehicle at the emergency site. CAUTION: Watch out for potential hazards, such as unsecured scene of an accident, violent people, risk of fire, moving traffic or hazardous substances.</li>
</ol>
3. Examination of the Patient at the Emergency Site
<ol>
	<li>Check consciousness using the Glasgow Coma Scale (GCS).</li>
	<li>Follow the structured &#34;ABCDE algorithm&#34; for the initial assessment of the patient&#39;s status: Airways, Breathing, Circulation, Disability, Exposure13.</li>
	<li>Explore medical history of the patient. If stroke is suspected clinically assess severity of symptoms using the National Institutes of Health Stroke Scale (NIHSS).</li>
	<li>Determine the exact onset of symptoms by questioning the patient/witnesses.</li>
	<li>Ask for current medication with a main focus on anticoagulation therapy.</li>
	<li>Measure and log the vital signs, such as heart rate, blood pressure, blood sugar concentration, and oxygen saturation.</li>
</ol>
4. Insert a&#160;Peripheral Intravenous (IV) Line and Perform Blood Withdrawals
<ol>
	<li>Apply a tourniquet around the upper arm.</li>
	<li>Search for a suitable hand, forearm, or antecubital vein. The best choice for the iv line is a vein on the dorsum of the hand.</li>
	<li>Disinfect the skin.</li>
	<li>Remove needle sheath from the indwelling venous catheter. Ensure needle bevel is upwards.</li>
	<li>Apply traction distal to the vein to prevent vein from rolling during cannulation.</li>
	<li>Insert the needle into the vein at 20-40&#176;. The flashback of blood confirms that the needle tip is inside the vein. Advance the catheter off the needle into the vein.</li>
	<li>Fix the catheter using adhesive tape.</li>
	<li>Remove the needle, discard it to a sharps container and connect a plastic adapter containing a shrouded needle, which enables to start with a blood draw from the indwelling venous catheter.</li>
	<li>Perform blood draw using several Vacutainer blood test tubes. Some of these blood tubes contain different anticoagulatory additives, such as EDTA, citrate and heparine. The type of blood test tube is color-coded: 1. Purple for complete blood counts; 2. Blue for coagulatory assays; 3. Green for electrolytes, BUN, and other basic blood parameters; 4. Orange for specialized serum analysis.</li>
	<li>Push a Vacutainer blood test tube into the plastic holder, so that its rubber cap is pierced by the shrouded needle. (The negative pressure in the Vacutainer tubes forces blood into the blood test tubes.)</li>
	<li>Remove the Vacutainer tube after it was filled with blood and repeat this procedure with the other Vacutainer tubes.</li>
	<li>After the last Vacutainer tube was filled, remove the tourniquet, flush the indwelling venous catheter with normal saline solution, and close the catheter using a closing cone.</li>
</ol>
5. Determine the International Normalized Ratio (INR), using a Bedside Point-of-care Analyzer
<ol>
	<li>Take a test strip from its container. Slide it into the guide in the direction indicated by the arrows.</li>
	<li>Take a lancet and twist the protective cap off. Press the tip of the lancet against the side of the fingertip and press the trigger button.</li>
	<li>Apply the blood sample on the target area of the test strip within 15 sec of sticking the fingertip. After a few seconds the result (INR) is displayed.</li>
	<li>Place the used strip and the lancet into containers for biohazards and sharps, respectively.</li>
</ol>
6. Advanced Diagnostics and Intervention
<ol>
	<li>Immediately transfer the patient into the STEMO vehicle.</li>
	<li>Position the patient on a stretcher.</li>
	<li>Insert the purple Vacutainer blood test tube into the point-of-care laboratory (Horiba ABX Micros 60). Measure additional blood parameters such as platelet count, total leukocyte count, erythrocyte count, hemoglobin concentration, hematocrit, electrolytes.</li>
	<li>Insert the patient&#39;s insurance card into the card reader (installed in the control room).</li>
	<li>Call the neuroradiologist on-call to discuss the indication for CT scanning and prepare for examination.</li>
	<li>Explain benefits and risks of CT scanning to the patient. Afterwards, obtain informed consent from the patient, if possible.</li>
	<li>Start the CT. CAUTION: X-ray radiation is released from the CT scanner. Radiology technician has to be in the shielded control room. The rest of the STEMO staff is requested to leave the vehicle during the examination in order to avoid unnecessary exposure to x-ray radiation (STEMO vehicle is lead covered). Furthermore, protective measures (eye protection) should be applied to the patient.</li>
	<li>Transmit the CT image via on-board telemetric infrastructure and request teleradiological support for decision making regarding diagnosis and therapy. (Parallel analysis of images in the STEMO by the neurologist.)</li>
	<li>Ask the patient for contraindications against thrombolytic therapy using a standardized check list.</li>
	<li>Explain benefits and possible risks of thrombolysis. Inform the patient that the treatment is part of a clinical study and obtain informed consent, if possible.</li>
</ol>
7. Administration of Recombinant Tissue Plasminogen Activator (rtPA or Alteplase)
<ol>
	<li>Calculate the dose of alteplase (trade name: Actilyse) based on the best approximation of bodyweight available. The recommended dose is 0.9 mg/kg bodyweight. Maximum dose is 90 mg6.</li>
	<li>Reconstitute the dry solid alteplase using the solvent provided. Use the transfer cannula, which must be introduced vertically into the rubber stopper of the phials and through the mark at its center.</li>
	<li>Dissolve the dry solid by gentle agitation.</li>
	<li>Initiate thrombolysis by administering 10% of the calculated total dose as a bolus injection over 1 min. Keep record of the point in time, when alteplase bolus is injected. CAUTION: Pay attention to immediate allergic responses following administration. Be prepared to administer antiallergic drugs (i.e. antihistaminics, high-dose glucocorticoids, catecholamines) in case of an acute allergic response. In general, alteplase should be used only by a physician experienced in the treatment of ischemic stroke6.</li>
	<li>Inject the remaining dose via an injection pump syringe continuously over 60 min (after evacuation of the tubing to avoid the injection of air bubbles).</li>
</ol>
8. Transportation of the Patient to a Suitable Hospital
<ol>
	<li>Make an advanced notification to the emergency room of the closest hospital with a certified stroke unit.</li>
	<li>Start the transportation immediately. Communicate the selected hospital to the dispatch center via radio.</li>
	<li>Monitor neurological deficits and vital signs during transfer to the hospital.</li>
	<li>Print&#160;out and sign the admission letter (using Vimed software) including diagnosis, history, results of neurological examination, neuroradiological report (sent by the neuroradiologist on call via UMTS), results of laboratory investigations, and description of actions taken. Copy CT-scan on a CD for the hospital.</li>
	<li>On arrival at the hospital (press status button 8) provide concise present and past medical histories of the patient to the neurologist on-call and to the primary team in the Emergency Room. Hand over printed report, CD containing CT images (step&#160;8.4), and the blood-filled blue, green and orange Vacutainer blood test tubes (step&#160;4.9).</li>
</ol>
9. Restoring the Operational Readiness
<ol>
	<li>Clean and disinfect hands and all equipment that has been used during the EMS response.</li>
	<li>Report operational stand-by status to the dispatch center using button 1 on the onboard radio. Return to the local fire station.</li>
</ol>

<ol><li>Meretoja, A., Strbian, D., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Reducing+in-hospital+delay+to+20+min+in+stroke+thrombolysis%5BTitle%5D)+AND+%22Neurology%22%5BJournal%5D)">Reducing in-hospital delay to 20 min in stroke thrombolysis.</a> Neurology. 79 (4), 306-313 (2012).</li>
<li>Herlitz, J., Wireklintsundström, B., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Early+identification+and+delay+to+treatment+in+myocardial+infarction+and+stroke%3A+differences+and+similarities%5BTitle%5D)+AND+%22Scand.+J.+Trauma+Resusc.+Emerg.+Med%22%5BJournal%5D)">Early identification and delay to treatment in myocardial infarction and stroke: differences and similarities.</a> Scand. J. Trauma Resusc. Emerg. Med. 18 (48), (2010).</li>
<li>Worthmann, H., Schwartz, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Educational+campaign+on+stroke+in+an+urban+population+in+Northern+Germany%3A+influence+on+public+stroke+awareness+and+knowledge%5BTitle%5D)+AND+%22Int.+J.+Stroke%22%5BJournal%5D)">Educational campaign on stroke in an urban population in Northern Germany: influence on public stroke awareness and knowledge.</a> Int. J. Stroke. , (2012).</li>
<li>Köhrmann, M., Schellinger, P. D., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Avoiding+in+hospital+delays+and+eliminating+the+three-hour+effect+in+thrombolysis+for+stroke%5BTitle%5D)+AND+%22Int.+J.+Stroke%22%5BJournal%5D)">Avoiding in hospital delays and eliminating the three-hour effect in thrombolysis for stroke.</a> Int. J. Stroke. 6, 493-497 (2011).</li>
<li>Ford, A. L., Williams, J. A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Reducing+Door-to-Needle+Times+Using+Toyota%27s+Lean+Manufacturing+Principles+and+Value+Stream+Analysis%5BTitle%5D)+AND+%22Stroke%22%5BJournal%5D)">Reducing Door-to-Needle Times Using Toyota's Lean Manufacturing Principles and Value Stream Analysis.</a> Stroke. , (2012).</li>
<li>Committee ESOEECEW,, et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Guidelines+for+management+of+ischaemic+stroke+and+transient+ischaemic+attack%5BTitle%5D)+AND+%22Cerebrovasc%22%5BJournal%5D)">Guidelines for management of ischaemic stroke and transient ischaemic attack.</a> Cerebrovasc. 25 (5), 457-507 (2008).</li>
<li>Gierhake, D., Weber, J. E., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Mobile+CT%3A+Technical+Aspects+of+Prehospital+Stroke+Imaging+before+Intravenous+Thrombolysis%5BTitle%5D)+AND+%22Rofo%22%5BJournal%5D)">Mobile CT: Technical Aspects of Prehospital Stroke Imaging before Intravenous Thrombolysis.</a> Rofo. , (2012).</li>
<li>Ebinger, M., Rozanski, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((PHANTOM-S%3A+the+prehospital+acute+neurological+therapy+and+optimization+of+medical+care+in+stroke+patients+-+study%5BTitle%5D)+AND+%22Int.+J.+Stroke%22%5BJournal%5D)">PHANTOM-S: the prehospital acute neurological therapy and optimization of medical care in stroke patients - study.</a> Int. J. Stroke. 7 (4), 348-353 (2012).</li>
<li>Körting, E., Notarztdienstverordnung,, et al. , Available from: 
 <a target="_blank" href="www.berlin.de">www.berlin.de</a> (2010).</li>
<li>Krebes, S., Ebinger, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Development+and+Validation+of+a+Dispatcher+Identification+Algorithm+for+Stroke+Emergencies+%28DIASE%29%5BTitle%5D)+AND+%22Stroke%22%5BJournal%5D)">Development and Validation of a Dispatcher Identification Algorithm for Stroke Emergencies (DIASE).</a> Stroke. 43 (3), 776-781 (2012).</li>
<li>Weber, J. E., Ebinger, M., Rozanski, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Pre-hospital+thrombolysis+in+acute+stroke+-+results+of+the+PHANTOM-S+pilot+study%5BTitle%5D)+AND+%22Neurology%22%5BJournal%5D)">Pre-hospital thrombolysis in acute stroke - results of the PHANTOM-S pilot study.</a> Neurology. , (2012).</li>
<li>Walter, S., Kostopoulos, P., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Diagnosis+and+treatment+of+patients+with+stroke+in+a+mobile+stroke+unit+versus+in+hospital%3A+a+randomised+controlled+trial%5BTitle%5D)+AND+%22Lancet+Neurol%22%5BJournal%5D)">Diagnosis and treatment of patients with stroke in a mobile stroke unit versus in hospital: a randomised controlled trial.</a> Lancet Neurol. 11 (5), 397-404 (2012).</li>
<li>Thim, T., Krarup, N. H., Grove, E. L., Rohde, C. V., Loefgren, B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Initial+assessment+and+treatment+with+the+Airway%2C+Breathing%2C+Circulation%2C+Disability%2C+Exposure+%28ABCDE%29+approach%5BTitle%5D)+AND+%22Int.+J.+Gen.+Med%22%5BJournal%5D)">Initial assessment and treatment with the Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach.</a> Int. J. Gen. Med. 5, 117-121 (2013).</li>
<li>Saver, J. L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Time+Is+Brain+-+Quantified%5BTitle%5D)+AND+%22Stroke%22%5BJournal%5D)">Time Is Brain - Quantified.</a> Stroke. 37 (1), 263-266 (2006).</li>
<li>Lees, K. R., Bluhmki, E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Time+to+treatment+with+intravenous+alteplase+and+outcome+in+stroke%3A+an+updated+pooled+analysis+of+ECASS%2C+ATLANTIS%2C+NINDS%2C+and+EPITHET+trials%5BTitle%5D)+AND+%22Lancet%22%5BJournal%5D)">Time to treatment with intravenous alteplase and outcome in stroke: an updated pooled analysis of ECASS, ATLANTIS, NINDS, and EPITHET trials.</a> Lancet. 375 (9727), 1695-1703 (2010).</li>
<li>Rothwell, P. M., Buchan, A. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/pubmed?term=((Mobile+acute+stroke+units%3A+bringing+the+hospital+to+the+patient%5BTitle%5D)+AND+%22Lancet+Neurol%22%5BJournal%5D)">Mobile acute stroke units: bringing the hospital to the patient.</a> Lancet Neurol. 11 (5), 382-383 (2012).</li>
</ol>

The authors declare that they have no competing financial interests.

Prehospital thrombolysis may be able to revolutionize acute specific stroke treatment. However, it is a cost and resource consuming way of treatment delivery. In general, a &#39;stay-and-play&#39; rather than a &#39;load-and-go&#39; approach needs to be justified by specific characteristics of the emergency at hand. Ischemic stroke has distinctive features that warrant a &#39;treat-and-run&#39; compromise: The benefits of acute stroke treatment are enormously time dependent. During an ischemic stroke approximately 2,000,000 neurons die per minute14. Intravenous treatment with rtPA enhances the chances of reperfusion and favorable functional outcome in stroke patients15. Treatment should be started as soon as possible. By now, it is the only evidence-based, effective and approved treatment for acute ischemic stroke. Associated with the risk of severe bleeding, the exclusion of intracranial bleeds and other contraindications is mandatory prior to thrombolysis. STEMO is set up to prove that this specific treatment can be safely administered in a prehospital setting and actually safes time compared to regular care8,11. First results from 12 prehospital thrombolyses in the Saarland State, Germany, seem promising in this respect12. In this study, Walter and colleagues reported that after randomized weeks between November, 2008, and July, 2011 and an interim analysis at 100 of 200 planned patients (53 in the prehospital setting, 47 in the control group), the median time from alarm to therapy decision (primary end-point) was substantially reduced in the 12 cases of prehospital thrombolysis: 35 min (IQR 31-39) versus 76 min, p&#60;0.0001; median difference 41 min (95% CI 36-48 min). Overall, the additional costs have to be weighed against benefits that patients may experience. For this, the final results of the ongoing PHANTOM-S will be crucial. In this prospective study (<a href="http://clinicaltrials.gov/ct2/show/" target="_blank">http://clinicaltrials.gov/ct2/show/</a> NCT01382862), weeks with and without STEMO on duty are randomized until 228 patients have received iv rtPA in both treatment arms. Primary end-point of the study is time from alarm to thrombolysis. Secondary end-points include modified Rankin Scale score after three months, symptomatic intracranial hemorrhage, mortality and cost effectiveness. Results of this study will help decision makers whether to implement prehospital thrombolysis of acute ischemic stroke patients with specialized ambulances in their emergency systems. Site specific adaptations may be necessary. For instance, in regions with a shortage of neurologists telemedicine may provide the expertise to the emergency physician on board. Similarly, the results of the PHANTOM-S study may help to identify regions with the most likely benefit for patients and cost effectiveness for authorities. So far, it is not known whether prehospital thrombolysis is the most appropriate approach in mega-cities, urban, or rural settings16. Taken together, prehospital thrombolysis seems to be a logical step when the need of shortening time to treatment is taken seriously. Only a sufficiently powered study may provide the evidence of actual benefit to stroke patients.

Thrombolysis with intravenous recombinant tissue Plasminogen Activator (rtPA) is the only proven effective treatment in acute ischemic stroke. The benefits of thrombolysis are time-dependent. Efficacy of thrombolytic therapy for ischemic stroke decreases with time elapsed from symptom onset1. Therefore, delays until initiation of treatment must be avoided. However, there are prehospital and in-hospital reasons for delays in treatment initiation. Patients&#39; decision time to call emergency services and the time from emergency call to arrival at the hospital are factors in the prehospital delay. In hospital, reductions of both the time to CT scanning and of the time between CT scan and start of thrombolysis remain challenging2. Stroke awareness campaigns shorten patient related times to emergency call3, but effects are only temporary and require repetition of such campaigns. While there are successful examples of reducing in-hospital delay&#160;4,5 many centers struggle to remain within the required 60 min from door to needle. One way to avoid these delays may be a start of specific stroke treatment at the emergency site, i.e. prehospital thrombolysis. Until recently, several requirements made this unfeasible. First, only physicians experienced in stroke care are qualified to make acute treatment decisions. Second, computed tomography (CT) is necessary to rule out intracranial hemorrhage. Third, laboratory tests should be available to exclude coagulation disorders6. In order to overcome these challenges, a stroke emergency mobile (STEMO) was constructed. This special ambulance is equipped with a CT scanner, a point-of-care laboratory and an infrastructure for teleradiological support7. It is operated by a highly specialized crew consisting of experienced neurologists, paramedics of the Berlin Fire Brigade, and radiology technicians8. To meet the legal requirements and the requirements of the Berlin Medical Board, each neurologist involved completed an additional training in emergency medicine. Radiology technicians completed a three month formal training in emergency care9. STEMO has been integrated in public emergency medical services (EMS) provided by the Berlin Fire Brigade. For the identification of eligible patients with suspected stroke during the emergency call, a special interview algorithm was developed and integrated at the dispatcher level10. During a three months pilot-study, we demonstrated safety and feasibility11. Our colleagues from Homburg, Germany, recently published their experience with the first 12 prehospital thrombolysis in the Saarland State12. We believe that prehospital stroke care using STEMO can reduce the alarm-to-needle time compared to regular care ultimately leading to improved patients care. However, prior to implementation final results of sufficiently powered studies need to confirm safety and efficacy of this approach. Here we present the methods used in the &#34;prehospital acute neurological therapy and optimization of medical care in stroke patients&#34; study (PHANTOM-S).

<table><tbody><tr><td colspan="4">&lt;strong&gt;Drug&lt;/strong&gt;</td></tr><tr><td>Alteplase (rtPA)</td><td>Boehringer-Ingelheim</td><td></td><td>Licensed drug</td></tr><tr><td colspan="4">&lt;strong&gt;Table 1. &lt;/strong&gt;Alteplase. Alteplase (tissue-Plasminogen Activator) is the only licensed drug for acute ischemic stroke that has proven effectiveness within 4.5 hr of symptom onset in randomized controlled trials.</td></tr><tr><td colspan="4">&lt;strong&gt;Device&lt;/strong&gt;</td></tr><tr><td>ABX micros 60</td><td>Horiba Medical</td><td></td><td>Point-of-care laboratory</td></tr><tr><td>CereTom</td><td>NeuroLogica</td><td></td><td>CT-Scanner</td></tr><tr><td>CoaguChek XSPlus</td><td>Roche</td><td></td><td>Handheld blood analyzer</td></tr><tr><td>EBA 20</td><td>HettichLab</td><td></td><td>centrifuge</td></tr><tr><td>FastPack System</td><td>Qualigen</td><td></td><td>Point-of-care immunoassay</td></tr><tr><td>i-STAT</td><td>Abbot</td><td></td><td>Handheld blood analyzer</td></tr><tr><td>OptiStat</td><td>Siemens</td><td></td><td>Contrast agent delivery system</td></tr><tr><td>Pilot A2</td><td>Fresenius</td><td></td><td>Infusion pump</td></tr><tr><td>TGL 12.250 4 x 2 BL</td><td>MAN</td><td></td><td>Vehicle chassis</td></tr><tr><td>Van body</td><td>Fahrtec Systeme GmbH</td><td></td><td>Custom-built</td></tr><tr><td>Vimed COMM</td><td>MEYTEC GmbH</td><td></td><td>Video communication system</td></tr><tr><td>Vimed GATEWAY</td><td>MEYTEC GmbH</td><td></td><td>Network solution</td></tr><tr><td>Vimed STEMO-DOC</td><td>MEYTEC GmbH</td><td></td><td>Documentation software</td></tr><tr><td>Vimed TELEMED</td><td>MEYTEC GmbH</td><td></td><td>Equipment for telemedicine</td></tr><tr><td>Vimed WEB-ENTRY</td><td>MEYTEC GmbH</td><td></td><td>Teleradiology</td></tr><tr><td colspan="4">&lt;strong&gt;Table 2. &lt;/strong&gt;Table of specific equipment. The software solution used in the ambulance was developed by a partner of the STEMO-consortium, MEYTEC GmbH, Germany. MEYTEC designed and implemented the overall technical solution. The entire system can be obtained from the partner MEYTEC under the name VIMED STEMO.</td></tr></tbody></table>

prehospital thrombolysis: a manual from berlin

Prehospital Thrombolysis: A Manual from Berlin

In acute ischemic stroke, time from symptom onset to intervention is a decisive prognostic factor. In order to reduce this time, prehospital thrombolysis at the emergency site would be preferable. However, apart from neurological expertise and laboratory investigations a computed tomography (CT) scan is necessary to exclude hemorrhagic stroke prior to thrombolysis. Therefore, a specialized ambulance equipped with a CT scanner and point-of-care laboratory was designed and constructed. Further, a new stroke identifying interview algorithm was developed and implemented in the Berlin emergency medical services. Since February 2011 the identification of suspected stroke in the dispatch center of the Berlin Fire Brigade prompts the deployment of this ambulance, a stroke emergency mobile (STEMO). On arrival, a neurologist, experienced in stroke care and with additional training in emergency medicine, takes a neurological examination. If stroke is suspected a CT scan excludes intracranial hemorrhage. The CT-scans are telemetrically transmitted to the neuroradiologist on-call. If coagulation status of the patient is normal and patient&#39;s medical history reveals no contraindication, prehospital thrombolysis is applied according to current guidelines (intravenous recombinant tissue plasminogen activator, iv rtPA, alteplase, Actilyse).
Thereafter patients are transported to the nearest hospital with a certified stroke unit for further treatment and assessment of strokeaetiology. After a pilot-phase, weeks were randomized into blocks either with or without STEMO care. Primary end-point of this study is time from alarm to the initiation of thrombolysis. We hypothesized that alarm-to-treatment time can be reduced by at least 20 min compared to regular care.

From February 8 to April 30, 2011, a total of 152 subjects were treated in the STEMO vehicle. Informed consent was obtained from 77 patients. Forty-five patient's (58%) had an acute ischemic stroke and 23 (51%) of these patients received rtPA. The mean alarm-to-needle time using STEMO was 62 min compared to 98 min in a control cohort of 50 consecutive patients thrombolysed in Berlin in 2010. Two (9%) of the rtPA-treated patients suffered a symptomatic intracranial hemorrhage and one of these patients (4%) died in hospital. Technical failures comprised one CT dysfunction and two delayed CT-image transmissions11.
<img alt="tPA administration timing box plot; compares STEMO vs. hospital setup; highlights efficiency differences." fo:content-width="5in" fo:src="/files/ftp_upload/50534/50534fig1highres.jpg" src="/files/ftp_upload/50534/50534fig1.jpg" data-altupdatedat="1787630408000" data-alt="Figure 1"> 
Figure 1. Call-to-needle-time. Comparison of acute ischemic stroke patients who received tissue-Plasminogen Activator (tPA). STEMO-treated patients (n=23) vs. in-hospital treated patients in 2010 (n=50). Boxes show standard deviation (SD) with the line representing the mean call-to-needle time (62 minutes vs. 98 minutes); whiskers indicate the distribution width within 2 x SD. Based on data from Weber et al.11 <a href="https://www.jove.com/files/ftp_upload/50534/50534fig1highres.jpg" target="_blank">Click here to view larger figure</a>.
<img alt="Stroke emergency response flowchart; process includes dispatch, examination, and hospital transfer." fo:content-width="5in" fo:src="/files/ftp_upload/50534/50534fig2highres.jpg" src="/files/ftp_upload/50534/50534fig2.jpg" data-altupdatedat="1787630408000" data-alt="Figure 2"> 
Figure 2. STEMO overall concept. Flow diagram of EMS response with main focus on stroke emergencies responded by STEMO. Modified according to an original design by Audebert, H.J. STEMO (Stroke-Einsatz-Mobil). <a href="http://tsb-berlin.de%20/media/uploads/zukunfsfonds/STEMO_(Stroke-Einsatz-Mobil).pdf" target="_blank">http://tsb-berlin.de /media/uploads/zukunfsfonds/STEMO_(Stroke-Einsatz-Mobil).pdf</a>. <a href="https://www.jove.com/files/ftp_upload/50534/50534fig2highres.jpg" target="_blank"> Click here to view larger figure</a>.

Identification of suspected stroke in the dispatch center of the Berlin Fire Brigade prompts the deployment of a CT-equipped ambulance. If ischemic stroke is confirmed and contraindications are excluded prehospital thrombolysis is applied.

In acute ischemic stroke, time from symptom onset to intervention is a decisive prognostic factor. In order to reduce this time, prehospital thrombolysis ...

The overall goal of pre-hospital thrombolysis is to improve the outcome of acute ischemic stroke patients. The effects of thrombolysis are time dependent. Every 15 minutes lost results in fewer patients being successfully treated to reduce the delays between symptom onset and thrombolysis.A previously developed and validated algorithm is used by a dispatch center. A pre-hospital stroke team is trained and a specialized ambulance. The demo is equipped with a computed tomography, scanner, and point-of-care laboratory.Ultimately, this pre-hospital concept results in faster and more frequent thrombolysis of acute ischemic stroke patients without increased risks. The main advantage of pre-hospital thrombolysis compared to routine thrombolysis in hospitals is that this time dependent treatment can be delivered earlier. This video shows the simulation of a stroke emergency responded to by a real pre-hospital stroke team.Using the STEAM O, a specialized ambulance equipped with a CT scanner and a point of care laboratory. An incoming medical emergency call presents as a stroke emergency. The dispatcher answers the call using daes and radios, the alarm to demo.The demo emergency response team receives the alert immediately grabs the facts, containing the detailed information and rushes to the demo vehicle after the critical status of the patient is assessed. Explore the patient's medical history. If a stroke is suspected clinically, assess the severity of the symptoms using the NIH stroke Scale.Determine the exact onset of symptoms and ask for current medication with a focus on anticoagulation therapy. At the same time, measure and log the patient's vital signs such as heart rate, blood pressure, blood sugar concentration, and oxygen saturation. Next, after disinfection place a peripheral venous catheter and take some blood samples.Now, determine the international normalized ratio. Apply the blood sample to the target area of the test strip in a few seconds. The ratio will display when interventions and advanced diagnostics are required.Immediately transfer the patient to the STEM via a stretcher and contact the on-call neuroradiologist to discuss the indication for CT scanning. To rule out in intercerebral bleeds, a CT scan is required when stroke is suspected. Thrombolysis is contraindicated in case of hemorrhagic stroke, and in case CT reveals other conditions associated with increased bleeding.In this demo, insert the vacutainer tubes into the lab and measure the standard set of blood parameters. Position the patients on the stretcher for CT scanning. Then start the CT scan.Taking the appropriate precautions, the radiology technician must be shielded and the other staff must leave the vehicle. The CT images are then transferred to the neuroradiologist on call, who will send back a written report after the CT scan. Ask the patient for contraindications against thrombolytic therapy using a standardized checklist.If neither this checklist nor the CT scan, reveal contraindications. Explain the benefits and possible risks of thrombolysis and obtained informed consent if possible. If in doubt, further expert opinion from an outside expert may be requested using onboard telemedicine equipment.First, calculate the dose of Alta Place based on the patient's estimated body weight. Next, prepare the Alta place for injection. Initiate the thrombolysis by administering 10%of the calculated total dose as a bolus injection over one minute.Record this time point, and be prepared to administer antiallergic drugs in case they are needed. Evacuate the air from an injection pump syringe and tubing and proceed with injecting the remaining dose of Alta Place. Over 60 minutes now, prepare your summary for handover at hospital arrival.Notify the ER of the closest hospital with a certified stroke unit of your impending arrival and while in transit, monitor the patient's neurological deficits and vital signs. En route. Print out and sign the admission letter containing the diagnosis.Patient history, neurological exam on-call, neuroradiologist report, lab results, and a description of actions taken. Also, copy the CT scan data to a CD for the hospital. During a three month pilot study in 2011, informed consent was given by 77 subjects treated in this demo.45 of these patients had an acute ischemic stroke and 23 received TPA. The meantime from emergency call to TPA administration was 36 minutes faster than that of a control cohort of 50 patients within hospital thrombolysis in Berlin during 2010. The pre-hospital thrombolysis concept assures that TPA can be given as soon as possible if the same precautions are taken as in the routine hospital thrombolysis, there's no additional risks with TPA delivered in sti.We may be able to treat many more patients within the so-called golden hour, yielding the highest treatment effects.

prehospital-thrombolysis-a-manual-from-berlin

Research

JoVE Journal

Medicine

Thromboembolic stroke models are vital tools for optimizing the recanalization therapy. Here we report a murine thrombotic stroke model based on transient cerebral hypoxic-ischemic (tHI) insult, which triggers thrombosis and infarction, and responds favorably to tissue plasminogen activator (tPA)-mediated fibrinolysis in a therapeutic window similar to those in stroke patients.

A Thrombotic Stroke Model Based On Transient Cerebral Hypoxia-ischemia

The RAPID blood processing method can be used in humans and yields higher peptide levels as well as allows for assessment of the correct molecular form. Therefore, this method will be a valuable tool in peptide research.

A RAPID Method for Blood Processing to Increase the Yield of Plasma Peptide Levels in Human Blood

Every min counts in acute stroke care. This guide shows how to establish a Stroke Team algorithm and enhance its performance with regular simulation training. The principles of Crew Resource Management (CRM) facilitate a straight workflow, reduce door-to-needle times and increase staff satisfaction.

Setting Up a Stroke Team Algorithm and Conducting Simulation-based Training in the Emergency Department - A Practical Guide

The outcome of patients with acute ischemic stroke depends on swift restoration of cerebral blood flow. This protocol aims at optimizing the management of such patients by minimizing peri-procedural timings and rendering the time from hospital admission to reperfusion as short as possible.

Optimized Management of Endovascular Treatment for Acute Ischemic Stroke

Traditional photothrombotic stroke (PTS) models mainly induce dense platelet aggregates of a high resistance to tissue plasminogen activator (tPA)-lytic treatment. Here a modified murine PTS model is introduced by co-injecting thrombin and photosensitive dye for photoactivation. The thrombin-enhanced PTS model produces mixed platelet:fibrin clots and is highly sensitive to tPA-thrombolysis.

A Fibrin-Enriched and tPA-Sensitive Photothrombotic Stroke Model

Histotripsy-aided lytic delivery or lysotripsy is under development for the treatment of deep vein thrombosis. An in vitro procedure is presented here to assess the efficacy of this combination therapy. Key protocols for the clot model, image guidance, and assessment of treatment efficacy are discussed.

An In vitro System to Gauge the Thrombolytic Efficacy of Histotripsy and a Lytic Drug

In-vitro thrombolysis assays have often struggled to replicate in-vivo conditions whether in the model thrombus being digested or in the environment in which thrombolysis is occurring. Herein, we explore how coupling the Chandler loop and Real-Time Fluorometric Flowing Fibrinolysis Assay (RT-FluFF) is used for high-fidelity, ex-vivo, clot lysis monitoring.

Tracking Fibrinolysis of Chandler Loop-Formed Whole Blood Clots Under Shear Flow in An In-Vitro Thrombolysis Model

To simulate thromboembolic stroke, emboli prepared from heterologous rat blood were injected into the middle cerebral artery, followed by administration of systemic thrombolysis for recanalization. This version of the model is optimized for use in a multi-laboratory network and supports testing multiple candidate therapeutics.

The Stroke Preclinical Assessment Network Multi-Laboratory Model of Thromboembolic Stroke with Thrombolysis: TE-MCAo

This protocol describes the Nijmegen Hemostasis Assay, which enables simultaneous, time-resolved measurement of thrombin and plasmin generation to provide an integrated assessment of coagulation and fibrinolysis. The assay aims to improve characterization of hemostatic balance in research and clinical settings beyond the scope of conventional hemostatic tests.

The Nijmegen Hemostasis Assay: Simultaneous Fluorogenic Measurement of Thrombin and Plasmin Generation in a Single Well

Survivors of acute respiratory distress syndrome (ARDS) and critical illness frequently develop long-lasting muscle weakness. Manual muscle testing (MMT) is a standardized clinical examination commonly used to measure strength of peripheral skeletal muscle groups.  This video demonstrates MMT using the 6-point  Medical Research Council scale.

Manual Muscle Testing:  A Method of Measuring Extremity Muscle Strength Applied to Critically Ill Patients 

Learn pre-hospital thrombolysis for acute ischemic stroke using a mobile stroke unit equipped with CT scanner and point-of-care laboratory. This protocol reduces treatment time by 36 minutes and enables earlier intervention.

Prehospital Thrombolysis: A Manual from Berlin

Explore More Videos