Paramedics may effectively be the first line of treatment in patients with stroke and also can be partners in bringing research into a prehospital setting. This finding in the Feb. 5 issue of the New England Journal of Medicine tempers the result that the treatment used, magnesium sulfate, did not improve outcomes over placebo.
Utilizing a network of 315 paramedic-staffed ambulances and 60 receiving hospitals in Los Angeles and Orange counties in California, Jeffrey L. Saver, MD, of the Comprehensive Stroke Center in Los Angeles, and colleagues in the Field Administration of Stroke Therapy–Magnesium (FAST-MAG) trial enrolled 1,700 patients. Patients were randomized by being provided with one study kit at a time containing a preloaded bolus for intravenous administration. The bolus was either magnesium sulfate or a placebo. Magnesium sulfate was intended to provide cerebroprotection when provided as part of early treatment.
Using an eight-item, modified version of the Los Angeles Prehospital Stroke Screen, paramedics identified eligible patients in one to two minutes. Patient condition was further assessed by cell phone call to an associated physician. Paramedics acquired explicit written informed consent from patients (59.8 percent) or their representatives (38.9 percent) en route in most cases. The cell phone call between the physician, paramedic and patient or patient representative reduced the proportion of patients enrolled with stroke mimicking conditions to 3.9 percent, they found.
As a result, 74.3 percent of patients received treatment in the first 60 minutes after symptom onset, while 24.7 percent were treated within two hours.
While magnesium sulfate offered no shift in 90-day disability outcomes, rate of death, neurological deficit, good or excellent recovery or functional dependence from the placebo, Saver et al reported success at early treatment delivery, especially within the first “golden hour” after symptom onset.
“The trial succeeded in its goal of devising a means to deliver promising drugs to stroke patients in the first minutes, when there's the greatest amount of brain to save. We have opened a new therapeutic window that is now being used to test other compounds and deliver clot-busting drugs to patients in the field,” Saver said in a press release.