Neues in der prähospitalen Schlaganfallversorgung

Zusammenfassung

Nach Etablierung der systemischen Thrombolyse in der Akutversorgung des ischämischen Schlaganfalls konzentrieren sich die Bemühungen zunehmend auf eine Verkürzung der Latenz bis zum Therapiebeginn. Während Patienten-bezogene Verzögerungsfaktoren bisher allenfalls moderat und kurzfristig durch entsprechende Aufklärungsmaßnahmen reduziert werden konnten, ergeben sich sowohl für die prähospitale Rettungsdienstversorgung als auch die initiale Versorgung im Krankenhaus zahlreiche Ansatzmöglichkeiten um die Zeit bis zum Beginn der Thrombolyse weiter zu verkürzen. Verschiedene Diagnosealgorithmen sollen der Einsatzzentrale helfen, umgehend auf einen Notruf mit Schilderung von möglichen Schlaganfallsymptomen zu reagieren. Die Aufgabe der Rettungskräfte ist dann nach Sicherung der Vitalfunktionen in erster Linie die unverzügliche Zuweisung in eine Stroke Unit, wobei eine telefonische Vorankündigung mit Angabe der Symptome und Vormedikation dort die Reaktionszeit verkürzen kann. Die sogenannte Door-to-Needle-Zeit im Krankenhaus kann dann durch weitere einfache Maßnahmen auf Latenzen deutlich unter 1 h gesenkt werden. Der Einsatz von Labordiagnostik, Schnittbildgebung oder Ultraschall bereits im Rettungswagen zur Indikationsstellung einer systemischen Lysetherapie ist derzeit Gegenstand mehrerer Studien. In 2 Projekten mit einem Computer­tomografen im Rettungswagen konnte so bereits eine deutliche Verkürzung der Latenz bis zum Beginn der Lysetherapie nachgewiesen werden. Vor einer Übernahme in die Regelversorgung in Ballungsräumen oder ländlichen Gegenden ist jedoch eine gesundheitsökonomische Analyse der erzielbaren klinischen Effekte erforderlich.

Abstract

Following systemic thrombolysis in acute ischemic stroke, efforts must be directed to reducing delay between symptom onset and start of thrombolysis. While patient-related delays in the past could at best be improved only modestly and for a limited time by educational campaigns, there are multiple ways to shorten delays in pre-hospital patient management as well as during early hospital care. Various diagnostic algorithms can support dispatch services to quickly react to an emergency call with suspected stroke symptoms. After securing the vital functions, emergency (para)medical personnel should immediately transfer a suspected stroke patient to the nearest stroke unit. In-advance information to the hospital team about symptoms and previous medication can further shorten the admission process. The door-to-needle time can thus be reduced to less than an hour by relatively simple measures. Studies are currently investigating the potential benefit of laboratory diagnostics, cerebral imaging or transcranial ultrasound before or during transfer. Two projects with a CT built into an ambulance car have already demonstrated a markedly reduced delay between symptom onset and systemic thrombolysis. However, an economic analysis of clinical benefits is needed before this concept can be adapted to metropolitan or rural regions.

Schlüsselwörter

Schlaganfall - prähospitale Versorgung - Thrombolyse - Zuverlegungstriage - Hirninfarkt

Keywords

stroke - prehospital management - thrombolysis - referral strategy - cerebral infarction

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