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Easy Stroke Scoring Tool Helps EMS Get Patients the Right Care
Los Angeles Motor Scale deemed "powerful out-of-hospital tool" for prediction of intervention, outcomes
DENVER -- The Los Angeles Motor Scale (LAMS)
can give emergency medical services (EMS) a streamlined way to identify
large vessel occlusions in the field, and correlate the score to
hospital interventions for acute stroke, a researcher said here.
From January 2016 to March 2019, the Polk County Fire Rescue in Bartow, Florida, picked up 2,374 suspected stroke patients, and scored them on LAMS: 19% had a LAMS 0; 14% had LAMS 1; 13% had LAMS 2; 17% had a LAMS 3; 16% had LAMS 4, and 21% had LAMS 5, explained Tej Stead, a student at Brown University in Providence, Rhode Island, in a presentation at the American College of Emergency Physicians (ACEP) annual meeting.
LAMS
assesses facial droop, arm drift, and grip strength with scores ranging
from 0-5. For the study, patients were split into two groups of high
LAMS (4-5) or low LAMS (0-3).
If a patients had a high LAMS there was a 3.61 relative risk they would require mechanical intervention, Stead reported, along with a 3.15 relative risk of in-hospital death; a 2.11 relative risk they would require CT perfusion imaging; 2.07 relative risk they would receive tissue plasminogen activator (tPA); a 1.45 relative risk of a diagnosis of ischemic stroke; and a 1.36 relative risk of not being discharged home (P<.001 for all).
He noted that, among all patients with appropriate data, 49% were discharged to their homes; 19% were discharged to nursing facilities; 13% were discharged to rehabilitation, and 7% died.
"We like the KISS method -- 'Keep it simple, stupid,'" Stead said, adding that the three-item LAMS can be easily taught to emergency medical technicians (EMT), and is "easy for them to perform in the field."
"We can't just send everyone to a comprehensive stroke center because they are often further away," Stead stated. "We don't want to delay treatment for no reason, and we don't want to overwhelm the comprehensive stroke centers with patients who could be easily treated with tPA at a community hospital."
For
the study, Stead and colleagues worked with eight receiving hospitals
to provide discharge outcomes on all patients transported to a given
hospital for stroke, as well as data on demographics, NIH Stroke Scale
(NIHSS) at hospital arrival and discharge, hospital length of stay, and
the ultimate disposition of the patient. EMTs administered the LAMS
prior to hospital arrival.
Patients in the study had a median age of 71.5. The cohort was 52% female. The median scene time was 15 minutes.
The median NIHSS at hospital arrival was 6. The median NIHSS for low LAMS was 4 versus 13 for high LAMS. The authors used the Wilcoxon's rank-sum test, and found that the high LAMS group had a significantly higher NIHSS (P<0.0001).
The median hospital length of stay for low LAMS was 3 days versus 5 days for high LAMS. The high LAMS group had a significantly longer hospital stay (P<0.0001).
"There was no significant association between LAMS score and age, sex, or EMS Rankin score," Stead's group reported.
Joseph Piktel, MD, of Case Western Reserve University/MetroHealth in Cleveland, told MedPage Today,
"This was an excellent presentation by probably the youngest presenter
at this meeting. There have been other studies that have looked at LAMS
as well, and based on these studies and this one presented here, I would
be comfortable enough to use LAMS to determine which facility a patient
should be sent."
While Piktel suggested that LAMS is not perfect, "If you have a large city where you can get to hospitals in a reasonable amount of time, I think it would be of benefit to take a patient directly to a comprehensive stroke center. I think the LAMS can do that."
Piktel served as co-chair of the ACEP Research Forum that selected the study by Stead's group for presentation. He explained that during the selection process, abstracts were de-identified so the committee was unaware that the study was led by an incoming college freshman. Study co-authors were Latha Ganti, MD, MBA, of the University of Central Florida in Orlando, and Paul Banerjee, DO, of Polk County Fire Rescue.
From January 2016 to March 2019, the Polk County Fire Rescue in Bartow, Florida, picked up 2,374 suspected stroke patients, and scored them on LAMS: 19% had a LAMS 0; 14% had LAMS 1; 13% had LAMS 2; 17% had a LAMS 3; 16% had LAMS 4, and 21% had LAMS 5, explained Tej Stead, a student at Brown University in Providence, Rhode Island, in a presentation at the American College of Emergency Physicians (ACEP) annual meeting.
If a patients had a high LAMS there was a 3.61 relative risk they would require mechanical intervention, Stead reported, along with a 3.15 relative risk of in-hospital death; a 2.11 relative risk they would require CT perfusion imaging; 2.07 relative risk they would receive tissue plasminogen activator (tPA); a 1.45 relative risk of a diagnosis of ischemic stroke; and a 1.36 relative risk of not being discharged home (P<.001 for all).
He noted that, among all patients with appropriate data, 49% were discharged to their homes; 19% were discharged to nursing facilities; 13% were discharged to rehabilitation, and 7% died.
"We like the KISS method -- 'Keep it simple, stupid,'" Stead said, adding that the three-item LAMS can be easily taught to emergency medical technicians (EMT), and is "easy for them to perform in the field."
"We can't just send everyone to a comprehensive stroke center because they are often further away," Stead stated. "We don't want to delay treatment for no reason, and we don't want to overwhelm the comprehensive stroke centers with patients who could be easily treated with tPA at a community hospital."
Patients in the study had a median age of 71.5. The cohort was 52% female. The median scene time was 15 minutes.
The median NIHSS at hospital arrival was 6. The median NIHSS for low LAMS was 4 versus 13 for high LAMS. The authors used the Wilcoxon's rank-sum test, and found that the high LAMS group had a significantly higher NIHSS (P<0.0001).
The median hospital length of stay for low LAMS was 3 days versus 5 days for high LAMS. The high LAMS group had a significantly longer hospital stay (P<0.0001).
"There was no significant association between LAMS score and age, sex, or EMS Rankin score," Stead's group reported.
"The
LAMS is a powerful out-of-hospital tool for prediction of intervention
and neurological outcomes after acute stroke," they concluded.
While Piktel suggested that LAMS is not perfect, "If you have a large city where you can get to hospitals in a reasonable amount of time, I think it would be of benefit to take a patient directly to a comprehensive stroke center. I think the LAMS can do that."
Piktel served as co-chair of the ACEP Research Forum that selected the study by Stead's group for presentation. He explained that during the selection process, abstracts were de-identified so the committee was unaware that the study was led by an incoming college freshman. Study co-authors were Latha Ganti, MD, MBA, of the University of Central Florida in Orlando, and Paul Banerjee, DO, of Polk County Fire Rescue.
Stead and Piktel disclosed no relevant relationships with industry.
Primary Source
American College of Emergency Physicians
Source Reference: Stead T, et al "A High Los Angeles Motor Scale Score is an Effective Tool for Triaging Stroke Patients in the Out-of-Hospital Setting" ACEP 2019; Abstract 3.
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