뇌졸중은 내과적 혹은 경우에 따라서는 외과적 응급질환이다. 여러 임상연구에서 뇌졸중 환자의 초기 대응은 응급의료서비스(119)를 이용한 경우가 증상 발생 후 병원 도착까지의 시간을 단축시키고 혈전 용해 치료율을 높였다. 또한 뇌졸중의 적절한 치료를 위해서는 응급의료서비스 종사자들에 대한교육과체계화된 환자관리가 필요하다.

근거

뇌졸중 환자의 초기 대응은 응급의료서비스/9-1-1 (EMS/911)을 이용한 경우가 증상발생 후 병원도착까지의시간 뿐만아니라 초기이학적 검사, CT 촬영및 신경학적 검진까지 소요되는시간을 모두 단축시켰다.^1-3 또한 뇌졸중의 판별 및 치료에 대한 교육을 응급의료서비스팀, 병원 및 지역사회 일반의를 대상으로 실시한 경우가 그렇지 않은 지역보다 초기 혈전용해 치료율이 더 높았으며(8.65% vs.2.21%), 특히 혈전용해술(rt-PA) 치료 대상군내에서는 월등히 높은(52% vs. 14%) 치료 결과를 보였다.⁴ 또한 중학생 및 그 가족을 대상으로 한 임상실험에서도 뇌졸중 급성기 대처방안에 대한 교육을 받은 경우가 받지 않은 대조군에 비해 응급의료서비스 활용 및 뇌졸중의 초기 대응에서 의미있는 차이를 보였다.⁵ 응급의료서비스팀을 통해 뇌졸중 환자가 적절한 치료를 받을 수 있는 병원으로 빠르게 이송 되는 것이 바람직하다.^6,7 응급의료서비스팀이 뇌졸중 환자를 빨리 파악하여 필요한 조치를 취할 수 있도록 병원 전단계에서 사용 가능한 뇌졸중 판별척도(Table 2) ^8,9 가 개발되었다.

Table 2. Prehospital stroke identification instruments

1. Activation of the 9-1-1 system by patients or other members of the public is strongly supported because it speeds treatment of stroke (AHA/ASA, EUSI, SIGN: LOE III, GOR B). Dispatchers should make stroke a priority dispatch.

2. To increase the number of patients who can be seen and treated within the first few hours after stroke, educational programs to increase public awareness of stroke are recommended (AHA/ASA EUSI, SIGN: LOE Ib, GOR A).

3. To increase the number of patients who are treated, educational programs for physicians, hospital personnel, and EMS personnel also are recommended (AHA/ASA, EUSI, SIGN: LOE III, GOR B).

4. Brief assessments by EMS personnel as outlined in Tables 1 are recommended (AHA/ASA, EUSI, SIGN: LOE III, GOR B).

5. The use of a stroke identification algorithm such as Los Angeles or Cincinnati screens is encouraged (AHA/ASA EUSI, SIGN: LOE III, GOR B).

6. The panel recommends that EMS personnel begin the initial management of stroke in the field, as outlined in Table 1 (AHA/ASA EUSI, SIGN: LOE III, GOR B). The development of stroke protocols to be used by EMS personnel is strongly encouraged.

7. Patients should be transported rapidly for evaluation and treatment to the closest institution that provides emergency stroke care (AHA/ASA EUSI: LOE I, GOR A) (SIGN: LOE III, GOR B). In some instances, this may involve air evacuation. EMS personnel should notify the receiving ED so that the appropriate resources may be mobilized.

Table 1. Guidelines for EMS management of patients with suspected stroke

1. 뇌졸중 환자 후송시 1-1-9/응급의료서비스를 활용하는 것이 권장된다. (근거수준III, 권고수준B)

2. 응급의료 서비스팀은 뇌졸중 환자를 최단시간 내에 뇌졸중에 대한 적정 진료가 가능한 병원으로 이송한다. (권고수준GPP)

1. Barsan WG, Brott TG, Broderick JP, et al. Time of hospital presentation in patients with acute stroke. Arch Intern Med. 1993;153:2558-2561.

2. Morris DL, Rosamond W, Madden K, et al. Prehospital and emergency department delays after acute stroke: The genentech stroke presentation survey.Stroke. 2000;31:2585-2590.

3. Lacy CR, Suh DC, Bueno M, et al. Delay in presentation and evaluation for acute stroke: Stroke time registry for outcomes knowledge and epidemiology (S.T.R.O.K.E.). Stroke. 2001;32:63-69.

4. Morgenstern LB, Staub L, Chan W, et al. Improving delivery of acute stroke therapy: The TLL temple foundation stroke project.Stroke. 2002;33:160-166.

5. Morgenstern LB, Gonzales NR, Maddox KE, et al. A randomized, controlled trial to teach middle school children to recognize stroke and call 911: The kids identifying and defeating stroke project. Stroke. 2007;38:2972-2978.

6. Morgenstern LB, Bartholomew LK, Grotta JC, et al. Sustained benefit of a community and professional intervention to increase acute stroke therapy. Arch Intern Med. 2003;163:2198-2202.

7. Alberts MJ, Hademenos G, Latchaw RE, et al. Recommendations for the establishment of primary stroke centers. Brain attack coalition. JAMA. 2000;283:3102-3109.

8. Kidwell CS, Starkman S, Eckstein M, Weems K, Saver JL. Identifying stroke in the field: prospective validation of the Los Angeles Prehospital Stroke Screen (LAPSS). Stroke. 2000;31:71-76.

9. Kothari RU, Pancioli A, Liu T, Brott T, Broderick J. Cincinnati Prehospital Stroke Scale: reproducibility and validity. Ann Emerg Med. 1999;33:373-378.