Background and Purpose: The purpose of this study was to assess factors causing delay in treatment of acute stroke in a tertiary care institute in South India. Methods: All clinically suspected cases of acute stroke presenting to the emergency department over a period of 1 year were prospectively followed up and data collected as per a preset pro forma. The various time intervals from stroke onset to definitive management and other pertinent data were collected. The time delays have been evaluated in the decision tree model: Chi-squared Automatic Interaction Detection. Significance was assessed at 5% level of significance (P < 0.05). Results: The mean prehospital time delay for all clinically suspected stroke (n = 361) in our institute was 716 min and the median time 190 min. The mean total in-hospital delay was 94.17 ± 54.5 min and median time being 82 min. The onset of symptoms to first medical contact was the main interval that influenced the prehospital delay. Computed tomographic (CT) diagnosis to stroke unit admission influenced the in-hospital delay the most. Conclusions: Lack of awareness regarding stroke leads to delayed seeking of treatment for the same. The factors that contribute to the in-hospital delay included patient admission procedure delay, lack of staff to transport the patient, and the distance between the stroke unit and CT room. Educating the community with regard to “stroke” and implementation of a better pre- and in-hospital stroke care system is a need of the hour in the country.

Evidence-based prehospital stroke care is effective in reducing stroke-related mortality and morbidity. The crucial period from symptom awareness to presentation at the hospital, the first step in the World Stroke Organization Road Map to Quality Care, is under-resourced in the majority of low- and middle-income countries (LMICs). Key challenges focus on a lack of stroke action awareness as well as human resources trained in stroke care. We aimed to identify prehospital stroke practices in LMICs and identify where innovation may address service gaps. We conducted scoping reviews focused on key domains of prehospital stroke care in LMICs that include organization of services, stroke action awareness in the community, educating primary care physicians and traditional/faith healers, diagnostic tools for prehospital stroke detection, and emergency medical service (EMS) provision. We sought to determine current practices and gaps in LMICs and evidence on effective interventions to address gaps in each domain. Recommendations are provided identifying priority considerations in each domain, based on evidence, and where lacking, expert opinion. Key recommendations include the need for adequately funded national-level strategies for prehospital stroke care; stroke action awareness education for the public, primary care physicians, community health workers, EMSs, and traditional and faith healers; affordable imaging solutions; and approaches to create or improve prehospital EMS (e.g., protocols). We found that efforts, although few, have been made to address gaps in LMICs; however, they have rarely been evaluated, and it is unclear if they are sustained. The required elements necessary to improve prehospital services and stroke outcomes are known. Creativity is and perseverance are required for implementation to ensure sustainability. This scientific statement has been reviewed and approved by the World Stroke Organization Executive.

Background: Only a small percentage of patients with acute stroke are currently eligible for thrombolysis, partly due to severe delays in hospital arrival. We had previously conducted the first regional study to assess the factors delaying acute stroke care in India. The present study aims to understand and describe in depth the variables associated with prehospital delay among patients admitted with an acute ischemic stroke. Methods: Data were prospectively collected by conducting an in-depth interview of 470 acute ischemic stroke patients and their bystanders, aged above 18 years, presenting to the Department of Emergency Medicine, Jubilee Mission Medical College and Research Institute, Thrissur. Patients who arrived within 4.5 h of symptom onset were considered as “early arrival” and those who arrived after 4.5 h were considered as “delayed arrival.” Univariate and multivariate analyses were undertaken to determine associations between variables of interest and delays to hospital presentation. Results: Of the 470 patients who met the inclusion criteria, 73 patients reached within 4.5 h (15.5%), whereas 397 patients arrived after 4.5 h. The mean age of acute stroke patients who reached within 4.5 h was 63 ± 13.7 years, whereas the mean age of those who reached after 4.5 h was 63 ± 12.1 years. Binary logistic regression performed to quantify the associations of prehospital factors showed an increased risk of prehospital delay among individuals with lack of awareness (odds ratio [OR] = 5.16 [3.040–8.757], P < 0.001), followed by those for whom a vehicle was not available at the site of event (OR = 3.745 [1.864–7.522], P < 0.001). Within the predefined socioeconomic strata, compared to lower class, upper middle class had less risk (OR = 0.135 [0.018–1.035], P = 0.054), whereas the distance from first medical contact to emergency department contributed moderate risk (OR = 1.071 [1.028–1.116], P < 0.001) for prehospital delay. Conclusions: Health promotion techniques that increase public knowledge about the early signs of stroke, transferring patients directly to hospitals with thrombolysis capabilities, and making ambulance services more widely available are appropriate measures to reduce prehospital delay.

N optic absorbance assay that can be used as a global clotting test. In this study, the objective was to assess the changes in CWA and to compare CWA to WBCT and aPTT in patients with Russell's viper envenomation. Methods: The datum was collected prospectively over 2 months as a pilot observational study in a tertiary care center. All proven cases of Russell's viper-envenomated individuals with preliminary CWA data and WBCT were included in the study. The clot wave (CW) of the five individuals, which met all the stringent inclusion criteria, was analyzed and interpreted. Results: CW absorbance sigmoid waveform was deranged in all 5 cases, of which 4 showed a change in CWA even before an abnormal aPTT. Three of the 5 had a normal WBCT but showed early changes in CWA. Atypical biphasic waveform reported in disseminated intravascular coagulation in other prior studies is seen in venom-induced consumptive coagulopathy also. In all patients where a second derivative was plotted, the second (lower) phase of the second derivative showed a slow rise to baseline. Conclusion: CWA showed changes which provided information earlier than the conventional coagulation studies in the snakebite victims studied. While aPTT or WBCT reflects clotting time, CWA conveys the dynamic process of clot formation and stabilization. CWA may reveal disorders of clotting in snakebite victims before the conventional tests become abnormal. Future research should assess the speed and accuracy of the test in diagnosing hemotoxic envenomation and its potential role in guiding antivenom therapy....

Introduction: Prehospital capabilities are inadequately developed to meet the growing needs for emergency care in most low- and middle-income countries. This study aims to describe the prehospital care received by the road traffic injury (RTI) victims presenting to a level I Trauma Care Center in Central Kerala, India. Methods: This was a hospital-based prospective observational study, which included consecutive victims of RTI attending the emergency department within 24-h of the event. A structured interview schedule was developed for collecting the data on various domains and the patients were followed up for their duration of hospital stay. Results: A total of 920 RTI victims, were included in this study. Two percent (17/920) of first responders had some sort of training in trauma care whereas the rest were untrained. The time taken to get any help at the scene after an RTI was 8 ± 12.9 min (95% confidence interval [CI] 7.16–8.84) and for first medical contact 25 ± 16 min (95% CI 24–26). No attempt at field stabilization occurred in any case. Three percent (26/920) had received some form of prehospital care, like arrest of hemorrhage using a compression bandage and splinting of the fractured limb with a wooden plank. None of the patients received supplemental oxygen, airway management, or cervical spine immobilization at the site of the accident or en route to the hospital. Conclusion: A lack of an organized prehospital care system results in minimal care before hospital admission. Urgent establishment of ambulance services and structured prehospital care tailored to our health-care system is imperative.