Performance of far forward iceless blood storage containers in controlled cold environments.

BACKGROUND: The Golden Hour Box (GHB), an iceless blood container designed for transfusion closest to the point of injury, is used by military medical teams in remote damage control resuscitation. While its performance is well-established in hot environments, it remains underexplored in cold conditions, a significant consideration in emerging global conflict zones. STUDY DESIGN AND METHODS: Four GHBs were preconditioned at +4°C or +18°C for 8 h and subsequently exposed to controlled laboratory simulated temperatures of -5, -15, and -25°C for 100 h. The study focused on their capability to maintain an internal temperature between +2 and +6°C, the recommended range for red blood cells unit storage and transport, using calibrated sensors for precise monitoring. RESULTS: When exposed to negative Celsius temperatures, GHBs showed varied performance depending on preconditioning temperatures. When preconditioned at +4°C, GHBs maintained an internal temperature within the target range (+2 to +6°C) for 100 h at -5°C, 52 ± 1 h at -15°C, and 29 ± 4 h at -25°C. In contrast, the internal temperature of GHBs preconditioned at +18°C exceeded this range in less than 30 min, then dropped below 2°C more rapidly than those preconditioned at +4°C, occurring within 20 ± 2 h at -15 and 13 ± 1 h at -25°C. CONCLUSION: The GHB, when properly preconditioned, effectively maintains internal temperatures suitable for blood product transport in extreme cold. Future research, including analyses of blood performances, is still needed to validate these results in more realistic operational conditions for use in cold environments.

The prehospital NEW score to assess septic shock in-hospital, 30-day and 90-day mortality.

BACKGROUND: The early identification of sepsis presenting a high risk of deterioration is a daily challenge to optimise patient pathway. This is all the most crucial in the prehospital setting to optimize triage and admission into the appropriate unit: emergency department (ED) or intensive care unit (ICU). We report the association between the prehospital National Early Warning Score 2 (NEWS-2) and in-hospital, 30 and 90-day mortality of SS patients cared for in the pre-hospital setting by a mobile ICU (MICU). METHODS: Septic shock (SS) patients cared for by a MICU between 2016, April 6th and 2021 December 31st were included in this retrospective cohort study. The NEWS-2 is based on 6 physiological variables (blood pressure, heart rate, respiratory rate, temperature, oxygen saturation prior oxygen supplementation, and level of consciousness) and ranges from 0 to 20. The Inverse Probability Treatment Weighting (IPTW) propensity method was applied to assess the association with in-hospital, 30 and 90-day mortality. A NEWS-2 ≥ 7 threshold was chosen for increased clinical deterioration risk definition and usefulness in clinical practice based on previous reports. RESULTS: Data from 530 SS patients requiring MICU intervention in the pre-hospital setting were analysed. The mean age was 69 ± 15 years and presumed origin of sepsis was pulmonary (43%), digestive (25%) or urinary (17%) infection. In-hospital mortality rate was 33%, 30 and 90-day mortality were respectively 31% and 35%. A prehospital NEWS-2 ≥ 7 is associated with an increase in-hospital, 30 and 90-day mortality with respective RRa = 2.34 [1.39-3.95], 2.08 [1.33-3.25] and 2.22 [1.38-3.59]. Calibration statistic values for in-hospital mortality, 30-day and 90-day mortality were 0.54; 0.55 and 0.53 respectively. CONCLUSION: A prehospital NEWS-2 ≥ 7 is associated with an increase in in-hospital, 30 and 90-day mortality of septic shock patients cared for by a MICU in the prehospital setting. Prospective studies are needed to confirm the usefulness of NEWS-2 to improve the prehospital triage and orientation to the adequate facility of sepsis.

FIRECARE: An Evidence-Based Prevention Program to Reduce Burnout among Prehospital Caregivers: Benefits of a Combined Mindfulness, Heart Coherence Training, and Positive Psychology Intervention.

BACKGROUND: Burnout among emergency health care professionals is well-described, especially during the COVID-19 pandemic. Prevention interventions, such as mindfulness, focus on the management of stress. OBJECTIVE: To evaluate the effects of the FIRECARE program (a mindfulness intervention, supplemented by heart coherence training and positive psychology workshops) on burnout, secondary stress, compassion fatigue, and mindfulness among advanced life support ambulance staff of the Paris Fire Brigade. MATERIALS AND METHODS: We used a non-randomized, two-group quasi-experimental study design with a waitlist control and before-and-after measurements in each group. The intervention consisted of six, once-weekly, 2.5-h sessions that included individual daily meditation and cardiac coherence practice. The study compared intervention and waitlist control groups, and investigated baseline, post-program, and 3-month follow-up change on burnout (measuring using the ProQOL-5 scale) and mindfulness (measuring using the FMI scores). Baseline burnout (measured using the ProQOL-5) was evaluated and used in the analysis. RESULTS: Seventy-four 74 participants volunteered to participate; 66 were included in the final analysis. Of these, 60% were classified as suffering from moderate burnout, the 'burnout cluster'. A comparison of intervention and waitlist control groups found a decrease in the burnout score in the burnout cluster (p = 0.0003; partial eta squared = 0.18). However, while secondary stress fell among the burnout cluster, it was only for participants in the intervention group; scores increased for those in the waitlist group (p = 0.003; partial eta squared = 0.12). The pre-post-intervention analysis of both groups also showed that burnout fell in the burnout cluster (p = 0.006; partial eta squared = 0.11). At 3-month follow-up, the burnout score was significantly reduced in the intervention group (p = 0.02; partial eta squared = 0.07), and both the acceptance (p = 0.007) and mindfulness scores (p = 0.05; partial eta squared = 0.05) were increased in the baseline burnout cluster. CONCLUSION: FIRECARE may be a useful approach to preventing and reducing burnout among prehospital caregivers.

Influence of antibiotic therapy with hemodynamic optimization on 30-day mortality among septic shock patients cared for in the prehospital setting.

BACKGROUND: In order to reduce septic shock mortality, international guidelines recommend early treatment implementation, antibiotic therapy (ABT) and hemodynamic optimisation, within 1-h. This retrospective multicentric study aims to investigate the relationship between prehospital ABT delivered within 1st hour and mean blood pressure (MAP) ≥ 65 mmHg at the end of the prehospital stage, and 30-day mortality among patients with septic shock. METHODS: From May 2016 to December 2021, patients with septic shock requiring pre-hospital Mobile Intensive Care Unit intervention (MICU) were retrospectively analysed. To assess the relationship between 30-day mortality and prehospital ABT delivered within 1st hour and/or MAP ≥ 65 mmHg at the end of the prehospital stage, Inverse Probability Treatment Weighting (IPTW) propensity score method was performed. RESULTS: Among the 530 patients included, 341 were male gender (64%) with a mean age of 69 ± 15 years. One-hundred and thirty-two patients (25%) patients received prehospital ABT, among which 98 patients (74%) were treated with 3rd generation cephalosporin. Suspected pulmonary, urinary and digestive infections were the cause of sepsis in respectively 43%, 25% and 17%. The 30-day overall mortality was 31%. A significant association was observed between 30-day mortality rate and (i) ABT administration within the first hour: RRa = 0.14 [0.04-0.55], (ii) ABT administration within the first hour associated with a MAP ≥ 65 mmHg: RRa = 0.08 [0.02-0.37] and (iii) ABT administration within the first hour in the prehospital setting associated with a MAP < 65 mmHg at the end of the prehospital stage: RRa = 0.75 [0.45-0.85]. Patients who received prehospital ABT after the first hour have also a 30-day mortality rate decrease: RRa = 0.87 [0.57-0.99], whereas patients who did not received ABT had an increased 30-day mortality rate: RRa = 2.36 [1.89-2.95]. CONCLUSION: In this study, we showed that pre-hospital ABT within the first hour and MAP≥65 mmHg at the end of prehospital stage are both associated with 30-day mortality decrease among patients suffering from septic shock cared for by a MICU. Further prospective studies are needed to confirm these preliminary results.

RELATIONSHIP BETWEEN SHOCK INDEX, MODIFIED SHOCK INDEX, AND AGE SHOCK INDEX AND 28-DAY MORTALITY AMONG PATIENTS WITH PREHOSPITAL SEPTIC SHOCK.

BACKGROUND: A relative hypovolemia occurs during septic shock (SS); the early phase is clinically reflected by tachycardia and low blood pressure. In the prehospital setting, simple objective tools to assess hypovolemia severity are needed to optimize triaging. OBJECTIVE: The aim of this study was to evaluate the relationship between shock index (SI), diastolic SI (DSI), modified SI (MSI), and age SI (ASI) and 28-day mortality of patients with SS initially cared for in a prehospital setting of a mobile intensive care unit (MICU). METHODS: From April 6, 2016 through December 31, 2021, 530 patients with SS cared for at a prehospital MICU were analyzed retrospectively. Initial SI, MSI, DSI, and ASI values, that is, first measurement after MICU arrival to the scene were calculated. A propensity score analysis with inverse probability of treatment weighting (IPTW) method was used to assess the relationship between SI, DSI, MSI, and ASI and 28-day mortality. RESULTS: SS resulted mainly from pulmonary, digestive, and urinary infections in 44%, 25%, and 17% of patients. The 28-day overall mortality was 31%. IPTW propensity score analysis indicated a significant relationship between 28-day mortality and SI (adjusted odds ratio [aOR] 1.13; 95% CI 1.01-1.26; p = 0.04), DSI (aOR 1.16; 95% CI 1.06-1.34; p = 0.03), MSI (aOR 1.03; 95% CI 1.01-1.17; p = 0.03), and ASI (aOR 3.62; 95% CI 2.63-5.38; p < 10-6). CONCLUSIONS: SI, DSI, MSI, and ASI were significantly associated with 28-day mortality among patients with SS cared for at a prehospital MICU. Further studies are needed to confirm the usefulness of SI and SI derivates for prehospital SS optimal triaging.

Mobile blood depots in ground ambulances in compliance with French legislation: A feasibility study.

BACKGROUND: Prehospital transfusion is a way of improving the management of hemorrhagic shock. In France, prehospital transfusion is struggling to develop, both because of logistical difficulties and particularly restrictive legislation. To comply with this, we propose to store the blood products (BPs) in ground ambulances with refrigerated boxes allowing remote continuous monitoring of storage conditions, called "NelumBox" (Tec4med Lifescience GmbH). To open them, the ambulance's team needs a code that is only given by the Transfusion Center if the request meets all required regulatory criteria. STUDY DESIGN AND METHODS: We conducted a prospective simulation-based feasibility study using dummy BPs. Two ambulances were equipped. Simulations were triggered unexpectedly, including during on-call hours. The ability to quickly access the BPs was the main judgment criterion. The quality of hemovigilance during these simulations was also examined. RESULTS: Twenty-two simulations were performed. The ambulance's team was able to access the BPs in 100% of cases. The average waiting time for receiving the unlocking code was 5 min 27 s (SD = 2 min 12 s, MAX = 12 min 00 s). The transfusion traceability was compliant with regulations in 100% of cases. The transfusion center was able to remotely monitor BPs storage conditions for the entire duration of their stockage in the NelumBox. DISCUSSION: The present procedure is efficient, repeatable, and fast. It guarantees a strict transfusion safety without slowdown a severe trauma management, while complying with French regulations.

Use of prehospital transfusion by French emergency medical services: A national survey.

BACKGROUND: Major bleeding is the leading cause of preventable mortality among trauma patients. Several studies have recently shown that prehospital plasma transfusion improves the outcomes of severely injured patients. Although no consensus has been reached, prehospital transfusion is regularly considered to reduce avoidable mortality. The objective was to assess the status of prehospital transfusion practices in France. STUDY DESIGN AND METHODS: A national survey among the 378 advance life support emergency teams (SMURs) in metropolitan France was conducted from December 15, 2020 to October 31, 2021. A questionnaire was distributed by e-mail to the physicians in charge of SMURs. The questions addressed the transfusion modalities, labile blood products (LBPs) used, and limitations encountered in implementing transfusion. RESULTS: The response rate was 48%, and 82% of the respondents performed prehospital transfusions. A designated pack was used by 44% of the respondents. The LBPs used were packed red blood cells (100%), of which 95% were group 0 RH:-1, fresh frozen plasma (27%), lyophilized plasma (7%), and platelets (1%). The LBPs were transported in isothermal boxes (97%) without temperature monitoring in 52% of the cases. Nontransfused LBPs were discarded in 43% of the cases. Reported limitations in implementing transfusion were the delivery time (45%), loss of LBPs (32%), and lack of evidence (46%). DISCUSSION: Prehospital transfusion was developed in France but access to plasma remains difficult. Protocols allowing the reutilization of LBPs and improving conservation could limit the waste of a rare resource. Implementing the use of lyophilized plasma could facilitate prehospital transfusion. Future studies will need to specify the role of each LBP in the prehospital setting.

Trends in survival from out-of-hospital cardiac arrest with a shockable rhythm and its association with bystander resuscitation: a retrospective study.

OBJECTIVE: Over 300 000 cases of out-of-hospital cardiac arrests (OHCAs) occur each year in the USA and Europe. Despite decades of investment and research, survival remains disappointingly low. We report the trends in survival after a ventricular fibrillation/pulseless ventricular tachycardia OHCA, over a 13-year period, in a French urban region, and describe the simultaneous evolution of the rescue system. METHODS: We investigated four 18-month periods between 2005 and 2018. The first period was considered baseline and included patients from the randomised controlled trial 'DEFI 2005'. The three following periods were based on the Paris Sudden Death Expertise Center Registry (France). Inclusion criteria were non-traumatic cardiac arrests treated with at least one external electric shock with an automated external defibrillator from the basic life support team and resuscitated by a physician-staffed ALS team. Primary outcome was survival at hospital discharge with a good neurological outcome. RESULTS: Of 21 781 patients under consideration, 3476 (16%) met the inclusion criteria. Over all study periods, survival at hospital discharge increased from 12% in 2005 to 25% in 2018 (p<0.001), and return of spontaneous circulation at hospital admission increased from 43% to 58% (p=0.004).Lay-rescuer cardiopulmonary resuscitation (CPR) and telephone CPR (T-CPR) rates increased significantly, but public defibrillator use remained limited. CONCLUSION: In a two-tiered rescue system, survival from OHCA at hospital discharge doubled over a 13-year study period. Concomitantly, the system implemented an OHCA patient registry and increased T-CPR frequency, despite a consistently low rate of public defibrillator use.

Association between prehospital shock index and mortality among patients with COVID-19 disease.

BACKGROUND: There exists a need for prognostic tools for the early identification of COVID-19 patients requiring intensive care unit (ICU) admission and mortality. Here we investigated the association between a clinical (initial prehospital shock index (SI)) and biological (initial prehospital lactatemia) tool and the ICU admission and 30-day mortality among COVID-19 patients cared for in the prehospital setting. METHODS: We retrospectively analysed COVID-19 patients initially cared for by a Paris Fire Brigade advanced (ALS) or basic life support (BLS) team in the prehospital setting between 2020, March 08th and 2020, May 30th. We assessed the association between prehospital SI and prehospital lactatemia and ICU admission and mortality using logistic regression model analysis after propensity score matching with Inverse Probability Treatment Weighting (IPTW) method. Covariates included in the IPTW propensity analysis were: age, sex, body mass index (BMI), initial respiratory rate (iRR), initial pulse oximetry without (SpO2i) and with oxygen supplementation (SpO2i.O2), initial Glasgow coma scale (GCSi) value, initial prehospital SI and initial prehospital lactatemia. RESULTS: We analysed 410 consecutive COVID-19 patients [254 males (62%); mean age, 64 ± 18 years]. Fifty-seven patients (14%) deceased on the scene, of whom 41 (72%) were male and were significantly older (71 ± 12 years vs. 64 ± 19 years; P 〈10-3). Fifty-three patients (15%) were admitted in ICU and 39 patients (11%) were deceased on day-30. The mean prehospital SI value was 1.5 ± 0.4 and the mean prehospital lactatemia was 2.0 ± 1.7 mmol.l-1. Multivariate logistic regression analysis on matched population after IPTW propensity analysis reported a significant association between ICU admission and age (adjusted Odd-Ratio (aOR), 0.90; 95% confidence interval (95%CI): 0.93-0.98;p = 10-3), SpO2i.O2 (aOR, 1.10; 95%CI: 1.02-1.20;p = 0.002) and BMI (aOR, 1.09; 95% CI: 1.03-1.16;p = 0.02). 30-day mortality was significantly associated with SpO2i.O2 (aOR, 0.92; 95% CI: 0.87-0.98;p = 0.01 P < 10-3) and GCSi (aOR, 0.90; 95% CI: 0.82-0.99;p = 0.04). Neither prehospital SI nor prehospital lactatemia were associated with ICU admission and 30-day mortality. CONCLUSION: Neither prehospital initial SI nor lactatemia were associated with ICU admission and 30-day mortality among COVID-19 patients initially cared for by a Paris Fire Brigade BLS or ALS team. Further prospective studies are needed to confirm these preliminary results.

Level of Onboard Care for Critical Patients: Analysis of the French Armed Forces Air Medical Evacuations From the Sahel Since 2013.

OBJECTIVE: Since 2013, the French Armed Forces have been engaged in the Sahel. The aim of our work was to study the characteristics of severe patients evacuated according to the composition of the air medical staff (ie, an anesthesiologist/intensive care physician [AICP] or an emergency physician [EP]). METHODS: This was a retrospective cohort analysis including all French service members repatriated from the Sahel with a speedy evacuation priority between 2013 and 2019. RESULTS: A total of 191 patients were evacuated. The causes were trauma for 103 patients and disease for 88. Trauma patients included war injuries (n = 58) and nonbattle injuries (n = 44). For disease patients, the main pathologies were cardiovascular (n = 17), infectious (n = 17), neurologic (n = 15), and gastrointestinal (n = 12). Highly dependent patients were significantly (P < .001) more likely to be managed by an AICP (n = 41) than an EP (n = 5). Moderately dependent patients managed by an AICP (n = 51) were more frequently unstable hemodynamically (n = 5 vs. n = 0, P < .05) and referred to an intensive care unit (n = 24 vs. n = 2, P < .001) than those managed by an EP (n = 41). There were no deaths in flight. CONCLUSION: Greater use of EPs, especially for transporting stabilized patients, would provide more personnel trained in long-distance air transport.

Insufficient quality of public automated external defibrillator recordings in the greater Paris area, a descriptive study.

BACKGROUND: Western countries report a significant increase in the proportion of patients who experience out-of-hospital cardiac arrests (OHCAs) and benefit from a public automated external defibrillator (pAED) before the arrival of rescue teams. However, recordings of devices recovered after resuscitation are of variable quality. Analysis of these data may inform decisions of whether to implement an internal defibrillator for survivors, and provide useful information about the performance of pAED algorithms and the actions of bystanders. OBJECTIVE: To investigate the quality of the information recorded by pAEDs during OHCAs in the Paris area. METHODS: pAED files used for some of the 8629 OHCAs that occurred in the greater Paris area between 1 January 2017 and 31 April 2019 on the day of the arrest were collected. The presence and accuracy of 23 factors required to interpret the recording was noted, including readability of the ECG, the presence of an impedance curve and the accuracy of the date and time. The recordings were analysed to assess the diagnostic and therapeutic performance of the pAEDs used. RESULTS: A total of 258 patients with an OHCA received assistance from a pAED, and 182 recordings were recovered. The pAEDs were made by 12 different manufacturers. Data extraction required eight different transmission modes and 16 software programmes; recordings were of highly heterogeneous quality. Two per cent of the recordings were of such poor quality that they were not interpretable. Among the 98% remaining, only 43% included a thoracic impedance curve, 34% the intensity of the shocks delivered and 8% the patient name. The date and time were accurate in 68% and 48% of recordings, respectively. The pAEDs had 87.6% (95% CI 83.7% to 91.0%) sensitivity and 99.5% (99.5% to 99.5%) specificity for defibrillating shockable rhythms (positive predictive value 98.2% (96.4% to 99.0%), negative predictive value 96.4% (95.3% to 96.8%)). The absence of important variables prevented the analysis of approximately half of the inappropriate decisions made by pAEDs. CONCLUSION: Collection of pAED recordings is a major challenge. Their analysis is compromised by heterogeneity and poor quality (incomplete maintenance records, patient details and logs). AED recordings are currently the most relevant resource to track pAED performance and bystander practices. The quality of these recordings needs to improve.

Five years of prolonged field care: prehospital challenges during recent French military operations.

BACKGROUND: French military operations in the Sahel conducted since 2013 over more than 5 million square kilometers have challenged the French Military Health Service with specific problems in prolonged field care. STUDY DESIGN AND METHODS: To describe these challenges, we retrospectively analyzed the prehospital data from the first 5 years of these operations within a delimited area. RESULTS: One hundred eighty-three servicemen of different nationalities were evacuated, mainly as a result of explosions (73.2%) or gunshots (21.9%). Their mean number evacuation was 2.2 (minimum, 1; maximum, 8) per medical evacuation with a direct evacuation from the field to a Role 2 medical treatment facility (MTF) for 62% of them. For the highest-priority casualties (N = 46), the median time [interquartile range] from injury to a Role 2 MTF was 130 minutes [70 minutes to 252 minutes], exceeding 120 minutes in 57% of cases and 240 minutes in 26%. The most frequent out-of-hospital medical interventions were external hemostasis, airway and hemopneumothorax management, hypotensive resuscitation, analgesia, immobilization, and antibiotic administration. Prehospital transfusion (RBCs and/or lyophilized plasma) was started three times in the field, two times during helicopter medical evacuation, and five times in tactical fixed wing medical aircraft. Lyophilized plasma was confirmed to be particularly suitable in these settings. One of the specific issues involved in lengthy prehospital time was the importance to reassess and convert tourniquets prior to Role 2 MTF admission. CONCLUSION: Main challenges identified include reducing evacuation times as much as possible, preserving ground deployment of sufficiently trained medics and medical teams, optimization of transfusion strategies, and strengthening specific prolonged field care equipment and training.

Fixed Wing Tactical Aircraft for Air Medical Evacuation in Sahel.

OBJECTIVE: The medical support of military operations over a 5 million km2 area in the Sahel-Saharan strip has justified the use of a medical fixed wing aircraft. Two CASA CN 235 aircraft currently perform medical evacuation (medevac) from the point of injury to forward surgical structures and then to the international airport before strategic medevac to France. METHODS: A retrospective observational study including all flights performed from January 2013 to December 2017 by the medical CASA located in Mali. RESULTS: Three thousand three flight hours were achieved. Four hundred twenty-four medevacs were performed for 898 patients. Seventy-five percent were evacuated from forward surgical structures. Their initial categorization included 10% Alpha, 23% Bravo, and 67% Charlie. Mechanical ventilation was performed for 5%; 34.5% had common medical or surgical pathologies, 34.2% were combat casualties mostly by explosion, and 18.7% were nonbattle injuries. No difficulties related to the aeronautical environment were reported by the teams. CONCLUSION: Tactical medevac with fixed wing aircraft has become a crucial link in the French medical evacuation chain in remote areas. Military emergency medical teams were able to provide in-flight intensive care before and after damage control surgery. Discussions are underway to consider possible doctrinal and logistical evolutions.

[Emergency plans in crisis situations]. / Les plans de secours en situation de crise.

In November 2015, in Paris, a wave of terrorist attacks brought horror to France. The medical and nursing teams were severely tested but demonstrated efficiency and courage. The organisation of the emergency response requires fast and essential decision making and actions.

Stroke: prospective evaluation of a prehospital management process based on rescuers under medical direction.

BACKGROUND: Improving access to thrombolytic therapy for patients with ischemic stroke is challenging. We assessed a prehospital process based on firemen rescuers under strict medical direction, aimed at facilitating thrombolysis of eligible patients. METHODS: This was a prospective observational study conducted over 4 months in Paris, France. Prehospital patients with suspected stroke were included after telephone consultation with a physician. If the time since the onset of symptoms was less than 6 hours, patients were transported directly to a neurovascular unit (NVU); if symptom onset was more than 6 hours ago, they were transported to an emergency department (ED). Confirmation of stroke diagnosis, the rate of thrombolysis, and the time intervals between the call and hospital arrival and imaging were assessed. Comparison used Fisher exact test. RESULTS: Of the 271 patients transported to an NVU, 218 were diagnosed with a stroke (166 with ischemic stroke), 69 received thrombolytic therapy, and the mean stroke-thrombolysis interval was 150 minutes. Of 64 patients admitted to the ED, 36 patients had a stroke (ischemic, 24). None were thrombolysed. Globally, 36% of ischemic strokes were thrombolysed (27% of all strokes diagnosed). The mean interval call-hospital was 65 minutes (ED vs NVU, P = .61). The interval call-imaging was 202 minutes (interquartile range, 105.5-254.5) for ED and 92 minutes (interquartile range, 77-116) for NVU (P < .001). CONCLUSIONS: The prehospital management of stroke by rescuers, under strict medical direction, seemed to be feasible and effective for selection of patients with stroke in an urban environment and may improve the access to thrombolysis.