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NR2 Antibody as a Predictor for Neurological Recovery in Post-Cardiopulmonary Resuscitation Patients
The Journal of Emergency Medicine
279
, THE DIFFICULT AIRWAY IN THE ED: COMPARISON OF VIDEO LARYNGOSCOPY TO DIRECT LARYNGOSCOPY. J. Sakles, Emergency Medicine, University of Arizona College of Medicine, Tucson, AZ; A. Patanwala, College of Pharmacy, University of Arizona, Tucson, AZ; J. Dicken, College of Pharmacy, University of Arizona, Tucson, AZ; J. Mosier, Emergency Medicine, University of Arizona, Tucson, AZ; I. Abraham, College of Pharmacy, University of Arizona, Tucson, AZ; M. Cosentino, Emergency Medicine, University of Arizona College of Medicine, Tucson, AZ Objective: To compare the efficacy of video laryngoscopy (VL) to direct laryngoscopy (DL) for intubation of emergency department (ED) patients with difficult airways. Methods: Between 2007 and 2012, emergency physicians recorded all consecutive intubations performed in the ED. The database included patient demographics and detailed information about each intubation, such as number of attempts, devices used, and difficult airway parameters (DAPs). In this study, adult patients with one or more DAPs who underwent rapid sequence intubation (RSI) were included. DAPs included blood in the airway, vomit in the airway, short neck, cervical spine collar, small mandible, obesity, airway edema, facial trauma, and large tongue. The videolaryngoscopes used were the C-MAC and GlideScope. First-attempt intubation success was compared between the VL and DL groups stratified by the number of DAPs. The chi-squared test was used to make these comparisons. A multivariate logistic regression analysis was conducted to adjust for potential confounders. Results: A total of 1124 intubations were included in the final cohort. The mean age of patients was 45 and 47 years in the VL and DL groups, respectively (p = 0.165). The proportion of males was 68% in both groups. First-attempt success by the number of DAPs was as follows in the VL and DL groups, respectively: one DAP (86% vs. 71%, respectively; p < 0.001), two DAPs (84% vs. 66%, respectively; p = 0.001), three DAPs (77% vs. 64%, respectively; p = 0.048), four or more DAPs (60% vs. 32%, respectively; p = 0.002). After adjusting for potential confounders, VL was associated with higher odds of first-pass success for patients with one (odds ratio [OR] 3.2, 95% confidence interval [CI] 1.9–5.2, p < 0.001), two (OR 3.1, 95% CI 1.6–5.9, p = 0.001), three (OR 2.0, 95% CI 1.0–3.9, p = 0.040), and four or more DAPs (OR 4.4, 95% CI 1.8–11.0, p = 0.001). Conclusions: In adult patients with difficult airway characteristics who undergo RSI in the ED, VL is associated with a greater first-pass success than DL.
nificant, as the view of the glottic inlet is from a camera positioned on the distal undersurface of the blade. To date, no literature exists evaluating the effect of RSI with video laryngoscopy. Objective: To determine the effect of RSI vs. sedation only/no medications (noRSI) on the success rate of intubation of patients intubated in the emergency department (ED) and intensive care unit (ICU). Methods: All intubations performed in the ED or ICU over a 12-month period at an academic medical center with a Level I trauma center and training programs in Emergency Medicine, Pulmonary, and Critical Care Medicine were included. The intubator completed a standardized data form, which included patient demographics and detailed patient- and procedure-related information pertinent to the intubation, such as number and outcome of each attempt, devices used, medications used, and difficult airway predictors (DAPs). All adult patients intubated with VL (CMAC or GlideScope) were included in this analysis. The primary outcome was first-attempt success. A multivariate logistic regression analysis was performed to adjust for potential confounders. Results: There were 443 intubations performed in the ED and ICU using VL during the study period; 238 (54%) were performed in the ED, 205 (46%) were performed in the ICU (p = ns). There were 360 patients (81%) intubated with RSI, and 83 (19%) were intubated without a paralytic. Two hundred patients (45%) were intubated with a GlideScope, 243 (55%) with a CMAC (p = ns). There was no significant overall difference in first-attempt success rate between devices (CMAC 78%, GlideScope 78%, p = ns). There was no significant difference between RSI and noRSI groups in terms of age (RSI mean 55 years, interquartile range [IQR] 45–66, noRSI mean 55, IQR 41–71, p = ns). Two hundred two patients (85%) in the ED were intubated with RSI, compared to 158 (77%) intubated in the ICU (p = 0.02). The noRSI group averaged more DAPs (mean 0.92, 95% confidence interval [CI] 0.61–1.24) than the RSI group (mean 0.57, 95% CI 0.46–0.68) (p = 0.01). RSI had a higher first-attempt success rate than noRSI (82% vs. 63%) (p = 0.001). A multivariate regression model controlling for difficult airway predictors and level of training of the intubator shows improved odds of success with RSI vs. noRSI (adjusted OR 3.01, 95% CI 1.71–5.23). Conclusions: Our data for out-of-OR intubations suggest that RSI has improved odds of successful first-attempt intubation compared to noRSI, even when controlled for difficult airway predictors and level of training of the intubator.
, RAPID SEQUENCE INTUBATION COMPARED TO SEDATION ONLY FOR OUT-OF-OR INTUBATIONS USING VIDEO LARYNGOSCOPY. R. Bouska, J. Sakles, U. Stolz, Emergency Medicine, University of Arizona, Tucson, Arizona; J. Mosier, Emergency Medicine and Critical Care Medicine, University of Arizona, Tucson, Arizona Background: Rapid sequence intubation (RSI) has been the preferred technique for out-of-OR (operating room) intubations due to the improved grade of glottic view and overall intubating conditions when using direct laryngoscopy. Given the design of video laryngoscopes (VL), the benefit of RSI may not be as sig-
, NR2 ANTIBODY AS A PREDICTOR FOR NEUROLOGICAL RECOVERY IN POST-CARDIOPULMONARY RESUSCITATION PATIENTS. A. Bidari, Emergency Department, Iran University of Medical Sciences, Tehran, IRAN; S. Vaziri, Emergency Department, Iran University of Medical Sciences, Tehran, IRAN; S. Farahmand, Emergency Department, Iran University of Medical Sciences, Tehran, IRAN; E. Talachian, Pediatric Gastroenterology, Iran University of Medical Sciences, Tehran, IRAN Background: Full neurological recovery is the benchmark of any successful cardiac resuscitation effort. Nevertheless, in early
Biomarkers, Diagnostic Tech./Radiology, and Imaging/ Ultrasound/Radiology 1
280 post-cardiopulmonary resuscitation (CPR) state, neurological compromise is very common and does not necessarily mean a poor outcome. Recently, NR2 antibody (NR2-ab) has been introduced as a sensitive biomarker to define high-risk transient ischemic attack. This antibody reacts with NR2 peptide of N-methyl-D-aspartate (NMDA) receptor, which has a wide distribution in brain tissue. Irreversible brain ischemia releases NR2 peptide and prompts antibody synthesis. Considering the analogy of irreversible brain ischemia in cerebrovascular accidents and cardiac arrest, this study was conducted to evaluate whether the NR2-ab is of value in predicting neurological recovery in postCPR patients. Methods: Adults with nontraumatic cardiac arrest who presented to the emergency department of two teaching hospitals and were resuscitated successfully to return of spontaneous circulation (ROSC) were recruited between December 2011 and November 2012. To be eligible, the ROSC had to last for at least 60 min with no intervening resuscitation effort. Venous samples were obtained 1 h after ROSC and serum extracted to be assessed for NR2-ab assay. Survival status of the patients as well as the Glasgow Coma Scale (GCS) score at 6, 24, and 72 h after ROSC were evaluated and patients were followed until death or hospital discharge. Results: Forty-nine patients, 24 male and 25 female, were included. Twenty-seven survived enough to be discharged from the hospital, 13 of them in good to excellent neurological status. In total, 12 (24.5%) had positive NR2-ab; none of them survived to discharge; whereas of 37 patients with negative NR2-ab, 27 (73%) were discharged alive (p < 0.0001). By 6 h after ROSC, 1 NR2-ab-positive patient and 2 in the other group died (p = 0.587). By 24 h, this figure rose to 8 and 6 (p < 0.002), and by 72 h, to 12 and 6 (p < 0.000) for NR2-ab-positive and -negative groups, respectively. GCS was significantly lower in survived NR2-ab-positive patients at 1 h (p < 0.02), 6 h (p < 0.0001), and 24 h (p < 0.0001) after ROSC. In our sample, NR2-ab was 54% sensitive and 100% specific to indicate the fatal outcome over hospital stay. Conclusion: Detection of NR2-ab in resuscitated patients may be a strong predictor of death and poor neurological outcome despite ROSC. Neurology 1 , METOCLOPRAMIDE VERSUS SUMATRIPTAN FOR EMERGENCY DEPARTMENT TREATMENT OF MIGRAINE HEADACHE. R. A. Khani, K. Golshani, B. Masoumi, S. Talebi, Emergency Department, Isfahan University of Medical Science (IUMS), Isfahan, IRAN Background: There are different options to manage benign headache in the emergency department (ED). The costs, side effects, and efficacies of these drugs are significantly different.The aim of this study was to compare intravenous metoclopramide with subcutaneous sumatriptan to relieve pain in the ED. Material and Methods: In this randomized, double-blinded clinical trial, after providing informed consent, patients presenting to the ED with acute benign headache received 20 mg of metoclopramide intravenously or 6 mg of sumatriptan subcutaneously. Pain intensity was assessed with 10-cm visual analogue scale at baseline and 60 min after treatment. The primary outcome was change in pain intensity between these two measures. The data were entered into SPSS (ver. 19; IBM, Armonk, NY),
Abstracts and Student’s t-test, paired t-test, chi-squared test, and analysis of covariance were used for data analyzing. Results: One hundred twenty-four subjects entered the trial and data were completed for all of them. Baseline pain score and age means were not similar for the metoclopramide and sumatriptan groups (6.7 vs. 6.1 cm for pain score and 34.9 vs. 26.8 years for age). Paired t-test showed the statistically significant pain reductions in both groups 1 h after treatment: in the metoclopramide group, mean pain score decreased from 6.7 to .6 cm (p = 0.000) and in sumatriptan, from 6.1 to 1.1 (p = 0.000). Comparing these two groups showed more pain reduction in the metoclopramide group with .55 (95% CI .25–.79 cm) mean difference, and this difference was statistically significant (p = .000). Conclusion: Intravenous metoclopramide is superior to subcutaneous sumatriptan in the treatment of acute migraine in the ED. , STROKE CODE. INTRAVENOUS THROMBOLYSIS IN ISCHEMIC STROKE. EXPERIENCE AND RESULTS. D. R. Seguı´, A. M. Destruels, J. G. Mora, M. C. B. Oliva, Emergency Department, Hospital Joan XXIII, Tarragona, SPAIN; A. P. Guinjoan, Neurology Department, Hospital Joan XXIII, Tarragona, SPAIN; F. X. Avile´s Jurado, Otorhinolaringology Department, Hospital Joan XXIII, Tarragona, SPAIN; X. Ustrell, Neurology Department, Hospital Joan XXIII, Tarragona, SPAIN Objectives: To analyze the performance and clinical outcomes of the implementation of a stroke code protocol in our field. Method: Descriptive, observational study of all patients treated with intravenous thrombolysis with alteplase (rt-PA) over a 5-year period and analysis of the stroke code circuit performance, response time, clinical, neurological (National Institutes of Health Stroke Scale [NIHSS]), and functional status (modified Rankin scale [mRS]) after treatment and 3 months later. Results: During the 2009–2013 period, 152 patients received treatment, 59.74% male and 40.26% female, with a mean age of 67.79 years (SD 12.45); 65.8% were activated by Emergency Medical Services. At their arrival, the average baseline NIHSS was 13.17 (SD 5.75), with a width range (WR) from 4 to 28. The mean door-to-needle time was 63.28 min (SD 25.76). After 24 h of treatment, the NIHSS was 8.32 (SD 7.3; WR 0–24). Our patients, after 3 months, had a modified Rankin scale: 51.9% mRS = < 3 (25% mRS 2–3 and 26.9% mRS 0–1). There is a statistical difference between the lower score of NIHSS at the arrival of the patient in the emergency department and the score at 24 h and 3 months (p < 0.001). Conclusions: Patients receiving alteplase have a functional improvement (NIHSS, mRS) at 24 h and 3 months later. Observed door-to-needle time is similar to that seen in literature. We should treat patients with better clinical and functional status to obtain better results in NIHSS and mRS scores at 3 months, and it is important to decrease door-to-needle time. , IMPACT OF EMERGENCY MEDICAL SERVICE SYSTEM ON FIBRINOLYSIS AMONG PATIENTS WITH ISCHEMIC STROKE IN THE NORTHERN FRENCH ALPS . C. Vallot, Emergency Department, Centre Hospitalier de la Re´gion d’Annecy, Annecy, FRANCE; C. Ricard, Northern
279
, THE DIFFICULT AIRWAY IN THE ED: COMPARISON OF VIDEO LARYNGOSCOPY TO DIRECT LARYNGOSCOPY. J. Sakles, Emergency Medicine, University of Arizona College of Medicine, Tucson, AZ; A. Patanwala, College of Pharmacy, University of Arizona, Tucson, AZ; J. Dicken, College of Pharmacy, University of Arizona, Tucson, AZ; J. Mosier, Emergency Medicine, University of Arizona, Tucson, AZ; I. Abraham, College of Pharmacy, University of Arizona, Tucson, AZ; M. Cosentino, Emergency Medicine, University of Arizona College of Medicine, Tucson, AZ Objective: To compare the efficacy of video laryngoscopy (VL) to direct laryngoscopy (DL) for intubation of emergency department (ED) patients with difficult airways. Methods: Between 2007 and 2012, emergency physicians recorded all consecutive intubations performed in the ED. The database included patient demographics and detailed information about each intubation, such as number of attempts, devices used, and difficult airway parameters (DAPs). In this study, adult patients with one or more DAPs who underwent rapid sequence intubation (RSI) were included. DAPs included blood in the airway, vomit in the airway, short neck, cervical spine collar, small mandible, obesity, airway edema, facial trauma, and large tongue. The videolaryngoscopes used were the C-MAC and GlideScope. First-attempt intubation success was compared between the VL and DL groups stratified by the number of DAPs. The chi-squared test was used to make these comparisons. A multivariate logistic regression analysis was conducted to adjust for potential confounders. Results: A total of 1124 intubations were included in the final cohort. The mean age of patients was 45 and 47 years in the VL and DL groups, respectively (p = 0.165). The proportion of males was 68% in both groups. First-attempt success by the number of DAPs was as follows in the VL and DL groups, respectively: one DAP (86% vs. 71%, respectively; p < 0.001), two DAPs (84% vs. 66%, respectively; p = 0.001), three DAPs (77% vs. 64%, respectively; p = 0.048), four or more DAPs (60% vs. 32%, respectively; p = 0.002). After adjusting for potential confounders, VL was associated with higher odds of first-pass success for patients with one (odds ratio [OR] 3.2, 95% confidence interval [CI] 1.9–5.2, p < 0.001), two (OR 3.1, 95% CI 1.6–5.9, p = 0.001), three (OR 2.0, 95% CI 1.0–3.9, p = 0.040), and four or more DAPs (OR 4.4, 95% CI 1.8–11.0, p = 0.001). Conclusions: In adult patients with difficult airway characteristics who undergo RSI in the ED, VL is associated with a greater first-pass success than DL.
nificant, as the view of the glottic inlet is from a camera positioned on the distal undersurface of the blade. To date, no literature exists evaluating the effect of RSI with video laryngoscopy. Objective: To determine the effect of RSI vs. sedation only/no medications (noRSI) on the success rate of intubation of patients intubated in the emergency department (ED) and intensive care unit (ICU). Methods: All intubations performed in the ED or ICU over a 12-month period at an academic medical center with a Level I trauma center and training programs in Emergency Medicine, Pulmonary, and Critical Care Medicine were included. The intubator completed a standardized data form, which included patient demographics and detailed patient- and procedure-related information pertinent to the intubation, such as number and outcome of each attempt, devices used, medications used, and difficult airway predictors (DAPs). All adult patients intubated with VL (CMAC or GlideScope) were included in this analysis. The primary outcome was first-attempt success. A multivariate logistic regression analysis was performed to adjust for potential confounders. Results: There were 443 intubations performed in the ED and ICU using VL during the study period; 238 (54%) were performed in the ED, 205 (46%) were performed in the ICU (p = ns). There were 360 patients (81%) intubated with RSI, and 83 (19%) were intubated without a paralytic. Two hundred patients (45%) were intubated with a GlideScope, 243 (55%) with a CMAC (p = ns). There was no significant overall difference in first-attempt success rate between devices (CMAC 78%, GlideScope 78%, p = ns). There was no significant difference between RSI and noRSI groups in terms of age (RSI mean 55 years, interquartile range [IQR] 45–66, noRSI mean 55, IQR 41–71, p = ns). Two hundred two patients (85%) in the ED were intubated with RSI, compared to 158 (77%) intubated in the ICU (p = 0.02). The noRSI group averaged more DAPs (mean 0.92, 95% confidence interval [CI] 0.61–1.24) than the RSI group (mean 0.57, 95% CI 0.46–0.68) (p = 0.01). RSI had a higher first-attempt success rate than noRSI (82% vs. 63%) (p = 0.001). A multivariate regression model controlling for difficult airway predictors and level of training of the intubator shows improved odds of success with RSI vs. noRSI (adjusted OR 3.01, 95% CI 1.71–5.23). Conclusions: Our data for out-of-OR intubations suggest that RSI has improved odds of successful first-attempt intubation compared to noRSI, even when controlled for difficult airway predictors and level of training of the intubator.
, RAPID SEQUENCE INTUBATION COMPARED TO SEDATION ONLY FOR OUT-OF-OR INTUBATIONS USING VIDEO LARYNGOSCOPY. R. Bouska, J. Sakles, U. Stolz, Emergency Medicine, University of Arizona, Tucson, Arizona; J. Mosier, Emergency Medicine and Critical Care Medicine, University of Arizona, Tucson, Arizona Background: Rapid sequence intubation (RSI) has been the preferred technique for out-of-OR (operating room) intubations due to the improved grade of glottic view and overall intubating conditions when using direct laryngoscopy. Given the design of video laryngoscopes (VL), the benefit of RSI may not be as sig-
, NR2 ANTIBODY AS A PREDICTOR FOR NEUROLOGICAL RECOVERY IN POST-CARDIOPULMONARY RESUSCITATION PATIENTS. A. Bidari, Emergency Department, Iran University of Medical Sciences, Tehran, IRAN; S. Vaziri, Emergency Department, Iran University of Medical Sciences, Tehran, IRAN; S. Farahmand, Emergency Department, Iran University of Medical Sciences, Tehran, IRAN; E. Talachian, Pediatric Gastroenterology, Iran University of Medical Sciences, Tehran, IRAN Background: Full neurological recovery is the benchmark of any successful cardiac resuscitation effort. Nevertheless, in early
Biomarkers, Diagnostic Tech./Radiology, and Imaging/ Ultrasound/Radiology 1
280 post-cardiopulmonary resuscitation (CPR) state, neurological compromise is very common and does not necessarily mean a poor outcome. Recently, NR2 antibody (NR2-ab) has been introduced as a sensitive biomarker to define high-risk transient ischemic attack. This antibody reacts with NR2 peptide of N-methyl-D-aspartate (NMDA) receptor, which has a wide distribution in brain tissue. Irreversible brain ischemia releases NR2 peptide and prompts antibody synthesis. Considering the analogy of irreversible brain ischemia in cerebrovascular accidents and cardiac arrest, this study was conducted to evaluate whether the NR2-ab is of value in predicting neurological recovery in postCPR patients. Methods: Adults with nontraumatic cardiac arrest who presented to the emergency department of two teaching hospitals and were resuscitated successfully to return of spontaneous circulation (ROSC) were recruited between December 2011 and November 2012. To be eligible, the ROSC had to last for at least 60 min with no intervening resuscitation effort. Venous samples were obtained 1 h after ROSC and serum extracted to be assessed for NR2-ab assay. Survival status of the patients as well as the Glasgow Coma Scale (GCS) score at 6, 24, and 72 h after ROSC were evaluated and patients were followed until death or hospital discharge. Results: Forty-nine patients, 24 male and 25 female, were included. Twenty-seven survived enough to be discharged from the hospital, 13 of them in good to excellent neurological status. In total, 12 (24.5%) had positive NR2-ab; none of them survived to discharge; whereas of 37 patients with negative NR2-ab, 27 (73%) were discharged alive (p < 0.0001). By 6 h after ROSC, 1 NR2-ab-positive patient and 2 in the other group died (p = 0.587). By 24 h, this figure rose to 8 and 6 (p < 0.002), and by 72 h, to 12 and 6 (p < 0.000) for NR2-ab-positive and -negative groups, respectively. GCS was significantly lower in survived NR2-ab-positive patients at 1 h (p < 0.02), 6 h (p < 0.0001), and 24 h (p < 0.0001) after ROSC. In our sample, NR2-ab was 54% sensitive and 100% specific to indicate the fatal outcome over hospital stay. Conclusion: Detection of NR2-ab in resuscitated patients may be a strong predictor of death and poor neurological outcome despite ROSC. Neurology 1 , METOCLOPRAMIDE VERSUS SUMATRIPTAN FOR EMERGENCY DEPARTMENT TREATMENT OF MIGRAINE HEADACHE. R. A. Khani, K. Golshani, B. Masoumi, S. Talebi, Emergency Department, Isfahan University of Medical Science (IUMS), Isfahan, IRAN Background: There are different options to manage benign headache in the emergency department (ED). The costs, side effects, and efficacies of these drugs are significantly different.The aim of this study was to compare intravenous metoclopramide with subcutaneous sumatriptan to relieve pain in the ED. Material and Methods: In this randomized, double-blinded clinical trial, after providing informed consent, patients presenting to the ED with acute benign headache received 20 mg of metoclopramide intravenously or 6 mg of sumatriptan subcutaneously. Pain intensity was assessed with 10-cm visual analogue scale at baseline and 60 min after treatment. The primary outcome was change in pain intensity between these two measures. The data were entered into SPSS (ver. 19; IBM, Armonk, NY),
Abstracts and Student’s t-test, paired t-test, chi-squared test, and analysis of covariance were used for data analyzing. Results: One hundred twenty-four subjects entered the trial and data were completed for all of them. Baseline pain score and age means were not similar for the metoclopramide and sumatriptan groups (6.7 vs. 6.1 cm for pain score and 34.9 vs. 26.8 years for age). Paired t-test showed the statistically significant pain reductions in both groups 1 h after treatment: in the metoclopramide group, mean pain score decreased from 6.7 to .6 cm (p = 0.000) and in sumatriptan, from 6.1 to 1.1 (p = 0.000). Comparing these two groups showed more pain reduction in the metoclopramide group with .55 (95% CI .25–.79 cm) mean difference, and this difference was statistically significant (p = .000). Conclusion: Intravenous metoclopramide is superior to subcutaneous sumatriptan in the treatment of acute migraine in the ED. , STROKE CODE. INTRAVENOUS THROMBOLYSIS IN ISCHEMIC STROKE. EXPERIENCE AND RESULTS. D. R. Seguı´, A. M. Destruels, J. G. Mora, M. C. B. Oliva, Emergency Department, Hospital Joan XXIII, Tarragona, SPAIN; A. P. Guinjoan, Neurology Department, Hospital Joan XXIII, Tarragona, SPAIN; F. X. Avile´s Jurado, Otorhinolaringology Department, Hospital Joan XXIII, Tarragona, SPAIN; X. Ustrell, Neurology Department, Hospital Joan XXIII, Tarragona, SPAIN Objectives: To analyze the performance and clinical outcomes of the implementation of a stroke code protocol in our field. Method: Descriptive, observational study of all patients treated with intravenous thrombolysis with alteplase (rt-PA) over a 5-year period and analysis of the stroke code circuit performance, response time, clinical, neurological (National Institutes of Health Stroke Scale [NIHSS]), and functional status (modified Rankin scale [mRS]) after treatment and 3 months later. Results: During the 2009–2013 period, 152 patients received treatment, 59.74% male and 40.26% female, with a mean age of 67.79 years (SD 12.45); 65.8% were activated by Emergency Medical Services. At their arrival, the average baseline NIHSS was 13.17 (SD 5.75), with a width range (WR) from 4 to 28. The mean door-to-needle time was 63.28 min (SD 25.76). After 24 h of treatment, the NIHSS was 8.32 (SD 7.3; WR 0–24). Our patients, after 3 months, had a modified Rankin scale: 51.9% mRS = < 3 (25% mRS 2–3 and 26.9% mRS 0–1). There is a statistical difference between the lower score of NIHSS at the arrival of the patient in the emergency department and the score at 24 h and 3 months (p < 0.001). Conclusions: Patients receiving alteplase have a functional improvement (NIHSS, mRS) at 24 h and 3 months later. Observed door-to-needle time is similar to that seen in literature. We should treat patients with better clinical and functional status to obtain better results in NIHSS and mRS scores at 3 months, and it is important to decrease door-to-needle time. , IMPACT OF EMERGENCY MEDICAL SERVICE SYSTEM ON FIBRINOLYSIS AMONG PATIENTS WITH ISCHEMIC STROKE IN THE NORTHERN FRENCH ALPS . C. Vallot, Emergency Department, Centre Hospitalier de la Re´gion d’Annecy, Annecy, FRANCE; C. Ricard, Northern