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1 원저 일개광역시응급의료서비스에서뇌졸중후병원도착전단계의지연요인과구급대원의뇌졸중환자식별 동아대학교의과대학신경과학교실 a, 부산울산권역별심뇌혈관센터 b, 부산광역시소방본부 c 김해종 a 김대현 a,b 박향이 a 이인영 c 차재관 a,b Prehospital Delay Factors After Stroke and Paramedic Identification of Stroke Patients in a Metropolitan City Emergency Medical Service System Hae-Jong Kim, MD a, Dae-Hyun Kim, MD a,b, Hyang-I Park, MD a, In-Young Lee c, Jae-Kwan Cha, MD a,b Department of Neurology a, Dong-A University College of Medicine, Busan, Korea Busan-Ulsan Regional Cardiocerebrovascular Center b, Busan, Korea Busan Fire Department c, Busan, Korea Background: Accurate recognition of stroke victims by ambulance paramedics is necessary to ensure the rapid transfer of these to the hospital. We carried out a prospective study to characterize the cause of prehospital delays after stroke by the emergency medical service (EMS) and to determine the accuracy of identifying acute stroke by paramedics. Methods: All paramedics in the Busan Metropolitan 119 EMS were asked to record the clinical presentations and time intervals from symptom onset to various points along the prehospital course on the ambulance admission sheets for suspected stroke during a month (February 1, 2010 to February 28, 2010). Neurologists in twenty four hospitals reviewed the hospital records for the who were given a diagnosis of stroke or transient ischemic attack by the paramedics. Results: Of the EMS on-scene evaluations, the diagnosis of stroke by ambulance paramedics was correct for 79 of the 186 (43%). Positive predictive values for main suspected stroke symptoms were 95% in hemiparesis, 88% in speech disturbance and 44% in impaired consciousness. The prehospital personnel transferred the suspected stroke to each hospital at a mean of 25 minutes after the emergency 119 call. However, only 62% of the stroke called EMS within the first 2 hours of stroke. Conclusions: Public education for the need to seek EMS promptly after stroke as a medical emergency, and strokespecific training for EMS personnel are essential so that stroke receive effective acute treatment. J Korean Neurol Assoc 29(2):89-94, 2011 Key Words: Stroke recognition, Emergency medical service, Prehospital delay, Paramedics 서론 Received November 15, 2010 Revised December 16, 2010 Accepted December 16, 2010 *Dae-Hyun Kim, MD Department of Neurology, Dong-A University College of Medicine, 1 Dongdaesin-dong 3-ga, Seo-gu, Busan , Korea Tel: Fax: kdh6542@hanmail.net * This work was supported by the Dong-A University research fund. 뇌졸중은국내사망원인질환빈도순위중두번째이고, 단일질환으로는최고를차지할만큼흔하고중요한질병이다. 1 급성기뇌경색환자에서 3시간이내에혈전용해제사용은확실한효과를가진치료법으로정립되어있고, 2 혈전용해제투여가빠를수록뇌졸중으로인한장애가적은것으로알려져있다. 3 따라서뇌졸중발생후환자나가족의빠른뇌졸중증상인지와구조요청, 구급대원들의빠른환자이송과적절한병원선택, 병 J Korean Neurol Assoc Volume 29 No. 2,

2 김해종김대현박향이이인영차재관 원에서신속한치료시작이급성기뇌졸중치료에서중요한요소들이다. 4 그러나국내외에서아직도응급실에서혈전용해요법을시행받는환자는많지않은데 5 가장흔한원인은급성기뇌졸중환자의응급실도착지연이다. 6,7 뇌졸중환자의응급실내원경로중가장신속한방법은증상발생후응급의료서비스를이용하는것으로알려져있다. 8,9 그러므로응급의료구급대원은환자발생을보고받은후, 뇌졸중증상을빠르게인지하고최대한신속히환자를이송하도록사전준비가되어있어야한다. 4 외국에는응급의료구급대원들의뇌졸중인지도나진단정확성에관한연구와 응급의료서비스를이용하는뇌졸중환자의응급실도착지연원인에대한분석자료가많이있지만, 9,13 국내연구는부족한실정이다. 본연구에서는일개광역시구급대원에의해뇌졸중이의심되어이송되는환자가실제로뇌졸중으로진단되는비율과발병후응급의료서비스를통해환자이송지연의중요한원인이무엇인지알아보고자하였다. 대상과방법 본연구는동아대학교병원뇌졸중센터에서부산광역시소방본부에협조를구해서구급대원들에게환자이송시에뇌졸중이라고생각하는환자를기록하게한후, 이자료를이송한병원신경과전문의에게의뢰하여뇌졸중유무를확인하였다. 부산광역시소방본부산하에지역별로 10개의소방서가있고연구기간당시총 55대의응급구급차와약 300 명의구급대원이 2인 1조로 24시간응급환자발생시에이송을담당하고있었다. 환자발생신고시에배치담당자 (dispatcher) 는전화로신고내용을확인후각소방서의구급대원에게연락을해서현장으로출동하게되며동시에같은지역내에환자가발생하였을경우에는담당지역이아니어도가장가까이있는구급차의구급대원들이환자이송을담당하는체계로이루어져있었다 구급대원의뇌졸중의심환자조사부산광역시소방본부에의뢰하여부산시내각소방서별로모든구급대원이 2010 년 2월한달간 119 를통해환자발생신고를받고현장출동시에병력청취, 임상증상과징후를바탕으로뇌졸중이라고생각하는환자의정보를기록하고매일자료를모았다. 연구당시에는구급대원들에게뇌졸중증상에대해특별히교육하지않았고뇌졸중에대한판단은현장에출동한구급대원들에의해이루어졌다. 구급대원은환자이송시에성별, 나이, 주증상, 의식상태, 신체활력징후, 연락받은시간, 현장도착시간, 이송병원도착시간, 현장에서병원까지의거리등을기록하므로이정보를이용하여환자발생보고후현장도착및병원도착까지소요시간을계산하였다. 이중증상발생또는발견후 119 에연락할때까지소요된시간은증상발생후혈전용해제투여가능한시간이 3시간이내인것을고려하여증상확인후 2시간을경계로이분하였다. 환자의주증상은이송환자가뇌졸중이라고판단하게된가장중요한증상을기재하도록하였다. 2. 이송병원별뇌졸중의심환자정보분석연구기간동안구급대원이기록한뇌졸중의심환자명단을모아서전원한병원별로분류하였다. 그리고전원된병원에서근무하는신경과전문의에게의뢰하여구급대원이기재한내원날짜, 시간, 이름을기준으로환자의의무기록과뇌영상판독을통해서최종진단을확인하였다. 뇌졸중은뇌경색, 일과성허혈발작, 뇌출혈로분류하였고뇌출혈에는거미막하출혈과뇌내출혈을포함하였다. 일과성허혈발작은 24시간이내에뇌졸중증상이사라지는경우로정의하였지만뇌자기공명영상의확산강조영상에서증상과관련된병변이보이는경우는뇌경색으로분류하였다. 뇌경색환자의경우혈전용해제투여여부를조사하였다. 그외분석항목은성별, 나이, 증상발생또는확인시간, 주증상, 최종진단명, 타병원전원유무등을확인하였다. 3. 통계최종진단이뇌졸중인군과비뇌졸중군, 뇌졸중환자중에는일과성허혈발작을제외하고뇌경색군과뇌출혈군으로나누어서두군간에성별, 나이, 각단계별소요시간, 이동거리, 대표증상을비교분석하였다. 모든수치는평균 ± 표준편차로기술하였고그룹간의비교에서연속변수는 t-검정, 비연속변수는카이제곱검정으로차이를분석하였다. 모든데이터는양측검정으로처리하였으며, 유의성은 p<0.05 로하였다. 결과 연구기간동안부산광역시 119 구급대원에의해뇌졸중이의심되어 33개부산시내병원으로이송된환자는총 237 명이었고, 이중신경과전문의가근무하지않는 9개병원으로이송한환자 24명과이송병원에서의무기록자료가부족하거나누락된환자 27명을제외한후 186명을분석하였다 (Fig.). 90 대한신경과학회지제 29 권제 2 호, 2011

3 일개광역시응급의료서비스에서뇌졸중후병원도착전단계의지연요인과구급대원의뇌졸중환자식별 Paramedics Figure. Selection and diagnosis of stroke suspected transferred by 119 paramedics. 전체이송환자중남자가 50.5% 였고, 평균연령은 66 세였다. 내원시간단계별분석을보면증상발생후 2시간이내에응급의료서비스에연락을취한환자는 48.4% 였고연락까지평균시간은 39.1 분이었으며, 연락후구급대원이현장에도착하는시간이평균 5.9 분, 연락후환자를병원까지후송하는데걸린시간은평균 26분이었다. 부산소방본부자료에의하면같은기간동안타질환의심환자의평균이송시간은 25분이었다. 뇌졸중으로최종진단받은환자는 79명으로구급대원의뇌졸중진단양성예측도는 42.5% 였고, 뇌경색이 45명. 뇌출혈이 30 명, 일과성허혈발작이 4명이었다 (Table 1). 구급대원이기록한뇌졸중의심증상중가장흔한것은의식장애, 상하지편마비, 어지럼, 언어장애순이었으나, 최종뇌졸중진단환자에서는편마비 (50.6%), 의식장애 (26.6%), 언어장애 (18.9%) 순이었고, 각증상별로뇌졸중진단에대한양성예측도는각각 95%, 44%, 88% 였다. 이중의식장애는뇌출혈환자에서많았고마비와언어장애는뇌경색에서많았다 (Table 2). 62% 의뇌졸중환자가 2시간이내, 평균 36.6 분에응급의료서비스에연락을취하였고, 뇌출혈환자가뇌경색환자보다더일찍연락하는경우가많았다. 51.1% 의뇌경색환자가증상확인후 2시간이내, 평균 37분에응급의료서비스에연락을취했고이중 48% 가이송병원에서혈전용해제를투여받을수있었다. 혈전용해제를투여받지못한원인으로는경미한뇌경색 (3 명 ), 보호자거부 (2명 ), 불명확한발생시점 (2명 ), 과도한병변크기 (2명 ), 뇌영상촬영후치료시간초과 (2명 ) 가있었다. 병원별분류에서는중재적시술이가능한병원으로이송된환자는뇌졸중환자군에서 58% 로좀더많았다. 응급의료서비스에연락후구급대원의도착시간, 병원까지후송시간, 이동거리는모든군간에차이가없었다 (Table 3, 4). Table 1. Demographic characteristics and final diagnosis of Patients with final diagnosis (n=186) Male, n (%) 94 (50.5%) Age, yr 66.0±13.4 Symptom onset to call 119, n (%) 0-2 hours 90 (48.4%) Over 2 hours 96 (51.6%) 119 call to paramedic arrival on-scene, min 5.9± call to arrival at hospital, min 25.8±11.2 Distance from the scene to hospital, km 7.1±6.5 Hospital, intra-arterial thrombolysis, n (%) Possible 88 (47.3) Impossible 98 (52.7) Final diagnosis, n (%) Stroke 79 (42.5%) Cerebral infarction 45 (24.2%) Transient ischemic attack 4 (2.2%) Hemorrhage 30 (16.1%) Non-stroke 107 (57.5%) Peripheral vertigo 23 (12.4%) Seizure 12 (6.5%) Metabolic disease without prior stroke 8 (4.3%) Anxiety disorder 7 (3.8%) Syncope 6 (3.2%) Hypoglycemia 6 (3.2%) Metabolic disease with prior stroke 6 (3.2%) Migraine/tension type headache 6 (3.2%) Cardiac disease, myocardial infarction 5 (2.7%) Drug or alcohol intoxication 5 (2.7%) Gastroenteritis 5 (2.7%) Peripheral neuropathy 5 (2.7%) Brain tumor 2 (1.0%) Others 11 (5.9%) Table 2. Main symptoms in assumed for stroke by the 119 paramedics Symptoms All (n=186) Non-stroke (n=107) Confirmed stroke (n=79) CI TIA H Altered mental status Hemiparesis Dizziness Aphasia, dysarthria Abnormal sensation General weakness Seizure 9 9 Headache Nausea and vomiting 5 5 Abnormal breathing 4 4 Visual dimness 1 1 CI; cerebral infarction,tia; transient ischemic attack, H; hemorrhage. J Korean Neurol Assoc Volume 29 No. 2,

4 김해종김대현박향이이인영차재관 Table 3. Time intervals for stroke/transient ischemic attack victims and non-stroke Stroke/TIA (n=79) Non-stroke (n=107) p-value Male, n (%) 46 (58.2) 48 (44.9) Age, yr 68.4± ± Symptom to call hours, n (%) 49 (62) 41 (38.3) Over 2 hours, n (%) 30 (38) 66 (61.7) 119 call to paramedic 5.7± ± arrival on-scene, min 119 call to arrival at 25.4± ± hospital, min Distance from the scene 7.7± ± to hospital, km Hospital, Intra-arterial 0.01 thrombolysis Possible, n (%) 46 (58.2) 42 (39.3) Impossible, n (%) 33 (41.8) 65 (60.7) Table 4. Time intervals for stroke Stroke (n=75) Cerebral Intracranial p-value infarction hemorrhage (n=45) (n=30) Male, n (%) 25 (55.6) 18 (60) 0.81 Age, yr 71.5± ± Symptom to call hr, n (%) 23 (51.1) 23 (76.7) Over 2 hours, n (%) 22 (48.9) 7 (23.3) 119 call to paramedic 5.4± ± arrival on-scene, min 119 call to arrival at 26.1± ± hospital, min Distance from the scene 8.0± ± to hospital, km Hospital, intra-arterial thrombolysis 0.81 Possible, n (%) 27 (60) 17 (56.7) Impossible, n (%) 18 (40) 13 (43.3) 고찰 부산지역 119 응급의료구급대원이뇌졸중으로판단한환자의뇌졸중진단양성예측도는 43% 였다. 과거샌프란시스코, 신시네티같은외국의주요대도시구급대원의뇌졸중양성예측도 72-77% 에비하면 본연구에서는비교적낮은양성예측도를보였다. 이런차이를보이는이유로는첫째, 외국연구들은모두지역내한두개특정대형병원의자료만분석했으나본연구는광역시내 24개병원자료를포함하고있는데이것을중재적시술이가능한대형병원자료만따로분석하면뇌졸중양성예측도는더높아진다. 따라서자료분석대상이된병원에 따라다소결과가다를수있을것이다. 둘째, 본연구는전향적연구로협조요청을받은구급대원이뇌졸중에대한판단을적극적으로하여더많은환자가포함되었을가능성도있다. 그러나뇌졸중증상과관련없는다수의환자들이포함된것을감안하면구급대원에게뇌졸중에관한교육이필요할것으로생각한다. 과거연구에의하면구급대원들에게뇌졸중교육과함께신시네티병원전단계뇌졸중척도 (Cincinnati prehosptial stroke scale) 14 같은뇌졸중진단도구를이용하면뇌졸중진단민감도및양성예측도가향상된다는연구가있는반면에 15,16 교육전후에정확성의변화가없었다는보고도있다. 12,17 이것은교육시간, 방법, 지속성, 결과에대한피드백등에따라결과가달라질수있으므로향후체계적인교육과평가가중요함을시사한다. 18 구급대원들이뇌졸중으로판단한증상중비교적정확도가높고흔한것은편마비, 언어장애, 의식장애등이었다. 응급의료서비스를통해뇌졸중집중치료실 (stroke unit) 로입원한환자를조사한최근의연구에서도세가지증상이가장흔했다. 19 이중언어장애와편마비는실제로뇌졸중증상과가장연관성이높았다. 이것은최근국내에서일반인이나응급구조대원들에게시행하고있는 Face Arm Speech Test (FAST), 20 또는 Melbourne Ambulance Stroke Screen (MASS), 21 Los Angeles Prehospital Stroke Screen (LAPSS) 22 과같이갑작스런안면마비, 팔다리마비, 언어장애가있을때뇌졸중의가능성이매우높아서즉각응급의료서비스에연락하거나신속히응급실로이송해야한다는교육의중요성을보여준다. 본연구에서환자발생신고후응급의료서비스를통해병원도착까지평균 26분이소요되었는데이것은외국의연구 41분, 63분에 11,19 비해빨랐다. 그러나뇌졸중증상확인후 2시간이내에응급의료서비스에연락을취한뇌졸중환자빈도는 62% 였다. 2시간이후에연락을취한뇌졸중환자는발생시점을모르는경우도있고정확한시간이기재가되어있지않은경우가많아서평균시간분석이불가능하였다. 그러나 38% 의환자가뇌졸중증상확인후 2시간이상경과한후응급의료서비스에연락을취한것은응급실내원까지도착지연은환자의연락지체가주원인이라고생각한다. 이전의연구에서도뇌졸중환자가응급실로내원하는경로중응급의료서비스에연락을취해서구급차를이용하는것이가장빠르다고알려져있고, 9,23-25 뇌졸중발생후병원도착까지시간지연의가장큰요인은증상발생후의료기관이나응급의료서비스에도움요청까지의시간지체였다. 11,13 뇌졸중유형별로보면증상확인후 2시간이내에연락을취 92 대한신경과학회지제 29 권제 2 호, 2011

5 일개광역시응급의료서비스에서뇌졸중후병원도착전단계의지연요인과구급대원의뇌졸중환자식별 하는경우는뇌경색환자에비해뇌출혈환자가좀더많았다. 뇌졸중에의한신경학적장애가더심한경우와 8,23,24 뇌출혈환자가 25 더일찍응급의료서비스에연락을취해서응급실에오는것을감안하면본연구에서뇌출혈환자가의식장애같은심한증상을동반한경우가더많았기때문에조기에응급의료서비스에연락을취한것으로추정할수있다. 뇌경색환자는 51% 만이증상발견후 2시간이내에응급의료서비스에연락을취하였고이중 48% 환자가혈전용해제를투여받았지만 2시간이상경과한후에응급의료서비스에연락을취한뇌경색환자중에서혈전용해제를투여받은사람은없었다. 환자이송단계에서현장도착시간, 병원도착까지걸린시간, 현장에서병원까지이동거리는뇌졸중환자군과비뇌졸중환자군간에차이가없었다. 이것은본연구가도로가잘발달된일개광역시에서시행되었고국내의응급환자후송시스템은뇌졸중환자들에게우선권 (stroke priority) 을주는체계가 26,27 아니라환자발생신고순으로구급대원들이최단거리에있는병원으로이송하기때문으로추측한다. 연구결과에서비록구급대원의뇌졸중진단양성예측도가낮았지만급성기뇌경색환자들이응급의료서비스에최소 2시간이내에연락을취하기만하면 30 분이내에각병원으로환자를이송할수있고혈전용해제를투여받을가능성이높다는것은고무적인현상이다. 뇌졸중초기에동맥내혈전용해술과같은적극적인중재적시술을받을수있는환자들이있을수있는데, 본조사에의하면각병원의치료여건이나시설을고려하지않고뇌졸중환자를이송하였다. 뇌졸중치료에적절한병원을선택해야환자의재이송을막을수있고병원전단계에서이송병원에환자정보를미리통보하는것 (prehospital notification) 이가능하다. 적절한병원의선택과함께병원도착전환자정보통보는병원도착후치료까지걸리는시간을단축시키므로 28 향후신속한급성기뇌졸중치료를위해서병원간네트워크구축과 119, 1339 를포함한국내응급의료시스템개선이필요할것으로생각한다. 본연구는조사방법에몇가지제한점이있다. 첫째, 전체뇌졸중의심환자들이다양한병원으로이송되기때문에모든환자들의정보를확인할수없어서상당수환자가누락되었다. 그러나나머지환자에대해서는신경과전문의가직접진료를하였거나진료차트와영상을확인하여비교적정확한정보를얻을수있었다. 둘째, 연구기간동안 119 를통해같은병원으로이송되었던환자중뇌졸중을의심하지않았더라도최종적으로뇌졸중진단을받았던모든환자의의무기록을확인할수없어서뇌졸중양성예측도외에민감도와위음성도등은확인할수없었다. 그러나현재까지국내에서구급대원들에의해뇌 졸중이의심되는환자에대한최종진단을확인하여그결과를평가한자료는없어서유용한자료로활용할수있을것으로생각하며향후지역내네트워크를형성하여진단민감도에대한후속연구를다시시행할계획이다. 셋째, 연구방법의한계점으로인해서환자의교육, 병력, 뇌졸중중증도등에대한상세한정보를확인할수없었는데향후여러병원이참여하는전향적인후속연구가필요할것이다. 결론적으로일개광역시구급대원들의뇌졸중양성예측도가낮아서향후뇌졸중에관한교육이필요할것으로생각한다. 그러나대부분의뇌졸중의심환자들은비교적신속히응급실로이송되므로뇌졸중환자발생시빨리응급의료시스템에연락을취하여급성기뇌졸중치료를신속하고효과적으로할수있도록대국민홍보가필요하다고생각한다. 감사의글 본연구를위해응급의료현장에서자료를취합해주신부산소방본부전구급대원들과자료분석을위해협조해주신부산시내 24개종합병원신경과전문의선생님들께감사드립니다. REFERENCES 1. Mortality rate of chronic disease. The 3rd Korea National Health and Nutritional Examination Survey, Ministry of Health and Welfare Available:from:URL: 2. Tissue plasminogen activator for acute ischemic stroke. The national institute of neurological disorders and stroke rt-pa stroke study group. N Engl J Med 1995;333: Hacke W, Donnan G, Fieschi C, Kaste M, von Kummer R, Broderick JP, et al. Association of outcome with early stroke treatment: pooled analysis of ATLANTIS, ECASS, and NINDS rt-pa stroke trials. Lancet 2004;363: Crocco TJ. Streamlining stroke care: from symptom onset to emergency department. J Emerg Med 2007;33: Chiu D, Krieger D, Villar-Cordova C, Kasner SE, Morgenstern LB, Bratina PL, et al. Intravenous tissue plasminogen activator for acute ischemic stroke: feasibility, safety, and efficacy in the first year of clinical practice. Stroke 1998;29: Barsan WG, Brott TG, Broderick JP, Haley EC, Levy DE, Marler JR. Time of hospital presentation in with acute stroke. Arch Intern Med 1993;153: Alberts MJ, Bertels C, Dawson DV. An analysis of time of presentation after stroke. JAMA 1990;263: Ryu JY, Eo EK, Kim YJ, Jung KY. Factors associated with delayed arrival at the in cases of acute stroke. J Korean Soc Emerg Med 2000; 11: Morris DL, Rosamond W, Madden K, Schultz C, Hamilton S. Prehospital and emergency department delays after acute stroke: the Genentech stroke presentation survey. Stroke 2000;31: J Korean Neurol Assoc Volume 29 No. 2,

6 김해종김대현박향이이인영차재관 10. Kothari R, Barsan W, Brott T, Broderick J, Ashbrock S. Frequency and accuracy of prehospital diagnosis of acute stroke. Stroke 1995;26: Smith WS, Isaacs M, Corry MD. Accuracy of paramedic identification of stroke and transient ischemic attack in the field. Prehosp Emerg Care 1998;2: Zweifler RM, York D, U TT, Mendizabal JE, Rothrock JF. Accuracy of paramedic diagnosis of stroke. J Stroke Cerebrovasc Dis 1998;7: Chang KC, Tseng MC, Tan TY. Prehospital delay after acute stroke in Kaohsiung, Taiwan. Stroke 2004;35: Kothari RU, Pancioli A, Liu T, Brott T, Broderick J. Cincinnati prehospital stroke scale: reproducibility and validity. Ann Emerg Med 1999;33: Bray JE, Martin J, Cooper G, Barger B, Bernard S, Bladin C. An interventional study to improve paramedic diagnosis of stroke. Prehosp Emerg Care 2005;9: Smith WS, Corry MD, Fazackerley J, Isaacs SM. Improved paramedic sensitivity in identifying stroke victims in the prehospital setting. Prehosp Emerg Care 1999;3: Frendl DM, Strauss DG, Underhill BK, Goldstein LB. Lack of impact of paramedic training and use of the cincinnati prehospital stroke scale on stroke patient identification and on-scene time. Stroke 2009;40: Bray JE, Bladin C. Success with paramedic diagnosis of stroke. Stroke 2009;40:e Handschu R, Poppe R, Rauss J, Neundorfer B, Erbguth F. Emergency calls in acute stroke. Stroke 2003;34: Nor AM, McAllister C, Louw SJ, Dyker AG, Davis M, Jenkinson D, et al. Agreement between ambulance paramedic- and physician-recorded neurological signs with face arm speech test (FAST) in acute stroke. Stroke 2004;35: Bray JE, Martin J, Cooper G, Barger B, Bernard S, Bladin C. Paramedic identification of stroke: community validation of the Melbourne ambulance stroke screen. Cerebrovasc Dis 2005;20: Kidwell CS, Saver JL, Schubert GB, Eckstein M, Starkman S. Design and retrospective analysis of the Los Angeles prehospital stroke screen (LAPSS). Prehosp Emerg Care 1998;2: Williams LS, Bruno A, Rouch D, Marriott DJ. Stroke ' knowledge of stroke. Influence on time to presentation. Stroke 1997;28: Derex L, Adeleine P, Nighoghossian N, Honnorat J, Trouillas P. Factors influencing early admission in a French stroke unit. Stroke 2002;33: Wester P, Radberg J, Lundgren B, Peltonen M. Factors associated with delayed admission to hospital and in-hospital delays in acute stroke and TIA: a prospective, multicenter study. Stroke 1999;30: Buck BH, Starkman S, Eckstein M, Kidwell CS, Haines J, Huang R, et al. Dispatcher recognition of stroke using the national academy medical priority dispatch system. Stroke 2009;40: Deakin CD, Alasaad M, King P, Thompson F. Is ambulance telephone triage using advanced medical priority dispatch protocols able to identify with acute stroke correctly? Emerg Med J 2009; 26: Kim SK, Lee SY, Bee HJ, Lee YS, Kim SY, Kang MJ. et al. Pre-hospital notification reduced the door-to-needle time for IV t-pa in acute ischemic stroke. Eur J Neurol 2009;16: 대한신경과학회지제 29 권제 2 호, 2011

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012임수진 Received : 2012. 11. 27 Reviewed : 2012. 12. 10 Accepted : 2012. 12. 12 A Clinical Study on Effect of Electro-acupuncture Treatment for Low Back Pain and Radicular Pain in Patients Diagnosed with Lumbar