Good morning,

In preparing to write this Monday Morning Message, I was thinking back on my experiences with stroke patients over the past few decades. I remember going on a stroke call and feeling sad for the patient because 20 years ago, that was it; sorry sir, you had a stroke, and this is how you’re going to spend the rest of your days. The call for a possible stroke is the same. The stroke patient and the way they present on arrival has not changed, and there is no high-tech device in the ambulance to help us care for our stroke patient. Then why do we spend time every year reviewing the research, changing and teaching new protocols, and sitting through countless stroke lectures? The answer is simple. The way we evaluate and assess a stroke patient is critical to the time-sensitive nature of stroke care. EMS is the first link in a chain of treatment that, in many cases, can lead to a more positive outcome for the patient, often restoring function and improving quality of life post-stroke. 

It all starts with the on-scene assessment. As always, you will begin your assessment with the Cincinnati Pre-hospital Stroke assessment. Assess facial droop, arm drift, and speech. If your patient has a deficit in one of these three areas, there is a 72% chance of a stroke. If there is a deficit in all three areas, there is an 85% chance they are having a stroke. This assessment should be done on the scene as soon as you make contact with the patient, provided there are no issues with the ABCs.

The next step in evaluating your stroke patient involves looking for a possible Large Vessel Occlusion.  Large Vessel Occlusions (LVOs) are blockages of the proximal intracranial anterior and posterior circulation that account for approximately 25% of acute ischemic strokes. LVO strokes are considered to be one of the most severe types of strokes. Patients tend to have worse outcomes and become disabled. Rapid identification and treatment of a stroke patient with an LVO improves the patient’s functional outcome. The VAN Assessment is the next assessment done while en route to the hospital. 

VAN stands for Vision, Aphasia, and Neglect. It is a screening tool used to assess functional neurovascular anatomy to identify an LVO. It is easy to do and requires no calculations. The patient is either VAN positive or VAN negative. The PLUS component has been added and agreed upon by our Medical Director and the UH Neurological Institute to more thoroughly evaluate for a possible posterior stroke. To start the VAN assessment, you will again look for arm drift or weakness in your patient. If no arm drift or weakness is present, the VAN portion of the assessment is done. The patient is VAN negative, and you will move on to the PLUS assessment. If arm drift or weakness is present, you will perform the components of the VAN assessment looking for deficits in Vision, the presence of Aphasia, or Neglect of one side of the body. If your patient cannot perform any one of the tasks during your VAN Assessment and the patient was positive for Arm drift or weakness, the patient is considered VAN positive. Once you determine that your patient is either VAN positive or VAN negative, you will move on to the PLUS assessment. This is done using the same two Ataxia tests we used in the MEND exam, the finger-to-nose, and the heel-to-shin tests. Report your VAN assessment findings as VAN positive or VAN negative, as well as your findings on the posterior (ataxia) assessment.

A patient with a suspected Large Vessel Occlusion, is less than 24hrs from last known well, is VAN positive, or has an NIHSS score ≥6, will be sent for an immediate CT BAT Angio of the head and neck. If an LVO is found, that patient may be a candidate for a thrombectomy, where a catheter is inserted and the clot removed with the hope of restoring and salvaging the Penumbra (salvageable brain tissue) and improving or restoring the patient’s function and quality of life.  

The UH EMS Training and Disaster Preparedness Institute will continue to work in partnership with the University Hospitals Neurovascular Institute to ensure that the care provided by our EMS services in the care of a stroke patient meets and even exceeds the current standards as part of a team approach that enables University Hospitals to continue to provide the highest quality stroke care available.

Dominic Silvestro, EMT-P, EMS-I

EMS Coordinator

PDE - December 12, 2022

Good morning,

Medicine is dynamic and ever-changing; as such, the EMS protocols must follow suit to keep up. This year is no different, and some exciting changes are taking place with this revision, set to go live in January. One of the important changes that you will be training on during this month’s CE is a revision to push dose epinephrine (PDE).

As we reviewed the last couple of years’ worth of usage and outcomes of the EMS uses of PDE, one thing became apparent. We may have written these protocols too strictly and not given enough wiggle room for adaptation to the patient’s clinical presentation. There will be 2 things affected by this change: the timing and the max dose. Otherwise, everything taught in the previous years will remain the same, such as preparation and the indications. 

Timing

In previous iterations, we asked that PDE be dosed every 2-5 mins. However, other variables may skew that number. 

• Most importantly, the time to get an actionable BP from your machine. Non-Invasive Blood Pressure (NIBP) devices are notorious for taking a long time to read in low perfusion states as it “hunts” for pulsation to do its measurements.

• If the provider is waiting for the previously described time frame to BEGIN the reading, by the time it’s available, they likely will have needed epinephrine for the time waited to start it + the read time.

• We cannot have patients hypo-perfused while waiting out some arbitrary time limit. Epinephrine is metabolized rather quickly, and even if the NIBP is started shortly after administration of the epinephrine, the tie to metabolize will likely be up anyway.

• The change will keep it very simple and note re-doses as PRN (as needed). In the most simplistic thought process, send it as soon as you know you need it.

• It is incumbent on the provider to ensure shocked patients get frequent BP reassessments. Do not allow yourself to be the NIBP “timer” and rely on yourself to remember to push the NIBP button every couple of minutes.

• Set the NIBP interval down to every minute or two; that way, nearly every time you glance down at the BP value, you will have actionable information. 

One additional word of caution about NIBP readings: “failed” readings or timed-out readings in a shocked patient should be considered “way not better”, and additional epinephrine given. Even if the machine did have a poorly timed error, the 100ths of a milligram we are giving are unlikely to hurt. This risk is really in not giving it. Remember you can always take a manual pressure if unsure, and you can always compare your BP readings with your capnography to validate the overall patient perfusion status.

Dose

Since epinephrine is metabolized quickly, by the time you know you need more, the first dose is likely “gone.” So, if the first 10mcg (1ml) doesn’t move your BP far enough, you will now be allowed to escalate subsequent doses for added effect. 

There is a caution for every push dose epinephrine box in the revision that will permit up to 50mcg (5ml) per dose. This should not be interpreted as everyone needing 50mcg right off the bat. Not everyone will need higher doses; for many, a little may go a long way. But, in sicker patients, you can escalate to meet their needs. 

Final thoughts

Epinephrine is a ubiquitous medication, and the only drug we carry with TWO DIFFERENT concentrations in the drug box. Now we are asking you to make a third concentration when using PDE. We owe it to our patients to clearly understand what concentrations are appropriate for them and what routes are safe. Given the number of uses and differing concentrations, all advanced providers should spend time understanding this before the need arises. 

Thanks,

Scott Wildenheim

Paramedic, EMSI

 PDE Part 2 and TXA - December 19, 2022

Good morning,

The way we train to mix the push dose epi is one of many ways to mathematically get the correct concentration of the medication. You are clearly permitted to know other ways to do the math. We (UH and the other participating hospitals in the Regional EMS Protocol) have decided to teach one method using the 1mg/ml epi and a 100 ml bag for several reasons:

• this method provides you with many doses (now more relevant since you may wind up escalating the dose)

• requires less work to get subsequent doses if needed

• is believed to mix the medication better than in a syringe

• uses a preparation that has been more resistant to shortages (1mg/ml vs. 0.1 mg/ml)

• can be transitioned to an IV drip if the provider wishes

• more cost-effective (1mg /ml vs. 0.1 ml/ml)

Some other exciting changes that will help improve your patient care and outcome include the ability to give tranexamic acid (TXA) in larger doses to shocked adults, as well as to pediatric patients. The adult dosing has now been increased to 2 grams (2000 mg) in the pre-hospital care arena for shocked trauma patients. None of the other preexisting protocol variables have been changed. The patients were getting 2 grams previously, broken up into 1 gram pre-hospital and 1 gram in the hospital. Giving the 2 grams out of the hospital should help with outcomes and ensure the second gram does not get missed as the patient is being routed to the OR.

The other permission change with TXA is that it can now be hand-pushed. Like previously practiced drips, that push needs to be over 10 minutes. That needs to be doubled down on; no matter the provider’s choice to mix and drip, or hand push the medication, it needs to go in over 10 minutes. IV push does not mean IV slam, so no running starts with the TXA. There are some concerns of side effects with quickly administered TXA, none of which benefit the shocked patient, specifically hypotension. 

Keep in mind that the TXA is provided in 1 gram (1000 mg) as a 10 ml vial. It means:

• that you will need to pop the top on 2 vials and draw the contents of both (20 ml). 

• You will need to use a 20 ml syringe to get all the product or be prepared to use multiple smaller syringes. 

• In addition, it takes time to update all the drug boxes in an EMS system of our size. You may find your box only has 1 early on. If this is the case, feel free to use a second box if available.

• If a second box is not available and you have not been updated to 2 vials, give what you have and make sure to explain this to the trauma center, so they know to give the other 1 gram, as well as outline this in your PCR.

There is now pediatric dosing for TXA as well. This is still in its infancy out of hospital in this region, so we are asking providers to call before the use of TXA on shocked pediatric patients (red boxed).

• Like the adult protocol, there are physiologic parameters of sustained tachycardia and hypotension caused by hemorrhagic shock as the entrance path to its use.

• The dosing, as expected, is weight-based at 15 mg/ kg, up to 1 gram.

• There is no hand push option for this currently in the protocol. 

• It will be mixed into a 100 ml bag and dripped over 10 mins. Keep in mind that hypotension in kiddos is relative to size.

• The formula to determine the lowest acceptable BP for a child is noted in the protocol, but we have already done this work for you.

• Please refer to the pediatric medication charts in the appendix tab #1. The far-right column has many resuscitation variables specific to the patient’s weight. The last number in the column is the SBP at which the patient is considered hypotensive. 

Lastly, there is also the inclusion using TOPICAL TXA for epistaxis not responding to traditional BLS care. In this case, one can pack the nostril(s) with a TXA soaked gauze product. There is no magic amount that the gauze needs to be soaked in. Whatever amount of gauze you think you will need to fill their nostril will just need to be saturated with the TXA undiluted straight from the vial. To help make this more likely to work, ensure you have the patient blow their nose to clean previous clots and use suction as necessary to make fresh blood “interface” with the medication-soaked gauze. It may not be effective in patients with clotting disorders and may not be tremendously effective in posterior bleeds.

Thank you all for your dedication to patient care. Have a happy holiday season.

Thanks,

Scott Wildenheim

Paramedic, EMSI

Happy New Year - December 26, 2022

Good morning,

In this last Monday Morning Medical Directors Message of 2022, we would like to take a minute to thank you, challenge you, and review our commitment to you as we look ahead to 2023.

Healthcare has continued to evolve, and the challenges of a pandemic, influenza, RSV, staffing and budget issues, and many other factors have made it more difficult than ever to do your job. The Medical Directors, staff, and instructors of the EMS Training and Disaster Preparedness Institute recognize this, and we would like to thank you. We are amazed at how well our EMS community adapts to these challenges. You continue to provide the highest quality care available to your patients. Your willingness to learn new protocols, procedures, and techniques is a credit to your professionalism and commitment to the communities you serve. We also want to thank you for your ideas and suggestions. Your input is critical and allows us to meet your need and provide you with the best medical direction and education possible.

Our challenge to you as we enter 2023 and beyond is that you have an open mind, are willing to learn and grow. Medicine is constantly changing, usually for the better. With those changes come changes in protocols, medications, and procedures that allow us to provide the highest quality evidence-based care to the people we serve. EMS care is driven by studies and best practices. The way we treated certain illnesses and injuries in the past may not be what is best for the patient. Remember the backboard, large fluid boluses, stacked shocks for VFib, and countless medications you use daily that are no longer used or used differently? Through evidence-based studies, we have learned over the years that there may be a better way. We need to be open-minded to the word we don’t like, “change.” We need to learn the new treatment options, accept them, and use them when protocol requires them.

The University Hospitals EMS Training and Disaster Preparedness Institute is committed to providing you with the highest level of medical direction possible. As in previous years, we will continue to provide you with evidence-based protocols and the highest quality education. We believe that our relationship with you is a partnership that allows us to learn from each other and work together to provide superior EMS care and medical services to our communities. Please feel free to contact any of our staff or medical directors at any time. We are here for you and look forward to another great year as your partner in EMS.