June 3, 2024

Stroke Recognition and Assessment

Each year, about 795,000 people have a stroke in the United States.1 Stroke is a leading cause of death and disability, so it is paramount for all prehospital providers to be proficient at recognizing and managing these patients. For any patient with stroke concern, or altered mental status, it is important to assess for immediate life threats, including assessment of ABCs and vital signs, as well as a blood glucose assessment.  

When examining the patient, there are many validated prehospital screening tools used when assessing for stroke. The Cincinnati Prehospital Stroke Scale (CPSS) is one of the most widely used screening tools and part of the UH Protocol. During initial assessment for suspected stroke, it is very important to gather essential history, including symptom onset and last known normal, as this will help guide possible interventions. Other information like medical history, any baseline neurologic deficits, recent trauma or surgeries, or use of anticoagulation medications may also be crucial for stroke management. 

For patients with a positive Cincinnati scale, it is important to screen for a large vessel occlusion (LVO). Large vessel occlusions are blockages of the proximal intracranial anterior and posterior circulation that account for approximately 25% of acute ischemic strokes. Identification of LVO is vital, as these patients may be candidates for mechanical thrombectomy. This procedure can be done up to 24 hours after the last known well, providing a valuable treatment option for LVO patients, who would often otherwise be left with severely disabling symptoms. Only certain hospitals have thrombectomy capabilities, so rapid identification is important for assisting the Emergency Department (ED) team to decide on advanced imaging tests and possible patient transfer. 

For the UH protocol, we also utilize the severity scoring tool, VAN Assessment for LVO. Vision, Aphasia, and Neglect (VAN) are the three components of the test.  

• Assess for arm drift. If absent, the test is negative and no further assessment is needed. If the patient does have unilateral arm drift, continue to the other parts of the VAN.  

• Vision assessment will be positive if the patient has double vision, a field cut, or loss of vision.  

• Aphasia exam includes either expressive (word finding) or receptive aphasia (unable to follow commands). 

• Neglect refers to ignoring one side of the body, denying deficits, or being unable to feel both sides at the same time.  

If any of these three parts are positive, then the VAN exam is positive.2,3

One stroke type, involving the posterior circulation, presents differently and is commonly missed by most stroke assessment tools. The patient may complain of dizziness, being unable to walk normally, and falling to one side. Ataxia, or incoordination, is the main sign of posterior stroke, which can be assessed by having the patient do the finger-to-nose and heel-to-shin testing for each side. If either of these cannot be done easily, then ataxia is likely concerning for posterior stroke.  

In addition to ischemic strokes, both traumatic and atraumatic intracranial hemorrhage can present similarly. There are many other stroke mimics as well, the most common is hypoglycemia, so it is essential to check blood glucose on all patients with stroke-like symptoms or altered mental status. Seizures and migraine headaches can also cause patients to experience symptoms like a stroke. and are often clinically indistinguishable in the prehospital environment. It is always safest to assume it could be a stroke. Obtaining additional history of seizure or history of similar symptoms with migraine headaches can be very important to pass on to the ED providers. 

Remember to assess for immediate life threats, look for hypoglycemia, and perform the CPSS. Then, if positive, assess VAN + ataxia. Additionally, the important history will assist the next providers in caring for the patient. By completing these steps effectively and efficiently, prehospital providers can provide excellent care for all stroke patients. 

References: 

1. “Stroke Facts”. Centers for Disease Control and Prevention. https://www.cdc.gov/stroke/data-research/facts-stats/ 

2. Swaminathan, A. 17 May 2018. “The VAN Assessment to Identify Large Vessel Occlusion Stroke”. https://coreem.net/journal-reviews/the-van-assessment/ 

3. Teleb, M. https://strokevan.com/

Signing off,

Amrou Sarraj, MD

Clinical Professor of Neurology, Neurology - CWRU School of Medicine

Director, Comprehensive Stroke Center - UH Cleveland Medical Center

Director, Stroke Systems, Neurological Institute - University Hospitals

Professor of Neurology, Neurology - CWRU School of Medicine

June 10, 2024

Heat Stroke: Temperature as an EMS vital sign 

The onset of summer is a great time for a refresher on heat stroke. The hallmark clinical findings in a patient suffering from heat stroke are an elevated body temperature and an altered mental status, both of which are found together in heat exposure.  

The specific temperature required for the diagnosis varies, and given the clinical variability found amongst patients, the exact temperature doesn’t matter. As a rule, however, we tend to think of heat stroke patients experiencing a temperature of more than 40 °C, (105 °F). Many EMS and “at home” thermometers are of questionable accuracy, but in the Emergency Department (ED), we tend to measure the patient’s core body temperature. 

Altered mental status can manifest itself in many ways including:  

• confusion 

• agitation and combativeness 

• disorientation and hallucinations 

• lethargy 

• seizures 

• unconsciousness

Be sure to check the glucose level of any patient with an altered mental status so as not to miss hypoglycemia, an easily treatable condition. 

The trigger for heat stroke is usually sustained heat exposure and the inability of the patient to cool themselves down. A person is more likely to encounter heat stroke at the start of the summer before the individual has had a chance to acclimate to strenuous exertion and hot, humid conditions. Scenarios include: 

• High school students during football practice on a hot afternoon.  

• Marathon runners, who are in great physical condition, but running in the summer puts them at risk for heat stroke. Luckily, large-scale marathon events often have treatment stations set up along the course in anticipation of encountering these patients.  

• Workers in a hot factory.  

• Children left in a car. 

• Police officers who are directing traffic all day at a road construction site. In this case, their uniform, the sun beating down and the heat reflecting from the black road surface sets them up for trouble. 

Your body is basically a chemical furnace, burning food to create energy for life. Normally your body rids the excess heat through sweating and evaporation, radiation (to a cooler environment), convection (fans or a breeze), and conduction. Exercise and absorbing heat from a hot environment increase the body’s heat production. If the patient cannot rid themselves of heat fast enough to keep up with the heat load, then their body temperature will rise. At some point, the thermoregulatory mechanisms are so overwhelmed that the individual’s body temperature will skyrocket, and the patient is in full-blown heat stroke. Without rapid intervention, this can be fatal! 

Pre-hospital care for patients with heat stroke can be lifesaving. Recognizing the heat stroke triad of an elevated body temperature, an altered mental status and heat exposure makes this diagnosis and initiates rapid interventions to cool the patient down:  

• Getting the patient out of the hot environment (the sun, the factory, the car) and into an air-conditioned squad.  

• Removing clothing and cooling them with a water spray bottle and a fan, and adding ice packs to the patient’s body.  

• Ice water immersion (one of the fastest ways to cool a patient down). Summer marathons often have large tubs of ice water set up just for this purpose. EMS can also rapidly create a make-shift cold water tank by placing the patient in a body bag with ice, or by wrapping them in a tarp or a MegaMover® and covering them with ice.  

The most important concept is to initiate rapid cooling in the field. Don’t wait to get the patient to the ED to initiate aggressive cooling. Every minute matters in stopping the progression of the disease process to optimizing the patient’s chances for recovery.   

There are several other conditions to keep in mind when considering the diagnosis of heat stroke: 

• Heat exhaustion: Patients may present with a normal or mildly elevated body temperature and a normal mental status.  

• Sepsis: Patients can certainly present with a fever and an altered mentation, but they typically lack the heat exposure as a precipitating event, and often their infectious etiology is obvious (cough and respiratory symptoms, foley catheter with malodorous and cloudy urine, marked abdominal pain from diverticulitis, appendicitis, or cholecystitis (gall bladder issues), etc.).  

• Meningitis: Patients with another serious infection that can present with fever, a headache, and sometimes an accompanying altered mental status. Like sepsis, however, the heat exposure component of the triad is missing. 

Rapid cooling saves lives and needs to be EMS initiated.  

Be safe and have a great summer! 

Signing off,

Jay Carter, MSEE, MD, FACEP, FAEMS  

June 17, 2024

Near Drowning

With summer comes an increase in water sports and an increase in EMS responses to victims of drowning. Many of the 5,000 drowning deaths per year in the U.S. occur in swimming pools, lakes, ponds, at beaches and in hot tubs. Drowning is one of the leading causes of accidental death in children, so the beginning of summer is a great time to review the treatment of both drowning patients and cardiac arrest care in pediatric patients. Reviewing and practicing pediatric airway skills (bag-valve-mask ventilation, oral airway, supra-glottic airway and endotracheal tube sizing and placement), as well as the dosing of pediatric resuscitative medications, will improve patient outcomes. 

When responding to any EMS call, Scene Safety (Rescuer Safety) is always the number one concern. We want our safety forces personnel to remain healthy and not become additional patients on the scene. This is particularly important in water rescue scenarios since the rescuer can become a second victim from a failed rescue attempt. The safest water rescue technique for lay-rescuers is for a non-contact rescue (i.e., using a pole, rope or a flotation device). Unfortunately, in the heat of the moment, direct contact rescues are often attempted and result in multiple drowning incidents. 

EMS will evaluate conscious patients who are out of the water, alert and oriented, and who have what appears to be minor respiratory symptoms. Even a “minor cough” confirms that these patients have experienced a submersion event and warrants EMS care and transport. Keep the patient warm and provide supportive care. EMS personnel should treat any wheezing (bronchospasm) with bronchodilators, just as they would a patient experiencing asthma exacerbation. Emergency Department evaluation may lead to a sustained period of observation to watch for any progressive worsening of the patient’s respiratory functioning.  

Post-rescue patients, presenting with an altered mental status, are treated similarly to other such patients. Check the patient’s glucose level and treat hypoglycemia. Treat a seizure with benzodiazepines similar to a seizing patient who has not experienced a non-fatal drowning episode. Hypotension is managed with fluid resuscitation and pressor support if needed. It is common for these patients to be intra-vascularly dehydrated due to a cold-induced diuresis from their submersion event, so cardiac monitoring is indicated. Non-fatal drowning victims can experience arrhythmias, most commonly: sinus tachycardia, sinus bradycardia, PEA and asystole. Even young patients can demonstrate ST segment elevation from several causes other than occlusive coronary artery disease. Ventricular dysrhythmias can also occur and may be exacerbated by “breath holding,” QT prolongation issues and by simultaneous activation of the patient’s sympathetic and parasympathetic nervous system. Torsades de Pointes is a very real possibility in these patients, so remember to treat this form of ventricular tachycardia with magnesium, not with amiodarone. 

Surfactant is a chemical that normally lines the lung’s alveoli (small air sacs where gas exchange takes place). Fluid aspiration from submersion can wash out the surfactant and destroy that which remains. This can lead to progressive respiratory failure. EMS can treat the non-fatal drowning patient with continuous positive airway pressure (CPAP), but remember that CPAP is not a ventilator, and the patient must have adequate respiratory effort and ventilation for it to be applied. Also, CPAP is contraindicated in hypotensive patients since CPAP can worsen hypotension. Capnography is indicated in every patient with respiratory symptoms and can be used along with pulse oximetry, the patient’s respiratory rate and effort to trend their respiratory status. 

Patients in cardiac arrest, barring other reasons for not initiating resuscitation, should undergo cardiac resuscitation as per the usual protocols. The adage “The patient is not dead until they are warm and dead” still applies to this day. Although its origin is likely from cold water drownings, hypothermia can still be a significant factor even during the summer months. EMS can rarely measure a patient’s core body temperature which is often a factor in determining the duration of resuscitative efforts. Most drowning victims where resuscitative efforts are initiated will require transport to the emergency department before stopping efforts. Contact On-Line-Medical-Control first if considering pre-hospital termination of resuscitative efforts. Mechanical CPR devices can be utilized in the care of these patients (body size permitting).  

Patients who are agitated or combative either post-rescue or post-ROSC may require sedation, to protect the patient from harming themselves and to facilitate medical care. In the EMS setting, this can best be accomplished through the administration of benzodiazepines, as per the Behavioral / Agitation / Combative protocol.  

Any discussion involving drowning patients’ care necessitates a comment regarding cervical spine considerations. Patients who dive into shallow water are at high risk for sustaining a coexisting cervical spinal injury or could be injured from others jumping into the water and landing on top of an individual. When a cervical spinal injury exists, patients who are unconscious or have an altered mental status will automatically require cervical spinal immobilization, with the application of a cervical collar. If one must manage a patient’s airway with either a supra-glottic device or an endotracheal tube, it may be necessary to have another EMS provider maintain in-line stabilization of the patient’s head and neck while the front of the collar is temporarily released during the airway insertion. 

Thank you for providing great care to your patients! Be safe on scene and have a great summer! 

Signing off,

Jay Carter, MSEE, MD, FACEP, FAEMS  

June 24, 2024

Review of C-Spine Protocol

Every time you complete an EMS patient medical record it becomes part of the patient’s hospital medical record. Then, it undergoes a quality-of-care review and goes to your agency’s billing company. What you might not be aware of is that the data from your report is also sent to NEMSIS, the National Emergency Medical Services Information System, and becomes part of the State and National EMS databases. 

The national database shows that the most common EMS call by category is “Trauma,” which accounts for roughly one out of every five EMS calls. A quick review of the “C-Spine Protocol” is worthwhile because it is a frequently used protocol that requires significant judgement from the EMS provider. The “Spinal Motion Restriction” protocol guides the EMS provider on when to apply a cervical collar for a trauma patient and when to omit it. The cervical collar minimizes the motion of the patient’s cervical spine and prevents any additional injury from occurring after the initial traumatic event.  

One of the first judgement decisions is whether the protocol applies to your patient. A patient involved in a vehicle crash, a fall, or a significant altercation will need to undergo a cervical spine assessment. Patients with isolated extremity trauma, such as a chainsaw vs. leg injury, or where the patient denies hitting their head, are exempt from this protocol once enough is known about the injury to exclude them. 

As you approach your trauma patient, use the information you have available to you from dispatch, your scene size-up, and your initial interaction with the patient, to determine if they may have hit their head or neck. If yes, then gently apply and maintain in-line stabilization of the patient’s head and neck while you explain to them what you are doing. Ask the patient if they have any [radiating] pain, numbness, or tingling in their neck or upper back. If they do, maintain in-line stabilization while your partner applies a cervical collar, and do not have the patient perform any range-of-motion testing with their neck. 

Next, assess the patient’s mental status. A patient needs to be A&Ox4 to proceed with the remainder of their cervical spine assessment. If they have a mechanism of injury that could lead to a cervical spine injury and they are not fully A&Ox4, then they require a cervical collar. The patient’s mental status could be impaired by a head injury, drugs, alcohol, dementia, hypoglycemia, or other causes. One alcoholic beverage earlier in the evening does not necessarily make one impaired, but multiple alcoholic beverages do. Provider judgement is required in determining who is A&Ox4 and who simply gets a cervical collar without further evaluation. 

If the patient is A&Ox4 and denies neck pain, perform a motor and sensory examination of the patient’s extremities. Can they feel you touching their hands and their feet, and can they move their extremities on command? Any deficit found during the motor and sensory exam requires a cervical collar.  

The next step in “clearing” a patient’s cervical spine is a hands-on test; it can’t be done through questioning alone. Gently palpate the posterior cervical spine to assess for any pain-on-palpation, and, if present, apply a cervical collar.  

The last step in the spinal motion restriction protocol is to ask the patient to perform a gentle range of motion of their head and neck: 

• Tilt their head forward and touch their chin to their chest (flexion) 

• Look backward and up over their head (extension) 

• Rotate their head from side to side (i.e., bring their chin over towards their shoulders, a test of rotation) 

The patient needs to perform this range of motion testing themselves; the EMS provider should never manipulate the patient’s head and neck or assist them in the motion testing. If the patient experiences any pain with the range of motion testing, have them return to the neutral position (or to their position of comfort) and apply a cervical collar. 

Patients could have cervical spine injuries with other painful injuries. An example here would be if a geriatric patient experiences a fall, has a contusion and abrasion to their face or scalp, and their only complaint is significant hip pain. The hip pain can be considered a “distracting injury,” because it is masking pain from other injuries. Although the patient might have a cervical spine injury, it might not cause enough pain for them to feel in the presence of significant hip pain. A patient who has the potential for a cervical spine injury and has significant pain from another known injury should have a cervical collar placed without going through the formal “C-spine clearing” process outlined above. A pediatric patient who falls off their bicycle, hits their head, and has an obvious and painful wrist fracture is another example of a patient presenting with a possible cervical spine injury and a “distracting injury.” The assessment for what constitutes a “distracting injury” requires judgement from the EMS provider. A minor abrasion or contusion might not qualify, whereas an injury that the patient is complaining about likely does. 

If the patient requires a cervical collar, it is ideally applied with the patient’s head and neck in a neutral position (i.e., not flexed, extended, or rotated). However, you may also immobilize the patient if they prefer to hold their head and neck in a particular position. Never move a patient’s head and neck if that causes pain. In an unconscious patient, (e.g., an unconscious motorcyclist), it is permissible to carefully align the patient’s head and neck while applying a cervical collar.  

At times, one might have to perform a “rapid-rollout” extrication of a patient involved in a motor vehicle crash. A typical scenario includes a car on fire or the patient is in extremis (i.e., in the process of dying and needs to be extricated to facilitate further care and rapid transport). In such cases, one would place a cervical collar before the extrication if it can be done promptly. Otherwise, have one EMS provider maintain in-line stabilization of the patient’s head and neck during the extrication, if possible, and then apply a cervical collar as soon as possible thereafter.  

When applying a cervical collar, one can use either a classic “rigid” collar (e.g., “Philadelphia” collar) or a vacuum splint type collar (e.g., the SIPQuik Collar). The vacuum splint type cervical collars conform to pediatric and geriatric patients better than the rigid-type collars. Towel rolls and full body vacuum mattresses are other options for implementing spinal motion restrictions when a cervical collar doesn’t fit the situation at hand. 

Don’t forget the paperwork! Include in your narrative for the patient’s medical record your findings to support your decision to provide spinal motion restriction (i.e., apply a C-collar) or not. Your narrative shows that you assessed the patient’s cervical spine and it supports your actions. 

Until next week’s message, enjoy the summer, and be safe!

Jay Carter, MSEE, MD, FACEP, FAEMS