Medical Director Message June 2024

Dr. Amrou Sarraj

Dr. Sarraj is a Director for Stroke Systems and the Comprehensive Stroke Center at UH. 

Dr. Jay Cater

Dr. Carter is an EMS Medical Director for departments under UH Lake Hospitals


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.  


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: 




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:  

 

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: 

 

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:  


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: 

 

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