Medical Director Message May 2022

 Spinal Injuries - May  2, 2022

As the weather (finally) improves and Northeast Ohio embraces the summer months, we all can expect to be busier in caring for the acutely injured. Blunt traumatic mechanisms—falls, motor vehicle collisions, and struck pedestrians—represent about 80% of trauma at our level I center. It is essential to consider appropriate field triage and care for those at risk for significant spine injuries. An estimated 17,000 new spinal cord injuries occur each year in the United States. Over 50% of these patients are young adults ranging in age from 16 to 30 years and predominantly male.[i] The other half represents the aging patient population which will continue to grow at a significant rate over the current decade.

When it comes to potential spine trauma, proper spine motion restriction (SMR) is essential to prevent further injury to the spinal column. In March of this year, the American College of Surgeons (ACS) released their best practice guidelines for the care of spine injuries. The indications for SMR include:

• Altered level of consciousness (GCS < 15) 

• Midline neck or back pain 

• Focal neurologic symptoms

• Deformity of the spine

• Distracting injuries or other circumstances that yield concern for injury*[i]

This last item tends to be the most challenging for providers and clinicians to define. What is a distracting injury? What circumstances put a patient at higher risk for spine injury? A distracting injury, as identified by the NEXUS study, includes: 

• long bone fractures

• crush or degloving injuries

• burns

• injuries thought to cause functional impairment.[I]

As far as circumstances are concerned, the mechanism of an injury must be considered as well as anyone who may be deemed high risk for a spine injury, such as the elderly population. If SMR is indicated in the field, the ACS recommends that full SMR be employed given the risk for multiple sites of injury along the spine. This can be achieved by keeping the entire spine in alignment using a backboard, vacuum mattress, scoop stretcher, or cot. Once at the hospital, transfer from transport equipment should be performed together with other trained individuals. These early measures have the potential to lead to better outcomes for our patients. 

Amy P. Rushing, MD, FACS

May 9, 2022

Trauma is the leading cause of the morbidity and mortality in the children and adolescents in the United States. Globally, injuries cause over a million pediatric deaths per year. Over the last twenty years, the leading cause of this has been motor vehicle crashes, but this unfortunately has been overtaken in recent years by firearm related injuries.[1] Significant cause of morbidity is traumatic brain injury leading to about 50,000 permanently disabled children per year.

The principles of treatment of traumatic brain injury in children is similar to adults. Unfortunately, there is not much we can do about the initial injury, other than injury prevention efforts. But what we can do is prevent second injury to the nervous system caused by hypotension, hypoxemia, hypothermia, and increased intracranial pressure (ICP). In 2019, the Brain Trauma Foundation updated their guidelines for the management of severe TBI.[2]

The oxygen delivery to the brain is determined by the cerebral perfusion pressure (CPP) by which is a product of the mean arterial pressure and ICP. CPP = MAP – ICP. Thus are goals of treatment are to maintain a normal CPP by ensuring a normal MAP and lower any increase in ICP. The skull is a fixed space so any edema or space occupying lesion (i.e. epidural hematoma) will increase the ICP and decrease the CPP causing potential further brain death or even death.

The steps to treating severe TBI are:

-         Ensure airway security

-         Maintain normal MAP

· Control any hemorrhage that can lead to hypovolemia and shock

· Correction coagulopathy

-         Decrease ICP

· Increase the head of bed to 30 degrees

· Minimal stimulation

· Appropriate pain and sedation medication

· Osmotherapy to decrease cerebral edema via 3% saline and mannitol

· Operative inventions to remove space occupying lesions and relieve pressure

Michael Dingeldein, MD

Pediatric Surgery 

 Status Epilepticus- May  16, 2022 

Status epilepticus is the extreme end of a spectrum of seizure durations and frequencies. Because cumulative neuronal damage develops with increasing duration or frequency, status epilepticus is a medical emergency that must be treated quickly. The importance of rapid treatment is reflected in the current definition of status epilepticus. Old definitions required that convulsions persist for more than 30 minutes without a return to baseline, but a more clinically relevant duration is more than 5 minutes (1,2).

Clinical Picture

Generalized tonic-clonic status epilepticus is the most common and potentially damaging form. A generalized tonic-clonic seizure starts with a tonic contraction of the limbs (tonic phase). The patient may arch their back and neck and scream as air is forced through the closed vocal cords. This is followed by repetitive relaxation of tone (clonic phase). The jerks decrease in amplitude and frequency over several minutes. Autonomic activity is high and patients are usually hypertensive and tachycardic. Usually a period of apnea then begins, ending with a deep inspiration and subsequent unconsciousness for minutes to hours.

Initial Stabilization

Stabilization begins with ensuring adequate airway, breathing, and hemodynamics. Oxygen saturation and cardiac monitoring are typically initiated and a neurological evaluation is performed. Once IV access is obtained, blood should be withdrawn for a complete blood count and measurement of serum glucose, sodium, calcium, magnesium, blood urea nitrogen, anticonvulsant medication levels, and a toxicology screen. If hypoglycemia is documented or suspected, intravenous glucose should be given (preceded by thiamine).

UH EMS Seizure Protocol

Most patients with status epilepticus respond to therapy with a single antiepileptic drug. The longer seizures persist, however, the more difficult they are to control. Benzodiazepines are the first line of therapy. In pre-hospital settings, 10 mg of IM Midazolam was found to be superior to 4 mg of IV Lorazepam (because of delays in obtaining IV access). Intravenous Diazepam is equally effective, but Lorazepam is preferred due to its longer half-life. If the seizures don’t resolve, benzodiazepines should be followed with intravenous Levetiracetam, Fosphenytoin, or Valproic acid. If seizures persist, anesthetic doses of Midazolam or Propofol are used (this requires intubation and ventilatory support) (3,4).

UH Status Epilepticus Triage Protocol

All patients should be routed to the closest Emergency Department. Depending on the patient’s clinical characteristics, they will remain at the community hospital, be transferred to UH Ahuja Medical Center or UH St. John’s Medical Center, or be transferred to UH Cleveland Medical Center (see below).

The clinical outcome of status epilepticus largely depends on the underlying cause, however, prompt and appropriate treatment, significantly reduces mortality and morbidity (5).

Michael A. De Georgia, MD, FACP, FAHA, FCCM, FNCS 

Maxeen Stone and John A. Flower Endowed Chair in Neurology

Director, Neurocritical Care Center

Co-Director, Cerebrovascular Center

Director, Neurocritical Care Fellowship Program

Neurological Institute

University Hospitals Cleveland Medical Center

Cleveland, Ohio

Chief, Neurological Services

University Hospitals Ahuja Medical Center

Beachwood, Ohio

Professor of Neurology

Case Western Reserve University School of Medicine

Cleveland, Ohio

Stroke - May  23, 2022

Dear Chiefs, EMS Officers, and Providers, 

May is Stroke Awareness month and the time to recognize the expertise and service of our emergency medical service providers, our nurses, and our neuroscience nurses, who are all so critical to our mission of excellence in stroke care. Over the past two years, the pandemic has challenged our caregivers with the demands of sicker patients, loss of staff requiring long work hours and extra shifts, and the added stress of personal and family illness. Now more than ever we respect your skills and wish to express our heartfelt appreciation for your resilience and strength as the first links in the chain of stroke treatment and recovery!  

The University Hospitals System Stroke Program (UHSSP) has expanded to a 23-hospital network with additional hospitals supported by Tele-stroke services. All our participating hospitals were recognized for their high-quality care by the American Heart Association/ American Stroke Association’s Get with the Guidelines-Stroke quality program. And, for the 2nd year in a row, UH-Cleveland Medical Center was the only hospital in Ohio to receive the highest awards.  

The UHSSP works with the UH-EMS Institute to communicate our integrated clinical practice guideline to deliver acute stroke triage and emergency treatment with the goal of delivering the right care to the right patient at the right location. 

The key elements of emergency, pre-hospital stroke care include:  

• Dispatch a suspected stroke as a priority.

• Minimize on-scene time, stabilizing the patient and establishing the time Last Known Well, before the onset of any stroke symptoms.  

• Perform a rapid stroke screen, with the Cincinnati pre-hospital stroke exam assessing facial droop, arm drift, and dysarthria or language deficits.   

• Perform a stroke severity assessment using the VAN scale- assessing first for any arm weakness, and if present, then assessing for any Vision, Aphasia or Neglect, which is scored as a VAN-positive. This easy and reproducible stroke severity scale is comparable in accuracy to other scales in predicting a potential large vessel occlusion.   

• Transport to the nearest certified stroke center with pre-hospital notification so the waiting stroke team joins you straight to CT. With your help, the average door-to-CT time throughout our UH health system is less than 10 minutes. 

The key elements of emergency room stroke care include:  

• Rapid blood pressure control for hemorrhagic stroke <160/90 mmHg and consulting with UH Neurosurgery for further management. 

• Prioritizing the IV thrombolysis eligibility checklist and NIHSS exam if CT is negative for hemorrhage or major early ischemic stroke signs, with a goal door-to-needle time of <30 minutes of arrival. This summer we will transition IV-tPA (Alteplase) to IV-TNK (Tenecteplase), which is an equivalent therapy with simpler administration of a bolus dose only.  

• Evaluation for a potential Large Vessel Occlusion with an emergent CT angiogram if VAN-positive or NIH Stroke Scale score ≥6 or disabling deficit and a Last Known Well within 24 hours. Images at any UH facility can be immediately viewed by the Stroke team and the plan for Neuro-intervention is communicated while patients are en route to the angio suite. 

Since only 5-10% of acute stroke patients have a large vessel occlusion eligible for mechanical thrombectomy, the widespread and STAT availability of CT angiography in all UH emergency rooms has significantly improved timely diagnosis and increased access to mechanical thrombectomy, while reducing what would otherwise be 40-73% unnecessary hospital transfers that could overwhelm major medical centers. 

Thank you for being the first link in the chain of treatment and recovery for our stroke patients. Through the UH system stroke protocols, you are helping us achieve our goal of high-value care- through emergency evaluation protocols that prioritize advanced care for patients with the most complex strokes and identify patients who can be appropriately cared for by our community stroke teams to heal with their family close to home. 

Cathy Sila, MD

Gilbert W Humphrey Endowed Professor and Chair, Department of Neurology  

Director, UH Systems Stroke Program, Neurological Institute, University Hospitals

CARES - May 30, 2022

Who CARES?

Organizations that want to improve their cardiac arrest survivability should join CARES, the Cardiac Arrest Registry to Enhance Survival. The primary goal of CARES is to improve out-of-hospital cardiac arrest survival by providing communities, EMS providers, and health care systems with vital data and resources to help them improve performance and save lives. The national CARES database is one of the largest EMS/Health Care system registries in the world and one of the few that also includes patient outcome information from hospitals. This database is used to measure and report important cardiac arrest statistics, current treatment modalities, and survival outcome comparisons. The registry allows communities to benchmark their performance with local, state, or national metrics to better identify opportunities to improve their out-of-hospital cardiac arrest (OHCA) care. 

EMS-treated OHCA affects more than 250,000 Americans each year and is the third-highest disease burden nationally based on disability-adjusted life years (DALY), behind cardiovascular disease and back pain. Municipal EMS agencies and services under University Hospitals (UH) medical control treat over 2,000 out-of-hospital cardiac arrest patients per year. Less than 30% of these patients will survive on their way to hospital admission, and about 10% will survive to discharge. Fighting complacency on calls with such low survivability is difficult, but it is imperative that we work to improve our care in any way that we can.

Why CARES? If you do not measure your performance, you do not know how many lives you are losing. Enrollment into CARES provides the ability to compare your agency’s outcomes to those locally, regionally, and nationally. Ohio CARES and University Hospitals are also using this data to help drive education and deliver resources to communities. University Hospitals agencies alone submitted data to CARES for 560 OHCAs in 2021. Additionally, utilizing Health EMS UH is one of the only hospital systems in the US that is permitted to upload PCR data directly into the database for all of our CARES enrolled agencies. This procedure eliminates the manual data entry process that lower volume agencies would normally have to use.  

What else can be done to improve? 

• Code-Stat cardiac arrest case annotation. When cardiac monitor data is transmitted to Lifenet, as is done with Health EMS and EMS Charts, a report is generated that breaks down the call in detail showing items like the first arrest rhythm, pauses in compressions, end tidal CO2 values, defibrillations, etc. This report is sent within 48 hours of the cardiac arrest and should be reviewed as soon as possible, taking note of any items in which care could have been improved.

• Zoll Care Exchange portal. University Hospitals EMS Institute is advancing EMS care by connecting field providers with the patient’s outcomes to help facilitate measurable change and close the patient care loop. Utilization of the Care Exchange portal can provide outcome information on patients your organization transported to a UH facility. This process allows clinicians to verify if their field diagnosis and treatment was accurate and use that information to help drive future care.

• Set goals for yourself and your team. Use the data to see where improvements can be made. Are you able to minimize pauses in compressions for controllable procedures? Can you deploy the LUCAS in under 10 seconds and apply defibrillator patches in under 5 seconds? 

• Contact your dispatch center. Bystander CPR is critical in ensuring that you have a viable patient to resuscitate upon arrival at the patient. Work with the dispatch center to ensure they are providing CPR instructions over the phone. Performing bystander CPR can nearly double patient survival, and public access defibrillation results in an almost 50% survival rate for patients presenting in a shockable rhythm. 

There are currently 37 agencies under UH enrolled in CARES. If you are interested in getting your agency involved and improving your OHCA care, please contact Jon Cameron at University Hospitals.

Jon Cameron

University Hospitals EMS Institute

EMS Coordinator