VAN Plus Stroke Assessment 

Throughout October, our EMS Continuing Education has focused on the new VAN PLUS Stroke Assessment. As EMS Providers, we are presented with updates to our protocols, treatments, and assessments each year. These changes are based on the results of new evidence, trends, and outcomes data. One of the big questions that the EMS Provider wants to know is not only what the change is but why the change is being made. This message will explain the “why”? The specifics of “how” to perform the assessment will be addressed in the current monthly continuing education and the protocol rollout next month.

Why the change to the VAN PLUS Assessment?         

Legislation, signed into law on June 22, 2021, requires the State Board of Emergency Medical, Fire, and Transportation Services to develop guidelines for the assessment, triage, and transport of stroke patients to hospitals by emergency medical service personnel. The law also requires that first responders receive training about how to properly triage stroke patients, including those experiencing Large Vessel Occlusions (LVO’s). The new law requires the use of a validated LVO assessment tool/severity score. In addition, switching from the MEND to the VAN will streamline the assessment in the back of the ambulance, provide a common language between the EMS Crew and the ED Physician, and assist with the early identification of an LVO patient to decrease the time to obtain a CT Angiogram. 

Why the emphasis on LVOs? 

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. 

What is VAN PLUS? 

VAN stands for Vision, Aphasia, 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 evaluate for a possible posterior stroke more thoroughly. The process will always start with the Cincinnati Prehospital Stroke scale as soon as you arrive on scene to a patient with a suspected stroke. The VAN PLUS assessment will be done en route to the hospital. 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, then 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 you find that 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 2 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. The specifics of this assessment will be taught in your classes over the next several months.       

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. 

Respectfully Yours,

Julie Fussner BSN, RN, CPHQ, SCRN 

Stroke Operations Manager 

Comprehensive Stroke Center 

Dominic Silvestro EMT-P, EMS-I

EMS Coordinator

University Hospitals EMS Training and Disaster Preparedness Institute   

RSV - November 8, 2021

Respiratory Syncytial Virus (RSV)

Respiratory syncytial virus (RSV) was discovered in 1956 and has since been recognized as one of the most common causes of childhood illness. It causes annual outbreaks of respiratory illnesses in all age groups. RSV usually circulates from November to March. Interestingly, as shown in the graph, this year we saw a dramatic increase in RSV starting in May. It is believed that we had less RSV last winter because of the lockdown and social distancing. As the country reopened, RSV started circulating earlier than expected.

'Clinical Description and Diagnosis

In infants and young children: RSV infection causes Bronchiolitis, an inflammation of the lower respiratory tract. One to two percent of children younger than 6 months with RSV infection may need to be hospitalized. Severe disease most commonly occurs in very young infants. Additionally, children with any of the following underlying conditions are considered at high risk:

• Premature infants

• Very young infants, especially those 6 months and younger

• Children younger than 2 years with chronic lung disease, or congenital heart disease

• Children with suppressed immune systems

• Children who have neuromuscular disorders, including those who have difficulty swallowing or clearing mucus secretions

The Bronchiolitis causes the children to have wheezing and may have increased work from breathing with Tachypnea and accessory muscle use. Since the inflammation is in the smaller airways, our usual treatments of bronchodilators like Albuterol and steroids, have little effect. The symptoms are usually the worst on day 4. Besides respiratory concerns, infants may also become dehydrated because they struggle to suck and breathe at the same time. Our treatments revolve around suctioning the airway and controlling fever. Children with low oxygen levels will need to be hospitalized.

Adults can also get RSV, in fact, those who get infected with RSV usually have mild or no symptoms. In addition, the symptoms are usually consistent with an upper respiratory tract infection which includes runny nose, sore throat, cough, headache, fatigue, and fever. The disease usually lasts less than five days.

Tony Daher, MD

Emergency Management

CO Poisoning - November 15, 2021

Driving down to Ashland today, the leaves are down, and the air is cold. During our morning EMS meeting, one of the chiefs reminded us that it is CO peak season again. I felt this would be a great topic for a Monday Morning Medical Minute.

CO: Carbon monoxide (CO) poisoning is common, potentially fatal, and probably underdiagnosed because of its nonspecific clinical presentation.CO has profound effects on oxygen transport and, to a lesser degree, peripheral oxygen utilization.

CO poisoning is most common during winter in cold climates, but it may occur in all seasons and environments. Smoke inhalation is responsible for most unintentional cases. Other potential sources of CO include: 

• Poorly functioning heating systems

• Improperly vented fuel-burning devices (kerosene heaters, charcoal grills, camping stoves, and gasoline-powered electrical generators) 

• Motor vehicles operating in poorly ventilated areas

• Hookah (water pipe) smoking   

CO diffuses rapidly across the pulmonary capillary membrane and binds to the iron moiety of heme with approximately 240 times the affinity of oxygen. The degree of carboxyhemoglobin (COHb) is a function of the relative amounts of CO and oxygen in the environment, duration of exposure, and minute ventilation.

The clinical findings of CO poisoning are highly variable and largely nonspecific. Mild to moderate CO-intoxicated patients often present with constitutional symptoms, including headache (most common), malaise, nausea, and dizziness, and may be misdiagnosed with acute viral syndromes. In the absence of concurrent trauma or burns, physical findings in CO poisoning are usually confined to alterations in mental status, ranging from mild confusion to seizures and coma. A careful neurologic examination is crucial.

Cardiac ischemia can occur. Once the diagnosis of CO intoxication is confirmed, we recommend obtaining an electrocardiogram (ECG). Cardiac biomarker evaluation is warranted in patients with ECG evidence of ischemia, symptoms suggestive of ischemia, age greater than 65 years, or a history of cardiac disease or cardiac risk factors.

As a reminder, the pulse ox doesn’t change with CO poisoning because pulse ox measures O2 dissolved in the blood, which doesn’t change with CO poisoning. In other words, the pulse ox doesn’t know the difference between oxyhemoglobin and COHB. Use your clinical skills, and the pulse ox on your monitor can measure CO and has a beneficial safety program that will alarm automatically when high CO levels are detected. It is due to CO measurement software that is made by Massimo and is incorporated in the Physio platform.

There is a lot of controversy regarding hyperbaric care for CO poisoning. Knowing that room air half-life of CO is 240 minutes and NRB 100% can drop the half-life to 90 minutes, CPAP oxygen therapy can drop to less than 20 minutes, one would think hyperbaric isn’t needed with high flow O2.  However, it’s the hyperbaric care that is thought to wash the toxic CO from the mitochondrial organelles. For that reason, EDs consider hyperbaric care for anyone with a level over 25, or pregnant over 20, since the fetal hemoglobin has a higher affinity to CO, if there was a loss of consciousness, severe acidosis ph less than 7.1, or signs of end-organ disease, like an ischemic EKG. If there is smoke, remember to consider cyanide poisoning too.

Have a safe winter, stay warm, and enjoy the holidays. And thanks for all that you do to protect our communities. 

Sincerely,

Don Spaner, MD

Lift Assists - November 22, 2021

Why do we need to do vitals on all lift assists? This is a reasonable question, especially since many of your lift assists are frequent repeaters. I also assure you; I trust your ability to know who is sick and who isn't. Unfortunately, EMS does have risks that can be liable.

The most exposure you have is sign-offs. By doing vitals on all lift assists, you are performing a safety initiative that may uncover a situation that can save a patient's life. I have seen patients from lift assists who are septic, dehydrated, malnourished, have stroke events, have myocardial infarctions, and even GI bleeds. They have traumatic events and numerous other medical emergencies. Remember the 100/100 rule. If the systolic in any geriatric patient is less than 100, or the heart rate is over 100, this needs to be explained and the patient may benefit from a medical evaluation in the emergency department. If they do break the 100/100 rule, explain the need for evaluation. If they refuse, call medical control and ask to speak to the physician. The physician can assist in getting the patient to come, or at least authorize the sign-off, and reduce your exposure.

The evaluations you are doing have been great, including ensuring the patient can ambulate, make it to the bathroom, kitchen, and bedroom, all areas needed for ADLs, and activities of daily living. I know you all can properly evaluate your patients; I'm simply asking for our long-time safety initiative to be followed for all lift assists. I appreciate all your help in getting this safety initiative back on track and always putting our patients first.

Sincerely,

Don Spaner, MD

EMS Medical Director

UH EMS Institute President