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This was our panic episode when we realized that some months actually have 5 Mondays. It also happened to be national stroke awareness month. How better to merge these two things than to do a podcast on stroke. The guys work through many stroke topics and how they apply to EMS care. 

Strokes

Hemorrhagic stroke 

Is caused by bleeding into the brain by the rupture of a blood vessel. Hemorrhagic stroke may be further subdivided into intracerebral hemorrhage (ICH) and subarachnoid hemorrhage (SAH). ICH is bleeding into the brain parenchyma, and SAH is bleeding into the subarachnoid space. Hemorrhagic stroke is associated with severe morbidity and high mortality.[1] Progression of hemorrhagic stroke is associated with worse outcomes. Early diagnosis and treatment are essential given the usual rapid expansion of hemorrhage, causing sudden deterioration of consciousness and neurological dysfunction. 

Ischemic Stroke

An ischemic stroke occurs when a blood clot, known as a thrombus, blocks or plugs an artery leading to the brain. A blood clot often forms in arteries damaged by a buildup of plaques, known as atherosclerosis. It can occur in the carotid artery of the neck as well as other arteries. 

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. Large Vessel Occlusion (LVO) strokes are considered to be one of the most severe types of strokes. Patients tend to have worse outcomes and become disabled. 

• Internal carotid artery (ICA)

• Middle cerebral artery M1 or M2 segments

• Basilar artery (BA)  

Dec 2021 - Stroke laws - mandated EMS to adopt screening and triage for patients with LVO's. UH and other regional protocols have adopted the VAN score.

Different Stroke Centers

Acute StrokeReady Hospital (17 in Ohio)

• • Within 3 hours (provided through transferring the patient)

Primary Stroke Center (57 in Ohio)

• • Within 2 hours; operating room is available 24/7 in PSCs providing neurosurgical services

Thrombectomy Capable Stroke Center (5 in Ohio)

Comprehensive Stroke Center (13 in Ohio)

• • 24/7 availability of neurointerventionist, neuroradiologist, neurologist, and neurosurgeon 

EMS Care

Oxygen to maintain SpO2 > 94%, assess ability to handle secretions

• Early loss of airway in stroke suggests a hemorrhage or brainstem stroke 

Keep NPO, elevate head of bed to 30

• If nauseated or vomiting, position in left lateral recumbent position 

Hypoglycemia- can mimic an acute stroke 

Hypotension- is not a symptom of stroke 

• Treat BP systolic < 90 mmHg with Normal Saline 500 ml IV bolus

• Contact Medical Control, consider other causes   

Hypertension- is common and may be needed to maintain cerebral perfusion 

• Contact Medical Control for treatment recommendations if suspecting an acute MI or decompensated heart failure and BP diastolic >120 mmHg x 2

Last Known Well, glucose, Cincinnati Scale, VAN Scale 

Minimize On-scene Time, goal < 15 minutes

Contact Medical Control Early 

Cincinnati Prehospital Stroke Scale (On Scene)

If sudden and focal, the chance of stroke with 72% (1+ sign) to 85% (3+ signs)

• Face drooping with asymmetric smile

• Arm drift holding arm up for 10 sec

• Speech slurred, difficulty producing or understanding speech, or mute 

VAN (En route)

ARM Weakness

• Eyes closed, palms up for 10 seconds

• Negative- if no arm weakness, drift or poor grip strength

• Positive- if arm weakness is present, continue screen

Vision

• New onset blindness, Visual field defect, Double vision

• Does the patient report double-vision, field cut, or loss of vision? 

• Is it difficult for the patient to see your fingers clearly in a visual quadrant?

Aphasia

• Expressive- unable to name or repeat

• Receptive- cannot follow commands

• Global- cannot speak or understand

• Can the patient form words without difficulty? Can they repeat a short sentence? Can they recognize two objects correctly?

Neglect - Forced gaze, Ignoring one side, No insight to deficit

VAN PLUS

Quick screening for possible Posterior Stroke. These strokes are commonly missed and treatment can be delayed if they are not identified immediately. 

2 components of the MEND Exam (finger-nose and heel-shin tests) to evaluate coordination and possible Posterior Stroke

Why VAN PLUS?

Rapid identification and treatment of a stroke patient with an LVO  improves the patient’s functional outcome.  

An Endovascular procedure called a Thrombectomy can be done up to 24 hours of last known well in eligible patients to remove the clot and  improve their chance to return to independent functioning.  

Hospital Care

UH Goals

• Straight to CT

• Door to Doctor, 10 min 

• Door to neuro expertise, 15 min 

• Door to CT read, 30 min

• Door to IV Thrombolytic therapy, 30 min 

• Door-In/ Door-Out for Transfers 60 min

• Door to Groin for Thrombectomy 45 min 

CT imagery - what are you looking for? Nothing. The CT is done to rule out bleeding. If stroke is present, and it is not hemmorhagic then the patient may be a candidate for thrombolytic therapy.

TPA vs Tenecteplase

Alteplase has been the thrombolytic of choice for acute ischaemic stroke for more than two decades. A thrombolytic which is easier to administer and with improved or comparable safety and efficacy is desirable. Tenecteplase has emerged as a potential successor, and its off-license use in acute ischaemic stroke has increased in recent years. 

A single thrombolytic agent for all indications for thrombolysis in acute ischaemic stroke is desirable in streamlining workflows. Based on recent and upcoming trials, guidelines may soon recommend Tenecteplase as a suitable alternative to alteplase. 

The Protocols

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