Episode 5 - Stroke

Stroke

Released

May 2023 - 5th Monday bonus material - Stroke awareness month

Hosts

John Hill

Scott Wildenheim

Caleb Ferroni

Ray Pace

Links

VAN Stroke Score 

Ohio Stroke Certification and Recognition Program

Ohio Stroke Center Maps

Download The Official StrokeVAN Mobile App

Episode Video and Audio

Stroke Extra Episode

Show Notes

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. 


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)


Primary Stroke Center (57 in Ohio)


Thrombectomy Capable Stroke Center (5 in Ohio)


Comprehensive Stroke Center (13 in Ohio)


EMS Care

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


Keep NPO, elevate head of bed to 30


Hypoglycemia- can mimic an acute stroke 


Hypotension- is not a symptom of stroke 


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


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)


VAN (En route)

ARM Weakness

Vision

Aphasia

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


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

From The Episode

Dr. Hill and Caleb review the importance of a detailed medication history

Caleb reacting to a real-time search regarding IO thrombolytics

Ray and Scott work through posterior stroke assessment

Scott and Caleb discuss the differential diagnosis