It s Not Easy Weighing the Scales! EMS Stroke Triage and the Tools We Use

Transcription

1 It s Not Easy Weighing the Scales! EMS Stroke Triage and the Tools We Use

2 Raymond L. Fowler, MD, FACEP Professor of Emergency Medicine Chief of EMS Operations Co-Chief in the Section on EMS, Disaster Medicine, and Homeland Security UT Southwestern Medical Center Emergency Medicine Attending Faculty, Parkland Memorial Hospital

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5 I made $400 last night!!!

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7 The Year was hospitals No Stroke Centers No Coordinated Care No common language No data gathering

8 What Did We Do? DCMS AHA Commitment from certain area hospitals to participate (#4) Committed our OLMC

9 The Pepe Scale

10 Within a Year Uniform pathway Voluntary participation The Pepe Scale Rotations for On Call All without funding

11 Lessons Learned Finding the differences in the system - Variations in presentation - Variations in assessment capabilities - Variations in facility capabilities THIS is the present day issue Shall medics and EMS Docs be held accountable to all three issues?

12 Lessons Learned What is the variability? Of the Medic Sensitivity/Specificity (generally a 72% sensitivity) Of the Screen Tool Sens/Specif Of the Quality of Care Sens/Specif

13 We Are Early in This! CT and tpa in the field? Customary variability among providers Something ELSE yet to come? Risk vs. Benefit Cost vs. Outcome

14 Available Tools Cincinatti (Short) Los Angeles (a bit longer) Miami (a combo, longer still) NIHSS (can it be done in the field?) snihss

15 Cincinatti Stroke Scale Face, Arms, Speech If all three findings present, probability of acute stroke ~85%

16 The Pepe Scale Emphasis on Sudden

17 Los Angeles Stroke Scale CONCLUSIONS: A motor score derived from the LAPSS rapidly quantifies stroke severity in the field and predicts functional outcomes with accuracy comparable to that of the full NIHSS and the snihss.

18 Miami Stroke Scale Cincinatti Time Last Known Normal MEND (Miami Emergency Neurologic Deficit Screen) Using the LA Motor Scale to make decision as to Primary vs. Comp

19 NIH Stroke Scale

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22 Questions to Answer #1 Does the type of Stroke Scale matter? What do we want to know? Ø Sudden Ø Different Ø Last Known Normal Ø Face Ø Extremities Ø Speech Ø New AMS? Ø How bad is it?

23 Questions to Answer #1 How accurate is it? My elderly patient who was newly confused, ataxic, and incontinent (whose serum Na+ turned out to be in the mid-160 s) Medic Understanding of pathophysiology, including educators!

24 Questions to Answer #2 How low of a specificity (how high of a false positive rate) is acceptable before hospitals begin to push back? Driven by Joint Commission pressures to get patients treated: 50% of eligible candidates within 60 minutes of arrival How low do we go?

25 Questions to Answer #3 Are CT scanners in the field the future? Shall we try to rescue in a fantastically expensive way the occasional ischemic stroke patient while we are drowning in suicidal, AIDS+, HepC+, IVDA, septic patients who LIVE in our EDs? Odd, this world that we ve created!

26 Homburg Germany: Call-to-therapydecision times were approximately 35 minutes, and clinical outcomes were good. These times dramatically break current time limits for stroke management, i.e., the doorto-therapy-decision times of 60 minutes defined as a goal by current guidelines or the 60-minute times encountered in daily clinical practice.

27 The stroke unit will be located at The University of Texas Professional Building in the Texas Medical Center. It will respond to calls within a three- mile radius and pacents will be transported to comprehensive stroke centers including Memorial Hermann- TMC, Houston Methodist Hospital and St. Luke s Medical Center. It will carry a paramedic, neurologist, nurse and CT technician and run alternate weeks as part of the clinical trial at UTHealth.

28 Ruminations #1 Beware of the patient with a sudden change in neurological status For prehospital uses, FAST + AMS absent other issues (drugs, glucose) = CVA More information will have to be gathered, but have to focus on critical issues such as airway, HOB, seizures, BP, etc.

29 Ruminations #2 What are we to do in the era of intense competition between multiple centers? Can we reliably detect in the prehospital phase who should go to a Primary SC and who to a Comprehensive SC? Can we predict in the field who will need a rapid endovascular procedure?

30 Old emergency Conclusions physicians Have a scale Train to it do not die: Their sensitivity goes up Last known normal!! Follow your data Their specificity goes down Try not to hurt anybody

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