Urgent Care/Triage & Transport of the Severe Stroke Patient in the Field. Robert Knight, BSN, RN, CEN, NRP, CCEMT/P INTEGRIS TeleStroke
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1 Urgent Care/Triage & Transport of the Severe Stroke Patient in the Field Robert Knight, BSN, RN, CEN, NRP, CCEMT/P INTEGRIS TeleStroke
2 Suggested Protocols Suggested protocols are just that. They are not intended to replace or supersede current or active protocols or orders. Oversight by local medical director is required. Financial Disclosure: None. Employee of INTEGRIS Health Center
3 Objectives Sections / Objectives Quick review of brain anatomy Briefly discuss recent endovascular stroke trials New treatment regime Why the need for a new stroke triage tool and the new paradigm shift Stroke screening tools for EMS
4 Objectives Large vessel stroke versus small vessel stroke Correlating LVO assessment in the brain What is and how to perform the VAN exam See one do one practical application Suggested Prehospital Stroke guidelines
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8 WHY?
9 KILLS 140,000 People a year. That s about one out of every 20 deaths
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11 Each Minute Time Frame Neurons Lost Ages the brain by Every Second 32, hours Every Minute 1.9 million 3.1 weeks Every Hour 120 million 3.6 years 10 Hours 1.2 billion 36 years
12 Anatomy 1. Brain Map 2. All mammal brains and spinal cord with sensory input in back and movement in front. Spinal cord, brain stem, same orientation 3. Right vs Left side (neglect vs aphasia) 4. Gaze center used as pseudo neglect 5. Center of cortex being involved in movement & is the starting point of VAN 6. Vision in back
13 Frontal gaze center N N V A
14 A
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16 Brain: Blood Supply
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18 Penumbra (at risk) Core (irreversibly damaged)
19 Optimizing revascularization Small vessel occlusions Location of vessel occlusion is important How do you know? Symptoms & imaging
20 Optimizing revascularization Medium and large vessel occlusions Location of vessel occlusion is important How do you know? Symptoms & imaging
21 Case Example
22 You re only as good as your Collaterals This is the reason for BP and volume support in acute stroke cases
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29 STROKE is the new MI
30 NSTEMI MI MI Paradigm Shift is Needed Now Stroke STEMI NonLVO STROKE LVO Medical Txt Cath Lab TPA TPA & NeuroIR Suite LVO = Large Vessel Occlusion
31 Old Model CT of head 20 min IV & decide to go back for CTA 60 min NeuroIR team additional 30 min to come in now at 120 min New Model EMS notificatio n=fast- VAN TPA decision 45 min tpa started within min Transfer for NeuroIR Wait for read or call NeuroIR 60 to 90 min ED- CT/CTA 15 min TeleStrokenotification of NeuroIR Xfer Out of door after bolus (drip & ship)-30 minutes Retrieved from Teleb, M. J., Vertlage, A., Carter, J., Jayaraman, M. V., & McTaggart, R. A. (2016). Stroke vision, aphasia, neglect (VAN) assessment a novel emergent large vessel occlusion screening tool: pilot study and comparison with current clinical severity indices. NeuroIntervent Surg, 0, 1-5. doi: /neurintsurg
32 Assessment Tools Let s look on how we assess Stroke Patients
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34 NIHSS Gold Standard Composed of 11 items Each of which score a specific ability between 0 & 4 0 typically indicates normal function Higher score is indicative of some level of impairment Maximum score is 42 with minimum being 0 Pictures-placards to assess Takes time to assess-lengthy Environment Ref: National Institutes of Health
35 Field/ED Triage CSS = FAST We need something : Fast Easy Immediate results 60% of stroke patients call EMS more than 1 hour into symptoms
36 Stroke Clinical Tools for EMS
37 How do they compare?
38 Triage- But Are we seeing everything?
39 Ref: American Heart/American Stroke Association; Mission Lifeline
40 What if we could be better in predicting large vessel strokes?
41 Let s review some basic types of strokes and compare some prehospital large artery screening tools
42 Small Vessel / Lacunar vs Large Artery 1. Lacunar usually are either pure motor or pure sensory 2. Large artery usually have associated cortical symptoms such as Visual Field Cut, Aphasia (inability to talk or understand), or Neglect (gaze preference and ignoring one side) 3. For practical purposes we have simplified: (there are subcortical aphasias & visual field cuts from small artery strokes, etc)
43 Motor weakness used in all large vessel screening tools due to central location as well as its link to functional independence on modified rankin scale used for all 5 endovascular stroke trials Frontal Gaze Center Ability to Talk Ability to Understand Vision
44 Motor weakness used in all large vessel screening tools due to central location as well as its link to functional independence on modified rankin scale used for all 5 endovascular stroke trials Frontal Gaze Center Ability to Talk Ability to Understand Vision RACE Mohamed S Teleb et al. J NeuroIntervent Surg 2017;9: Copyright Society of NeuroInterventional Surgery. All rights reserved
45 RACE
46 Motor weakness used in all large vessel screening tools due to central location as well as its link to functional independence on modified rankin scale used for all 5 endovascular stroke trials Frontal Gaze Center Ability to Talk Ability to Understand Vision LEGS Mohamed S Teleb et al. J NeuroIntervent Surg 2017;9:
47 LEGS
48 Motor weakness used in all large vessel screening tools due to central location as well as its link to functional independence on modified rankin scale used for all 5 endovascular stroke trials Frontal Gaze Center Ability to Talk Ability to Understand Vision LAMS Mohamed S Teleb et al. J NeuroIntervent Surg 2017;9:
49 LAMS
50 Motor weakness used in all large vessel screening tools due to central location as well as its link to functional independence on modified rankin scale used for all 5 endovascular stroke trials Frontal Gaze Center Ability to Talk Ability to Understand Vision CPSSS Mohamed S Teleb et al. J NeuroIntervent Surg 2017;9:
51 CPSSS
52 Motor weakness used in all large vessel screening tools due to central location as well as its link to functional independence on modified rankin scale used for all 5 endovascular stroke trials Frontal Gaze Center Ability to Talk Ability to Understand Vision FAST-ED Mohamed S Teleb et al. J NeuroIntervent Surg 2017;9:
53 FAST ED
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56 VAN Visual Aphasia Neglect (Large Vessel Occlusions)
57 Time is Brain
58 Motor weakness used in all large vessel screening tools due to central location as well as its link to functional independence on modified rankin scale used for all 5 endovascular stroke trials Frontal Gaze Center Ability to Talk Ability to Understand Vision VAN Mohamed S Teleb et al. J NeuroIntervent Surg 2017;9:
59
60 Why use V A N? VAN is Easy to do! Identifies the Cortical Symptoms Screens for large vessel occlusions 1. Weakness 2. Visual Disturbances 3. Aphasia 4. Neglect Early screening gets the patient to where they need to be for the best outcome.
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62 Perform FAST as usual and add VAN (FAST VAN) to Stroke care If patient has any weakness with any one of the below Visual Disturbance (cross eyed, double vision, or new blindness) Aphasia (inability to speak or understand) Neglect (gaze to one side or ignoring one side) These are likely to be a large artery clot (cortical symptoms). These patients should be considered to go to a facility with EVT Stroke and Neurovascular Services
63 Hold both arms up for 10 seconds palm up. Do they have drift or severe weakness?
64 Have patient look straight ahead and ask them to tell you number of fingers on left and then right Double vision meaning eyes semi crossed, one eye out or in. Have them track your hand to right then left
65 Ask them to repeat: today is a sunny day & name 2 objects Ask them to close eyes and make a fist? If they understand and follow commands and are making words. Do Not Count Slurring of Words. Paraphasic errors are expressive aphasia.
66 Neglect is the classic term; but we added forced gaze from frontal eye fields to get more parts of the brain. Frontal lobe in addition to parietal lobe. Touch patient on right then left and then both. Can they feel right and left at same time?
67 Time of on set: < 4 hrs; > 24 hrs, or unknown
68 Usage Permission: Teleb, M,. MD
69 Conducting the VAN properly Weakness is the essential question Why? It s the middle branch of the MCA, it affects disability scales and outcomes for independence. It warrants the risk of endovascular treatment (EVT) if there is permanent motor weakness.
70 Prehospital Scales for Large Vessel Occlusion RACE LEGS LAMS VAN 3I-SS CPSSS Need to calculate score Yes Yes Yes No Yes Yes # of tests Sensitivity Specificity Mohamed S Teleb et al. J NeuroIntervent Surg 2017;9:
71 Why VAN was chosen? No calculation of numerical score which potentially leads to less observer differences: RACE, CPSS, LAMS, LEGS Uses Motor Weakness as central point/triage like LAMS, Hemiparesis only screening, making it simple for 30% of stroke codes. You don t have to finish the exam if there is no arm weakness Uses Cortical symptoms without severity/scoring allowing to screen patients with LVO despite a lower NIH stroke scale score. VAN teaches what cortical symptoms are & also the medical lingo (aphasia, neglect) Pneumonic helps tester to remember aspects tested Does not over test one division of MCA ie face, arm, and leg weaknessthis can lead to having many lacunar strokes being false +
72 Why VAN? And finally All of Oklahoma s BIG 6 Stroke Hospitals (those with EVT/IR) AGREED to utilize it!
73 Stroke Care is a TEAM Effort
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75 VAN
76 So Where Do I Go?
77 Suggested Transport Guidelines Patient presents with Stroke like symptoms LSW < 4.5 hours VAN Positive + Transport time is < 30 minutes to a Stroke Center with EVT clot removal capability Transport to the nearest Stroke Center with EVT capabilities
78 Suggested Transport Guidelines Patient presents with Stroke like symptoms Transport to the nearest Stroke Center with EVT capabilities LSW > 4.5 hours but < 24 hours VAN Positive + Transport time is < 30 minutes to a Stroke Center with EVT clot removal capability
79 Suggested Transport Guidelines Patient presents with Stroke like symptoms Transport to the nearest ED with thrombolytic capabilities (tpa) LSW < 4.5 hours VAN Positive + Transport time > 30 minutes to a Stroke Center with EVT clot removal capability
80 Suggested Transport Guidelines Patient presents with Stroke like symptoms Transport to the nearest ED with thrombolytic capabilities (tpa); if there is a LVO present prepare x-fer LSW > 4.5 hours and < 24 hours VAN Positive + or VAN - negative Transport time > 30 minutes to a EVT facility If dx. with LVO transport to Stroke Center w/evt capability
81 Suggested Transport Guidelines Patient presents with Stroke like symptoms LSW > 24 hours Transport to the nearest ED
82 True DRIP & SHIP (to a EVT facility) +VAN/LVO Notification for transfer/ transport Out of the ED < 30 minutes after tpa bolus/gtt started Transfer team educated in transfer of those w/htn & Thrombolytic infusions Protocols for transfer
83 Involvement Code Stroke Committee Involvement QI Community/Citizen/ Ist Responders/ EMS/ED/ ICU/ Rehabilitation Support Groups EMS/ED/ICU/Allied Health lab, radiology, hospitalist, rehab
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