The Stroke Revolution and Pivotal Role of EMS

The Stroke Revolution and Pivotal Role of EMS

By Mark Alberts, MD, FAHA Sep 05, 2017

Over the past 20 years, the acute care of stroke patients has progressed and improved significantly. This is due to a number of seminal events and advances, including improved brain and vascular imaging, the use of IV alteplase up to 4½ hours after stroke onset, and confirmation that clot removal using endovascular therapy can reduce major disability in some patients with large-artery occlusions. These advances mainly impact patients with ischemic strokes.

For patients with intracerebral hemorrhage, we now know the use of prothrombin complex concentrate is a safe and effective therapy to correct the anticoagulant effects of warfarin. For patients taking the direct thrombin inhibitor dabigatran, the use of idarucizumab rapidly reverses the anticoagulant effects and restores normal hemostasis. Patients with aneurysmal subarachnoid hemorrhage can be effectively treated with early surgery (in some cases), endovascular coiling and even stenting in complex cases, along with surgical clipping of the aneurysm.

A network of primary and comprehensive stroke centers provides the core facilities in which the above therapies are provided to patients with acute strokes. The challenge is that in many cases, patients with acute strokes may not be rapidly identified and/or transported to a stroke center, thereby delaying timely therapy. 

This is where the opportunities and challenges for prehospital care, including EMS, come into play. While the care of patients with acute stroke is of the utmost importance to many in the EMS and neuroscience communities, the reality is that calls for stroke make up only about 1%–2% of all EMS activity. The accuracy of EMS making field diagnoses of stroke is about 50% in some large series. This is understandable, since many common stroke symptoms (slurred speech, unsteady gait, confusion) can be caused by other common disease processes. 

Several recent studies have reported the accuracy of various field triage tools for distinguishing large-artery strokes from other types of strokes. These scales make up an alphabet soup of acronyms that would require a laptop computer to be functionally useful in the field. Although there is currently no consensus on the optimal scale, the larger issue is that these tools are only useful for patients with strokes. Many patients screened for stroke and EVT do not qualify, not for lack of a severe stroke but because they have not even had a stroke. The converse issue is that if EMS initially takes a patient to a hospital without sophisticated stroke services, the patient may languish there for hours and then not qualify for endovascular or other appropriate therapies. Therefore, having EMS accurately identify patients with known or suspected stroke is a critical step. 

Triage based on this diagnosis is made even more challenging due to the fragmentation of EMS care throughout the U.S. This lack of uniformity makes acute care inefficient in many cases and somewhat random in some areas. 

We do, however, have a nationwide network of primary and comprehensive stroke centers. Several studies have shown that patients cared for at PSCs or CSCs have improved outcomes compared to those cared for at general hospitals. However, of the approximately 5,000 acute care hospitals in the U.S., about 1,500 are PSCs, and perhaps 200 or 250 are CSCs. Thus, without some type of preferential triage, most stroke patients will be transported to facilities that aren’t stroke centers. 

In cases when the diagnosis of stroke is delayed or not obvious or the patient arrives at a hospital unable to make the correct diagnosis (or provide the proper acute therapy), the clinical outcome may be less than ideal. There is a certain randomness to this, since a host of factors are at play: where the patient has the event, the sophistication of EMS resources, proximity to a stroke center, time of day, etc. It is hoped that some degree of standardization of EMS systems and operations nationwide will help mitigate some of this uncertainty. 

A number of ideas are being developed to solve these issues. As you will read in the following pages and coming months, stroke registries—such as the one recently passed into law in Florida—are using big data to improve outcomes. Other technologies include field triage using iPads or cellphone audiovisual assessments, mobile stroke units and point-of-care biomarkers of acute stroke. 

What is still needed is a simple and reliable tool, analogous to a 12-lead EKG used for STEMI diagnosis in the field. Until we have such a resource, we will continue to use and refine our current tools, making diagnoses one patient at a time. Either way, EMS professionals will be the leaders in this endeavor. 

Continue Reading

Mark Alberts, MD, FAHA, is physician in chief at the Hartford HealthCare Neuroscience Institute and cochair of the Brain Attack Coalition. Reach him at Mark.Alberts@hhchealth.org.
 

Dr. Vincent Duron from the Columbia University Medical Center in New York received a $100,000 research grant to enhance standard pediatric trauma care.
The First Responders-Comprehensive Addiction and Recovery Act Grant will provide training and other resources to assist paramedics, law enforcement and health workers to prevent and treat opioid addiction.
The quake ironically struck on the anniversary of a 1985 earthquake that killed thousands of people in Mexico City.

A bus driver with a record of drunk driving crashed into another bus after speeding through an intersection in Queens, New York City, resulting in 3 deaths and multiple seriously injured patients. 

The new devices replace aging ones, allowing paramedics to provide better patient care and communicate more efficiently with the hospital.
The U.S. Department of Health and Human Services has awarded an additional $144.1 million in grants to prevent and treat opioid addiction in support of President Trump’s commitment to combat the opioid crisis.
The driver ran through a crowd of people after losing control of his vehicle, seriously injuring 11 people, several of whom were children.
The bills will provide more privacy for car accident victims who are bombarded by medical and legal offices pushing their services.
Caleb Sharpe, a student at Freeman High School, shot one student dead with a semi-automatic rifle and injured three other students until a custodian tackled and disarmed him.

An explosion at the London Tube Station has left 22 people injured and is being treated as a terrorist incident.

For more on this story, click here.

Physicians will provide free diagnoses and may even send prescriptions to the pharmacy for patients who have been displaced from Hurricane Irma.
Tourniquets are among the items in the medical kits, which are frequently used while ensuring scene safety before EMS personnel can treat patients.
While some hospitals affected by Hurricane Irma are beginning to open again, over 400 healthcare facilities statewide remain without power, water and sewer service.

An emergency crew responded to a call of a woman in labor in her home during Hurricane Irma.

The Orlando Fire Department began answering calls this morning after being on lockdown for eight hours while Hurricane Irma brought 50mph winds into the city.