EMS Cast: Advanced Continuing Education for Paramedics, EMTs & Prehospital Care Providers
 

EMS Cast: Advanced Continuing Education for Paramedics, EMTs & Prehospital Care Providers

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Paramedic training is over, you’re in the front seat now. Whether day 1 or day 1,000 you can’t shake the fear you’re underprepared. You were taught to systematically decide if A... do B. But what if “A” wasn’t in the book? The truth is each emergency call is too unique to teach the right response to every situation. We need to go beyond algorithmic thinking and understand deeper principles, the WHY behind the algorithm. When every decision counts you want to rely on a framework that will guide you when things don’t make sense. EMS cast is your resource to build that framework. Through discussions with experts, review of evidence-based best practices, and real-world case studies we teach you one step past what you learned in paramedic school. But all of this advanced education is connected back to the guiding principles that answer the question- “at the end of the day, what actually matters to the patient I have in front of me?” Our mission is to elevate your practice and help you improve patient outcomes in every emergency situation. You may not feel ready, you may not feel like you know enough, but by understanding the guiding principles of emergency medicine you can become an expert EMS clinician. Because what you do matters.

Episodes

Large Vessel Occlusions (LVO)

Wednesday Apr 01, 2020

Wednesday Apr 01, 2020

First and foremost, we would like to thank all pre-hospital providers for the work you do. You are all underpaid, understaffed, and under appreciated. However, the unsung work that you do matters now more than ever. We go to work every day in order to be there when the public needs us. Much of the focus as of late has been on COVID. And probably rightfully so. But patients continue to have MI’s, strokes, overdoses and many other emergencies. And these emergencies still deserve our excellent care and diligence not to miss. So although we plan to have another special-edition, COVID-update episode we don’t want to neglect these other emergencies. So let's talk about Large Vessel Occlusions.

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Ep. 2 Large Vessel Occlusion (LVO) Show Notes

 

First and foremost we would like to thank all prehospital providers for the work you do. You are all underpaid, understaffed, and under appreciated. However, the unsung work you do now more than ever matters. We go to work every day in order to be there when the public needs us. Much of the focus as of late has been on COVID. And probably rightfully so. But that being said, patients continue to have MI’s, strokes, overdoses and many other emergencies. And these emergencies too still deserve our excellent care and diligence not to miss. So although we plan to have another special edition COVID update episode soon we don’t want to neglect these other emergencies. This month we talk Large Vessel Occlusions.

 

  • How is EST performed? 
    • A catheter is guided through one of the femoral arteries and up through the carotid and into the distal internal carotid, anterior cerebral artery or the middle cerebral artery
    • A clot retrieval device is fed through the catheter in order to retrieve the clot
    • Unlike tPA which has only shown very marginal benefit in just a few studies that were admittedly methodologically flawed. EST has recently had multiple strongly positive trials showing impressive benefits (although these benefits are likely over estimated, see the link above for a deep dive on the researches strengths and weaknesses)

 

  • Who Qualifies for EST?
    • Similar to the early days of PCI for myocardial infarctions when cath lab centers were farer and fewer between
    • Will likely vary based on your stroke center and may change with future studies so make sure you stay up to date with your local protocols.
      • Initial studies looked at less than 6 hour time window and is what the American stroke guidelines currently recommend. 
      • A lot of places have started pushing this time window further out and locally here we us a cut off of less than 24 hours
    • Initially studies for all comers with stroke receiving EST found no benefit
    • It wasn’t until they identified a subset of patients with Large Vessel Occlusions (LVO) that they began to see these impressive benefits
    • An LVO is defined as clot located in either the distal internal carotid, proximal anterior cerebral artery (ACA), or the proximal middle cerebral artery (MCA)
    • Not every stroke center has the capability to perform EST
    • What is the timeline to qualify for EST
  • So do we need to start re-organizing our transport priorities and transporting all of our suspected strokes to EST centers similarly to how we transport all of our STEMI’s to cath centers?
    • With STEMI we have a clear diagnostic tool with our EKG to determine if somebody needs the cath lab. 
      • In order to know for sure if our patient would need EST we would need a CT scanner. And not just CT but also the ability to do CT with contrast in order to see which vessel the clot is in.
      • If there is even a clot at all. Given so many mimickers of stroke on a very small percentage of patients evaluated for concern for stroke actually end up having a stroke
    • Which brings us to the second point of why we don’t want to start transporting to only EST centers: Only a select number of stroke patients, those with clots in the large proximal vessels, will benefit from this therapy. 
      • It wasn’t until later trials when they narrowed the patients they were treating to those with identified LVO in the arteries mentioned before: distal internal carotid, proximal ACA, and proximal MCA that they started finding benefit. 
      • It turns out that only 1 in 770 of stroke patients will have an occlusion meeting criteria for EST. 
      • And that's in patients who WE KNOW are having a stroke. Can you imagine what that number would be if we included everyone we just suspected of having a stroke? We would overwhelm the hospital. 
      • Early trials from 2013 looked at utilizing this therapy for all comers with stroke and found no benefit when compared to tPA alone. 
      • So even if we were sure our patient was having a stroke based on our exam they still would only benefit from transport to an EST if it was in one of these specific large and proximal vessels.
    • No, here’s where we don’t wanna get ahead of ourselves

 

  • So are there any physical exam findings to help us determine those likely to have a LVO and thus should be transported to one of these centers?
    • There’s not strong enough evidence to suggest such a protocol yet so for now keep transporting to your nearest local stroke center per your protocol 
    • But there are researchers looking at some prehospital scores to help with this question and we should be aware of and keep on the lookout for future data and research on this. See some of the prehospital scores and their associated ealy research below.
      • VAN score - vision, aphasia, neglect
        • 62 patients, 31% (19) were VAN positive
        • 90% of those had an LVO and no LVO’s occured in the VAN neg group. 
        • This is a small feasibility study. This means it was a smaller study done solely to determine if a larger more robust trial should be completed. Feasibility trials should not be used to change current care.
        • Start with bilateral arm raise for 10 seconds
          •  if any drift then proceed with the VAN assessment, 
        • If any of the following are positive in a patient with arm drift then they are considered VAN positive
          • Check all 4 quadrants one eye at a time
          • I cover one eye and ask 1 or 2 fingers in each quadrant. 
          • If the patient is having difficulty cooperating you can blink to threat in all quadrants. 
            • Move your hand quickly towards their eye from the quadrant you are testing (but don’t actually hit them).
            • If they blink you assume the vision is intact.
            • Blink to threat
          • Aphasia either expressive or receptive. 
            • Can’t say words or doesn’t say the right words 
            • Unable to understand what you are saying. 
            • Expressive
            • Receptive
          • Important: 
            • Aphasia is different from dysarthria which is slurred speech.
            • Dysarthria is not what we are testing or scoring here.
          • Have the patient close both eyes and then you touch both of their arms with your fingers and ask which arm you are touching, if the patient fails to identify the weak arm (the arm you identified with a drift earlier) this is considered neglect. 
          • Other signs of neglect are an inability to track your finger beyond midline or a forced gaze deviation to one side. 
          • Visual fields
          • The next component is Aphasia
          • Finally Neglect

 

https://www.heart.org/en/professional/quality-improvement/mission-lifeline/mission-lifeline-stroke




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