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Call Me Anytime: Benefits of 911 and Getting to the Right Place

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Presentation on theme: "Call Me Anytime: Benefits of 911 and Getting to the Right Place"— Presentation transcript:

1 Call Me Anytime: Benefits of 911 and Getting to the Right Place
Mack Hutchison, BS, AS, NREMT-P Quality Manager

2 History of EMS The good Samaritan rendered aid to a man laying on the side of the road. Napoleon’s chief physician was the first to develop Pre-Hospital care in 1797. The United States first recognized the need for Pre-Hospital care after the first year of the Civil War.

3 History of EMS 1971, the hit television show “Emergency” caught the attention of the public prompting growing concern for their health. 1985, Trauma became a concern for EMS

4 Stroke Facts Every 45 seconds someone in America has a stroke.
About 700,000 Americans will have a new or recurrent stroke this year and over 163,000 of them will die (making it the third leading cause of death in the USA). There are approximately 266,000 stroke survivors with permanent disabilities.

5 More Stroke Facts Fewer than one in five Americans can identify even one stroke symptom. The economic impact of stroke is estimated to cost $40-$70 billion per year. A stroke can be devastating, that's why it's so important to minimize your risk. “CALL 911”

6 Case Presentation After returning home from the supermarket, a woman finds her 67-year-old husband in the kitchen with slurred speech and left-sided weakness. He was acting normally when she left the house earlier that evening. She immediately calls her friend across the street to ask for help. The friend arrives a few minutes later only to find that the patient’s symptoms are getting worse. They decide to call EMS personnel arrive within 5 minutes of the call. Paramedics evaluate the patient and are concerned that the patient may be having a stroke. What are the important elements of the pre-hospital management of potential stroke patients?

7 Stroke Presentation Objectives:
Describe the importance of rapid detection of CVA/TIA symptoms in the pre-hospital setting Describe why extensive neurological examinations are inappropriate in the pre- hospital setting Differentiate a Primary Stroke Center from a Comprehensive Stroke Center

8 Pre-hospital Management of Stroke
Detection Dispatch Delivery Door Detection: EMS personnel as well as laypersons should understand the symptoms of stroke and be able to recognize it early. Just as EMS personnel have been instrumental in educating their communities about the symptoms of a heart attack, so too should they play an important role in educating the public about stroke. -         Dispatch: As part of the educational campaign for stroke, laypersons should understand the important role of 911 in caring for stroke patients. Similarly, EMS dispatch protocols should reflect the emergent nature that stroke presents. -         Delivery: EMS personnel should be competent in the prehospital assessment and management of potential stroke victims. Initial patient stabilization and exclusion of other alternative etiologies should be performed in a timely fashion. -         Door: Patients should be triaged to appropriate hospitals capable of timely stroke care and intervention. Additionally, EMS personnel should assure a smooth transition of patient care from the prehospital setting. This includes direct contact with the healthcare providers of the receiving institution.

9 Pre-hospital Emergency Care 1999
A lack of awareness/understanding of TIAs A common sentiment that strokes could be managed non-emergently Less than half of survey participants were aware of the 3-hour time window for IV tPA. Three hundred fifty-five EMS personnel participated in this survey (256 paramedics and 99 advanced EMTs). A separate study by Kothari et al. found that paramedic diagnosis of stroke/TIA was correct in 72% of cases, yet EMS dispatchers correctly identified stroke/TIA in only 52% of cases. I

10 Time of Symptom Onset Question multiple sources
Actual time of symptoms vs. symptoms noticed How normal were they? Symptom onset: stuttering vs. acute Baseline level of neurological function The most important piece of historical information that an EMS provider can obtain is the time of symptom onset, and prehospital care providers are often in a unique position to do so. Friends, family, or bystanders are often immediately available to prehospital personnel for questioning regarding historical details. EMS providers must remember that there is a difference between the actual time of symptom onset and the time that the patient’s symptoms were noticed. To identify the true time of symptom onset, EMS personnel should follow some simple guidelines: How normal were they? EMS personnel should try to determine if the patient’s symptoms had a stuttering pattern of progression or an abrupt onset. Additionally, it is useful to know the patient’s baseline level of neurologic function. Some patients may have had prior strokes, for instance, and their usual level of neurologic function includes left-sided hemiparesis or slurred speech.

11 Pre-hospital Care Airway, Breathing, Circulation Assess vital signs
Neurologic exam Check serum blood sugar Determine time of onset Oxygen, IV, Monitor Notify the ED quickly      Airway, Breathing, Circulation: The ABCs are the foundation of emergency care and should be the first priority in stroke care just as it is in trauma management and cardiac arrest care. -         Assess vital signs: Blood pressure, heart rate, and respiratory rate may suggest the reason for the patient’s symptoms. Their early measurement is vital. -         Neurologic exam: Determine a Glasgow Coma Score and perform a prehospital stroke scale assessment. -         Check serum blood sugar: A serum blood sugar should be measured in any patient with an altered mental status. Additionally, hypoglycemia can mimic the symptoms of a stroke and should be excluded only after objective blood sugar measurement. -         Determine time of onset: Even if outside of the therapeutic window for intravenous or intra-arterial thrombolysis, knowing the time of symptom onset can be beneficial to the care of the patient. This may help in the interpretation of brain imaging and determining optimal patient management. -         En route: Establish an IV, O2, monitor. Cardiac monitoring and insertion of an IV can be helpful for the recognition and management of arrhythmias. Oxygen has not demonstrated any definitive benefit but should certainly be provided to any patient with hypoxemia. -         Notify the ED quickly: Early notification allows emergency department staff to mobilize resources and prepare for the patient’s arrival. -         Transport as soon as possible: Remember, time is brain!

12 What not to do Do not delay transport.
Do not give large volumes of fluid (unless the patient is in shock). Do not give dextrose (unless hypoglycemic). Do not lower blood pressure. Do not forget to determine time of onset. Unless the patient has significant hypotension, large volumes of intravenous fluid should not be administered. Large boluses of crystalloid may result in worsening brain edema and subsequent herniation. -         Do not give dextrose (unless hypoglycemic). Dextrose should only be administered in the setting of hypoglycemia. It is uncertain whether hyperglycemia worsens outcomes from stroke, but until further data is available, dextrose should only be utilized in the setting of hypoglycemia. -         Do not lower blood pressure. The prehospital reduction of elevated blood pressure should be avoided. Precipitous drops in blood pressure may worsen or precipitate an ischemic insult. -         Do not forget to determine time of onset.

13 Identify Time “Last Seen Normal”
A 75 year old man with HTN and diabetes finishes dinner with a friend at 8pm. He drives himself the short distance home that night, and a daughter stops by the next morning to find him still in bed and with right side weakness and severe aphasia. When do we assume the stoke occurred? (Answer: ?? A 35 year old hypertensive man who is known to be non-compliant with meds is found slumped over in his car in a job site parking area at 3pm. In the ED he was found to have a massive left hemispheric ischemic stroke. His wife said he left for work at 7am that morning as normal, and she had a clear and normal cell phone conversation with him at 12:30pm. At 1pm a co-worker stated the man said he wasn’t feeling well and was going to his car to rest. At the time the co- worker noticed his speech was slurred. What time can we use as the time “last seen normal”? (Answer: ??)

14 Case Outcome When the paramedics arrived, their first action was to evaluate the patient’s airway, breathing, and circulation status. Since these were found to be adequate, the patient’s vital signs were then assessed. The results were as follows: blood pressure = 180/96, heart rate = 106, and respiratory rate = While one paramedic then acquired some history from the patient’s wife, the other paramedic performed a concise physical examination which included a Glasgow Coma Score (GCS) and a pre-hospital stroke scale assessment.

15 Case Outcome (Cont’d)…….
Based upon the wife’s account, her husband was acting normally 45 minutes earlier when she went grocery shopping. He has never had symptoms like this before and is otherwise a very healthy person. She did not know what to do, so she called her friend across the street. By the time she arrived, he was getting worse, so she called 911. By this time, the second paramedic has determined that the patient has a GCS of 13 (E4 V3 M6). The pre- hospital stroke scale reveals the presence of left- sided facial droop, left-sided arm drift, and slurred speech.

16 Case Outcome (cont’d)……..
The paramedics then measure the patient’s blood sugar and oxygen saturation. Both are found to be normal. They explain to the patient’s wife that her husband appears to be having a stroke. Time is critical, and they encourage her to come with them since her assistance may be needed. The patient is promptly transferred to the ambulance. While enroute to the hospital, an IV is established, and the patient is placed on a cardiac monitor and low flow oxygen. The receiving hospital is contacted during the patient’s transport. Upon their arrival at the Emergency Department, the staff have already vacated a room and the physician begins evaluating the patient immediately.

17 Why you should call 911 for a Stroke
Dispatchers will offer you verbal instructions. Treatment begins when the paramedic arrives. The ambulance is the most appropriate and safest means of transportation. Inbound radio reports allow the hospital to get ready. You are transported to the closest appropriate hospital.

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21 Among patients with a proximal vessel occlusion in the anterior circulation, 60 to 80% of patients die within 90 days after stroke onset or do not regain functional independence despite alteplase treatment. We evaluated rapid endovascular treatment in addition to standard care in patients with acute ischemic stroke with a small infarct core, a proximal intracranial arterial occlusion, and moderate-to-good collateral circulation. Among patients with acute ischemic stroke with a proximal vessel occlusion, a small infarct core, and moderate-to-good collateral circulation, rapid endovascular treatment improved functional outcomes and reduced mortality. (Funded by Covidien and others;

22 Primary Stroke/comprehensive stroke Center

23 Over triage Patient taken to CSC who doesn’t need it delays tPA and starves PSC/ASRH - Volume ~ Outcomes Under triage Patient not taken to CSC who needs it delays endovascular care or neurosurgery - Transfer times for STEMI/Trauma

24 ER Goals for Acute Stroke Patients
MEMS will alert the ED in their Radio report that this is an AR Saves eligible CVA patient Stroke Alert should be done as early in the field as possible. Upon arrival to the ER, MEMS crew will stop by the Charge nurse station to have the patient received into the computer and get armbands placed. Proceed directly to CT/Radiology The primary RN will be following the EMS crew down to CT to receive report on the patient.

25 Emergent Stroke Care and the Chain of Survival
Patient Calling EMS ED Stroke Stroke Knowledge 911 System Staff Team Unit

26 Myths of EMS Facts of EMS
*Ambulance crews are trained to deal with the medical emergency that you are going to the hospital for. *Ambulances provide some of the same life-saving care that patients in emergency rooms will receive. *If you or your loved one go unconscious enroute to the hospital….what’s your plan? *I can get to the hospital before an ambulance arrives! *The ambulance is not going to do anything but take me to the hospital!

27 Summary: If you have signs of a stroke, the ambulance is the best option for you. Treatment starts when you call. Treatment continues all the way to the hospital. This sets up the best potential outcome for you!

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29 Thanks!....Mack Hutchison – MEMS QA MANAGER
GOT QUESTIONS?


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