EMS Protocol of the Week - Stroke (Cerebrovascular Accident) (Adult and Pediatric)

We have a particularly robust stroke service at MMC, between our stroke team, ability to obtain (relatively) rapid MRIs, and neurointerventional availability for thrombectomy. That latter point is what differentiates our hospital as a Thrombectomy Stroke Center rather than just a Primary Stroke Center, which is one equipped to manage strokes medically (tPA, risk modification, etc.). This distinction is especially important for the EMS evaluation of CVA when determining the most appropriate destination to transport patients.

After assessing ABCs and ruling out hypoglycemia as a causative factor, EMS providers will ascertain a last known well time and perform a rapid assessment of patient stroke severity. While prehospital stroke scores like the Los Angeles Motor Scale (LAMS) or the Cincinnati Stroke Scale (CSS) have been studied and widely utilized, NYC began utilizing a unique scoring system a couple years ago, referred to as S-LAMS, which is essentially a modified LAMS that includes an evaluation of speech. In the years since its advent, S-LAMS has been shown to be a fast, effective way of identifying patients experiencing a stroke, and particularly ones who may be undergoing an LVO that may benefit from thrombectomy. The components of S-LAMS, along with a patient evaluation flowsheet and list of thrombectomy centers in NYC, are found in the attached appendices.

Note that this protocol is primarily for BLS providers, with nothing additional in the paramedic portion. As we previously discussed, by making stroke a “BLS call,” you ensure a more timely response and more rapid transport due to the greater availability of EMTs in the city. Keep in mind, though, that this is one of the call types where you can expect to receive an OLMC call from an EMT requesting advice on where to transport decision. All you need to know is:

-          If the S-LAMS is 3 or less, transport to the closest appropriate Primary Stroke Center

-          If the S-LAMS is 4 or more and there are no exclusion criteria (as per the appendix), transport to the closest Thrombectomy Stroke Center instead

Crews should be familiar with both S-LAMS scoring and proximity of appropriate hospitals, but if there’s any confusion, you can always refer back to this email!

As always, reach out with any questions or comments. Otherwise, see you next week! www.nycremsco.org and the protocols binder for more.

Dave

EMS Protocol of the Week - Cold Emergencies and Heat Emergencies (Adult and Pediatric)

As the weather is (finally…hopefully) getting better, it seems as good a time as any to do a quick review of temperature-related emergencies. Not a ton that should shock you from the cold emergencies protocol - the name of the game is all about removal from the exposure. Also use this opportunity to remember that you’re not dead until you’re warm and dead; keep that in mind should you encounter a cardiac arrest for someone who fell into a pond or, like, a walk-in freezer.

Note that the heat emergencies protocol is designed to have you think about both passive environmental exposures and provoked hyperthermia from things like long-distance running. The latter point becomes more significant as we consider the eventual return of marathons and the like. In these cases, obviously control of environmental exposure is important, but don’t forget about other race-related pathology as well (electrolyte derangement related to hydration status, exercise-induced collapse, arrhythmias, etc.). The Key Points/Considerations section advises OLMC contact prior to oral hydration of patients with possible water intoxication, so just keep that mind if you take a call asking if it’s okay to give someone Gatorade.

That’s all, folks! www.nycremsco.org or the protocol binder for more. Until then, stay cool/warm/temperate!

Dave