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From Scene to Suite: Central South �Regional Stroke Paramedic Stroke Workshop� 6 to 24 Hours LAMS Positive Case

Rhonda Whiteman

September 14, 2023

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Objectives

  • To review the evidence for Stroke Endovascular Therapy within the 6 to 24 Hour Window
  • To discuss the Hospital Acute Stroke 6 to 24 Hours Protocol
  • To discuss how the Hospital and Paramedic Acute Stroke Protocol work in partnership
  • To discuss LAMS evolving work

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STROKE ENDOVASCULAR THERAPY EVIDENCE 6 TO 24 HOUR WINDOW

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  • Intracerebral or Middle Cerebral Artery Occlusion
  • Independent prior to stroke
  • NIHSS > 6
  • Clinical Mismatch between stroke severity and size of infarct on CT Perfusion with RAPID Automated Software

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Outcomes�

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DAWN

(6 to 24 hours)

DEFUSE 3

(6 to 16 hours)

Time from Last Known Well to Randomization

12.2 hours

(10.2 – 16.3)

10:29 hours

(8.09 – 11:40)

Witnessed Onset of Stroke

10%

34%

Wake Up Stroke

63%

53%

Median NIHSS

17 (14 – 21)

16 (10 - 20)

Infarct Volume on CT Perfusion

7.6 (2.0 – 18.0)

19.4 (2.3 – 25.6)

Improved Functional Independence

35%

28%

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Predicting Volumes of Ischemic Patients Eligible for EVT in 6 to 24 Hour Window in Central South�2238 Ischemic Stroke Patients

*Jadhav, A.P., Jovin, T.G et al. (2018) Eligibility for Endovascular Therapy Trial Enrollment in the 6 to 24 Hour Time Window: Analysis at a Single Comprehensive Stroke Centre. Stroke. 2018; 49:1015 – 1017.DOI: 10.1161/STROKEAHA.117.020273.

10% of these cases had an NIHSS greater than 6

234 patients

30% of Patients Arrive to Hospital Within 6 to 24 Hour Window

701 patients

2.7% of these cases meet either DAWN or DEFUSE3 imaging Criteria

63 patients

1.1% of cases meet both the DAWN AND DEFUSE3 Imaging Criteria

26 patients

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Central South Regional Stroke Network RAPID Implementation

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ACUTE STROKE 6 TO 24 HOUR WINDOW PROTOCOL

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Case 3 �Stroke 6 to 24 Hour Window

  • 77 year old female who lived alone and was previously independent was taken to Juravinski Hospital via ambulance.
  • Patient was talking to family yesterday at 1900 hours. Daughter in law found patient on floor at 1300 hours. Dinner was still sitting on the table.
  • Patient presents with slurred speech, word finding difficulties, right facial droop, right arm weakness. Afib on monitor and on Xarelto.

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Paramedic Prompt Card for Acute Stroke Bypass Protocol 2018

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ED MD to Complete ACT- FAST Stroke Screen

“ARM” (one-sided arm weakness)

Position both arms at 45 degrees from the horizontal with elbows straight

POSITIVE TEST

One arm falls completely within 10 seconds of being held up.

For patients that are uncooperative or cannot follow commands:

Witness minimal or no movements in one arm & normal movement in the other arm

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“CHAT” (severe language deficit)

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Ask the patient to repeat “You can’t teach an old dog new tricks” OR perform simple tasks (“make a fist”, “open and close your eyes”)

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POSITIVE TEST

Mute, Speaking incomprehensibly, unable to follow simple commands

If RIGHT ARM is weak

“TAP” (gaze and shoulder tap test)

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Stand on patient’s LEFT side & call name

POSITIVE TEST – Consistent gaze to the RIGHT

OR

Tap LEFT shoulder & call name

POSITIVE TEST - does not quickly turn head and eyes to you (neglects left side)

If LEFT ARM is weak

Proceed if Positive

Right ✔

Left X

ED MD to ensure patient is

NOT wheelchair or bed bound or has severe dementia

Yes

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Case 3�Stroke 6 to 24 Hour Window

  • Patient was rapidly triaged as a CTAS 2 at JH and seen by the ED MD
  • ED MD found the patient was ACT-FAST Positive
  • Notified the Stroke Neurologist at HGH and the patient was transferred Code 4 to the HGH
  • At the HGH after assessment by the Stroke Neurologist, underwent CT/CTP RAPID/CTA

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Imaging

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Case Study 3 �Stroke 6 to 24 Hour Window

  • Patient presented with new onset and aphasia and right sided weakness (NIHSS 17) as a stroke within the late window

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  • Successful EVT for Right MCA LVO with 1 pass

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  • Patient was discharged to inpatient rehab after 4 days with a right facial droop, right leg drift and slurred speech (NIHSS 3)

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PREHOSPITAL AND HOSPITAL STROKE PROTOCOL

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Working in Partnership with Paramedic Services and ED Staff

  • Paramedic Services Patch LAMS Clinical Screen Positive in the 6 to 24 hours to ED
  • ED Staff know a 6 to 24 Hour Stroke case within the window on route
  • ED Staff able to do a quick assessment on stretcher and facilitate transfer to closest stroke centre for advanced imaging

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Partnership with CPER – LAMS Data

  • Need to understand the volume of LAMS positive case in the expanded window to understand the impact to inform system planning

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  • Central South Regional Stroke Program is partnering with Centre for Paramedic Education and Research to look at LAMS Positive cases in 0 – 6 Hour window and 6 to 24 Hour Window to inform system planning

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Questions

mcnicolr@hhsc.ca