New Mission: Lifeline Stroke Documents for Prehospital LVO care -- What You Need to Know

This past week at the International Stroke Conference in Houston, Mission: Lifeline Stroke released two documents related to prehospital LVO care.

MEDICS, TAKE NOTE. THIS IS IMPORTANT.

1. There has been much talk over the past few years about emergent assessment and treatment of strokes. In the case of an LVO (Large Vessel Occlusion), there’s a renewed interest in early suspicion of an LVO stroke and subsequent emergent transport of that patient to a stroke center where endovascular therapy (EVT) can be completed. 

2. Per MISSION: LIFELINE STROKE, “As with any algorithm, it should augment but not replace clinician judgment and may need tailoring to address the needs of the communities that implement it.”

This is a dynamic field of medicine and research continually changes. We, as medics, need to be working as part of a regional system of care. The patient should be the focus. AND, it’s a team effort that includes EMS, ED, Radiology, Neurology, Cath, Pharmacy and many others.

WHAT ARE THESE TWO DOCUMENTS?

ABOUT THE SEVERITY-BASED STROKE TRIAGE ALGORITHM FOR EMS

EVERY EMS provider should read this document. It provides the most current stance on where we have limitations (in both research and capabilities), and it also outlines three core definitions.

1. Last Known Well (LKW). This is a defined term that confirms the point at which the patient was last seen at their baseline mentation and symptom-free by a bystander (Friend? Family member?). This phrase and “Time of Symptom Discovery” may be the same if it was a witnessed stroke. But if not, these times may be hours (or even days) apart. You need to understand the difference:
   
   “I last saw grandpa doing well last night before his 9pm bedtime. But then I stopped by this afternoon around 3pm and he was unable to speak.”
   
   Here, the “Last Known Well” is 9pm the day before and the “Time of Symptom Discovery” is 3pm the following day — 18 hours later.

2. Stroke Screening Tool. This is the most common form of EMS screening and it relates specifically to the Cincinnati Prehospital Stroke Scale and the Los Angeles Prehospital Stroke Scale. In a nutshell, think of these scales as ON or OFF switches. Either stroke is suspected or a stroke is not suspected.

3. Stroke Severity Tool. There are four currently accepted scales. However, expect these tools to continue to evolve with research. Similar to the pain scale, these tools have a range. The higher the number, the greater suspicion that this stroke may be secondary to an LVO and require EVT.

SEVERITY-BASED STROKE TRIAGE ALGORITHM FOR EMS

For those of you in EMS, you’re familiar with PALS, ACLS or BLS algorithms. This algorithm follows along similar lines, but for a patient who’s having a suspected stroke:

1. Dispatched for possible stroke.
   
   
2. ABCs, History, Physical Exam.
   
   
3. Assess for presence (or absence) of a stroke using a Prehospital Stroke Screening Tool and other assessment findings such as blood glucose check.
   
   
4. If it’s a suspected stroke, continue on with the Last Known Well (LKW) and Time of Symptom Discovery. Perform and document results from the Stroke Severity Tool.
   
   (NOTE: It's critically important that your region standardizes on the same scale!)
   
   
5. From there, follow the treatment and transport options based on your local responding area, local protocols and services offered at your receiving facilities.

QUESTIONS: Do you have updated stroke protocols? Do you provide standardized training across your entire EMS system? Would you bypass the closest hospital and transport directly to an EVT-capability stroke center? What if the hospital is 15 minutes further? What if it’s a 60 minute longer drive? When would you choose to transport via air medical vs. ground?

These are the conversations we should be having in our community. 

Our patients deserve it.