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Stroke Protocols


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#1 Ectopy

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Posted 10 January 2010 - 08:36 PM

Hey guys, I figured I'd let people much smarter than I have a go at this....

A stroke protocol that's been kicked around is to infuse 250 cc's NSS as well as apply low flow O2 (FiO2 of approximately .4-.5). Im having trouble understanding the potential pathophys behind this, especially in regards to the low vs. high flow 02. It seems that there is no definitive proof in the literature either way from the articles and journals I've seen.

Any help would be much appreciated.

All the best,
Matt
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Matthew George - NREMT-P, FP-C, CCP, Instructor

#2 TexRNmedic

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Posted 11 January 2010 - 12:08 AM

Hey guys, I figured I'd let people much smarter than I have a go at this....

A stroke protocol that's been kicked around is to infuse 250 cc's NSS as well as apply low flow O2 (FiO2 of approximately .4-.5). Im having trouble understanding the potential pathophys behind this, especially in regards to the low vs. high flow 02. It seems that there is no definitive proof in the literature either way from the articles and journals I've seen.

Any help would be much appreciated.

All the best,
Matt


Matt,
if you want to see research look up cerebral ischemic cascade, oxygen free radicals, oxidative effects of cellular function and vasoactive effects of oxygen. I really don't see a benefit of infusing 250ml of NS, and I believe IVF administration depends entirely on the individual patient condition. Dextrose solutions are contraindicated as it can worsen cerebral edema. Regarding oxygen administration in general, the FiO2 and method of delivery should be tailored with the goal of obtaining and maintaining a normal PaO2 (80-98). There is little benefit to having a Pa02 over 100 (dependant on oxy-hemoglobin disassociation curve and hemoglobin levels). To give a simplified answer, unnecessarily high FiO2ís may increase oxygen free radical formation, worsening cellular damage and apoptosis as well as causing negative vasoactive effects. I can remember when I started in EMS about 9 years ago, every patient was placed on a non-rebreather. Fortunately now we are encouraged to use our critical thinking skills and apply interventions based on our clinical judgment and the patientís actual needs. I hope this helps you and sets you in the right direction.

regards,
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Wes Seale
Houston , TX

#3 onearmwonder

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Posted 11 January 2010 - 12:58 AM

As well as maintaining appropriate
o2/co2 and map levels these pts. need to be well hydrated as well. Maybe that's their reasoning. Go to medscape.com...
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#4 JGreen

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Posted 11 January 2010 - 02:14 AM

Hi Matt,

I'm on vacation so I'm going to keep this one brief and I'll get back to you with supporting info:

Our protocols are very similar. 250ml bolus, mainly because our stroke guys have reported better outcomes on patient's who have received the bolus. It may just be personal preference of the MD's that are being consulted to see these patients. I've also heard tales of patients having faster resolution of symptoms when lytics are administered to the patients who have received bolus vs not.

We also transport all "stroke alerts" with the HOB flat, unless obvious s/s of bleed.

And probably our biggest and most controversial protocol is that ALL stroke alerts are transport to COMPREHENSIVE stroke centers vs. primary. We've found that when those patients are taken to primary centers that they are kept longer, intervention is delayed and more times than not they get transfered to a comprehensive center (our hospital).


Hey guys, I figured I'd let people much smarter than I have a go at this....

A stroke protocol that's been kicked around is to infuse 250 cc's NSS as well as apply low flow O2 (FiO2 of approximately .4-.5). Im having trouble understanding the potential pathophys behind this, especially in regards to the low vs. high flow 02. It seems that there is no definitive proof in the literature either way from the articles and journals I've seen.

Any help would be much appreciated.

All the best,
Matt


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#5 Ectopy

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Posted 12 January 2010 - 03:42 PM

Thanks for all the help guys, I'm studying for the CCP test and have had to look some of the stuff up in the books, but its really been helpful.

All the evidence that I've seen about the NSS bolus (regardless of hemodynamic status) seems to be personal preference of the receiving neuro team. It would be interesting to see a study comparing outcomes and providing a basis for why patients receiving a bolus "seem" to do better.


We also transport all "stroke alerts" with the HOB flat, unless obvious s/s of bleed.


Our neuro group requests 30 degree elevation as a happy medium thrombotic/hemorrhagic. Anybody have any thoughts on this?

What are some other protocols for scene contact strokes (i.e your crew is the one initiating treatment)? I've heard anecdotally of some services playing the 80/20 game of russian roulette and administering lytics pre-hospital.

All the best,

Matt
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Matthew George - NREMT-P, FP-C, CCP, Instructor

#6 dmiracco1

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Posted 12 January 2010 - 04:01 PM

Thanks for all the help guys, I'm studying for the CCP test and have had to look some of the stuff up in the books, but its really been helpful.

All the evidence that I've seen about the NSS bolus (regardless of hemodynamic status) seems to be personal preference of the receiving neuro team. It would be interesting to see a study comparing outcomes and providing a basis for why patients receiving a bolus "seem" to do better.




Our neuro group requests 30 degree elevation as a happy medium thrombotic/hemorrhagic. Anybody have any thoughts on this?

What are some other protocols for scene contact strokes (i.e your crew is the one initiating treatment)? I've heard anecdotally of some services playing the 80/20 game of russian roulette and administering lytics pre-hospital.

All the best,

Matt


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DEVIN MIRACCO
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#7 dmiracco1

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Posted 12 January 2010 - 04:17 PM

Matt,

According to the ASLS curriculum that was created by the University of Miami, you should keep the head elevated at least 15-30 degree to create a good toilet as well as to aid in decreasing ICP. Remember approximately 80-85% of strokes are Ischemic in nature. You should only apply low concentrations of oxygen unless they are truly hypoxic due to the possibility of free radicals which could in turn cause vasoconstriction. Other major things to consider would be what not to do with these patients versus what to do in the prehospital setting. Typically you do not give glucose unless there BGL is less than 50, do not treat HTN associated with a stroke as both of these have been proven to cause a bad outcome.
There is some studies currently going on as to the effectiveness of using neuroprotective agents such as mag sulfate to aid in saving the penumbra. There also looking at possibly given Insulin to these patients if they are hyperglycemic due to the increase risk of bleeding once TPA is given.
Basically the best treatment for acute stroke patients is low flow oxygen, raise head, nothing given PO and take the patient to the proper stroke center for the correct treatment.
I am not aware of any information out there showing that a 250cc bolus helps strokes patients in the long run so If you can find any literature on this let me know.
I teach the ASLS course and it is a great course that is 8 hours long that really covers a lot more information, assessment and treatment for stroke patients. If you get an opportunity to take the class you should take it as you would get a lot of useful information.

Good Luck.
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DEVIN MIRACCO
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#8 Speed

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Posted 12 January 2010 - 06:20 PM

What about anti-pyretics for >temp w/ CVA?
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#9 dmiracco1

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Posted 12 January 2010 - 09:45 PM

What about anti-pyretics for >temp w/ CVA?


Mike,

Good question, typically they will resort to antipyretics as a later intervention. Usually external cooling is the best first option if they are having a stroke with a fever. Some strokes like TBI can increase the body temperature depending on location and ICP. So really the question is did the acute stroke or injury cause the symptom or is it something underlying?
As far as pre hospital is concerned I would say external cooling is probably the best unless you have a very strict protocol that can address this issue but again nothing by mouth so it would have to be an IV medication and or cold saline IV.
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DEVIN MIRACCO
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#10 Speed

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Posted 12 January 2010 - 09:48 PM

Mike,

Good question, typically they will resort to antipyretics as a later intervention. Usually external cooling is the best first option if they are having a stroke with a fever. Some strokes like TBI can increase the body temperature depending on location and ICP. So really the question is did the acute stroke or injury cause the symptom or is it something underlying?
As far as pre hospital is concerned I would say external cooling is probably the best unless you have a very strict protocol that can address this issue but again nothing by mouth so it would have to be an IV medication and or cold saline IV.


I carry suppositories, but one could go NG if they felt the need.
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Mike Williams CCEMT-P/FP-C