Video Assessment of Stroke/AMS Patients?

[RocketMedic]

Here's a question for the world:

Stroke patients and AMS, with significant potential or actual deterioration of airway reflexes, or compromised ventilations, are often intubated in the prehospital setting, often via RSI/DSI, that involves complete sedation and paralysis. This makes sense from the perspective of life support, but it also complicates reassessment, particularly at transfer of care, especially if the patient is paralyzed. So, given this challenge, what solutions other than good handoff reports and imaging/labs are available?

My thought was an actual video assessment of the patient's initial presentation. Pictures are worth many words, right?

 

[MonkeyArrow]

There was a JAMA article a couple of months back on the legalities of using personal cell phone devices to record and transfer HIPAA-compliant things, as there must be a reasonable level of encryption and no way to deidentify the patient identifiers. The best way is a well-documented NIHSS score, as that is fairly thorough and standardized, however, requires training, which, judging by the attempted in-hospital implementation of, will be difficult to achieve in the field.

 

[SpecialK]

I don't reckon it makes a bit of difference; giving somebody a general anaesthetic and intubating them pre-hospital isn't going to change what is going on in their noggin so that same noggin is going to end up going through the CT scanner whether they're awake or not.

There could be some potential disadvantage for examining localising or focal neurological signs if they are paralysed but I'm not sure the downside outweighs the benefit, to be honest.

 

[Akulahawk]

The NIHSS is a standardized assessment method that I'm trained in. One of the difficulties with doing the full assessment is it takes time and we're pressured to not waste any of it. In the ED we do a quick assessment and off to CT we go. The NIHSS assessment happens right afterward. I can do one in about 5 minutes, maybe less. If a good NIHSS is done (helps to have the packet) in the field, I'd have something to compare my findings to. My NIHSS would be the one that's initially trusted because I'm presumably good at it.

For the field, I prefer other fast methods of screening as it's better to get the patient to a primary stroke center or comprehensive center so just do a quick screen and go from there. Let the stroke center do their work up. If you have to intubate, do it using the method your system allows and let the neurologist do their work.

I'm also all for remote assessment on stroke patients as I've seen this done in the ED and it works really well. If a neurologist can do the NIHSS with you assisting, or they can observe the patient before you must intubate, that could be beficial as they'd be able to give a recommendation where to take that patient. The same Doc could later do another NIHSS in the ED after the CT.

Just my 2 bits.

 

[VentMonkey]

What about just utilizing Succinycholine? You could also just explain that, like all meds, the paralysis will wear off. Post-RSI perhaps just utilize your sedative/ analgesic of (regional) choice.

It is what it is to me with things of this nature. Regardless of how you spin it, some EM docs won't trust your judgment or assessments for their own reasons, which is fine; others more often will. I still think at least in my area, the biggest factor is last known normal when trying to rule out a CVA. If a patient we were to bring in is having hyper-acute issues with airway control, and they need an artificial airway, then we induce. When we do a hand off we give the receiving team the most accurate last known well time, as well as an induction time.

I doubt I would be too keen on post-induction paralysis unless the patient is absolutely unable to be kept comfortably sedated in-flight, then all bets are off. At the end of the day I personally don't feel a video assessment will do much for the patient's overall outcome. The ER will still reassess, and order a CT for R/O CVA.

This is similar to some physicians at our trauma center wanting pictures of the scene/ M.O.I. Ironically enough, one of the heads of trauma surgery here is the same surgeon who harped on me as an intern how it's really not all that significant in the grander scheme of the patient's outcome and recovery. Pieces to a "then and there" puzzle? Sure, but what other purposes will it serve in the end?

 

[Akulahawk]

With trauma, knowing the mechanism can help point you to where an injury is likely to be. Mechanism itself is a poor predictor of actual injury. The reason I was thinking of using telemed as part of the initial field stroke stuff is that you have either an ED MD (or ideally) a neurologist on the other end doing the assessment and getting that done before the patient arrives at the hospital. You now have an NIHSS baseline as close to "last known well" time as you can get. The patient goes to CT and at 1 hour after the first NIHSS, a second one can be done. This leaves quite a bit of time to get other ancillary stuff going including arranging for transfer, neurosurgical team activation or tPA to be administered. In short, you're potentially speeding things up by maybe 30-45 minutes, which is a good thing (or at least not a bad thing).

 

[StCEMT]

Does it ultimately matter if they are heading straight to CT?

@Akulahawk, I'd like to actually learn more about NIHSS, but would the main benefit of doing it in the prehospital setting simply be speeding up moving the pt from the ED quicker? I tend to just meet in the middle and go with the MEND exam. I can knock it out quickly, feel like I cover my bases a little better and have yet to have any MD/RN seem to lack information during report on strokes I call in. I have recently used it on a call that the Cincinnati was not at all a strong diagnostic measure and it had enough of a hit to raise the red flag in my head.

 

[Akulahawk]

Does it ultimately matter if they are heading straight to CT?

@Akulahawk, I'd like to actually learn more about NIHSS, but would the main benefit of doing it in the prehospital setting simply be speeding up moving the pt from the ED quicker? I tend to just meet in the middle and go with the MEND exam. I can knock it out quickly, feel like I cover my bases a little better and have yet to have any MD/RN seem to lack information during report on strokes I call in. I have recently used it on a call that the Cincinnati was not at all a strong diagnostic measure and it had enough of a hit to raise the red flag in my head.

The main reason for doing the NIHSS in the field is you have the same screening and scores done in the field and in hospital and you can easily state the deficits with the ability to track changes. The MEND system should work well as it's close to the NIHSS but fast to implement. If that's also used in hospital, those scores could also be used to track changes. I'm not opposed to using MEND.

Sent from my Nexus 6 using Tapatalk

 

[Carlos Danger]

I don't reckon it makes a bit of difference; giving somebody a general anaesthetic and intubating them pre-hospital isn't going to change what is going on in their noggin so that same noggin is going to end up going through the CT scanner whether they're awake or not.

Well, CT isn't a good substitute for physical exam in these cases. Ischemic stroke and the decision to use fibrinolytics or proceed to angiography is primarily a clinical diagnosis, since CT isn't all that sensitive early in the progression of stroke. The main reason for early non-contrast CT in suspected stroke is to rule out a bleed. You may or may not see evidence of an ischemic stroke. I think it depends largely on where the lesion is.

Most ischemic strokes don't present like that, though. Deteriorating quickly enough that they need prehospital intubation probably means a bleed, which would be evident on CT and makes the specifics of the clinical exam less important.

Intubation and sedation is likely to complicate assessment and clinical decision making in the hospital; there's probably no way around that. Even if you use short acting agents (which of course you would), it could take some time for someone to become alert enough to follow specific commands, and it might be hard to determine whether continuing depressed LOC is due to the stroke, or lingering affects of sedative agents.

Video is an interesting idea. I'm generally a fan of the idea of telemedicine. I think there are potential practicality issues for sure, though.

 

[Tigger]

We are supposed to start doing NIH assessments but the rollout and education has been slow. I don't feel like I am going to ever be doing enough to make me competent and would prefer to use something like the MEND and/or an LVO scale.

We currently use the Pulsara app that allows us to send pictures to the receiving hospital, no video yet though.

On another related note, a neuro telemedicine startup visited us the other day to test their equipment, they were using a satellite connection that worked several miles west of the middle of nowhere. No idea what sort of cost would be involved, but the startup is trying to do exactly what @RocketMedic speaks of.

 

[Curt Bashford]

Doing stroke video in the field does need to be HIPAA compliant and should be FDA registered as well. Its actually easy and inexpensive (or free) for both video clips and live video from mobile devices. Both methods have utility in the real world setting. Live is ideal but the real-world is often not ideal. Sometimes the neurologist is not available when you are or the broadband is not good, so a video clip is great for documenting what you actually observed at time of presentation and for hand-off or justification for extending travel to the appropriate facility. I know of systems using e-Bridge for this. We all know that shortening time to perfusion is good for outcomes. Like the lessons learned from STEMI, process improvements lead to shorter times and time is brain. Change is what's hard.

 

[VFlutter]

We are supposed to start doing NIH assessments but the rollout and education has been slow. I don't feel like I am going to ever be doing enough to make me competent and would prefer to use something like the MEND and/or an LVO scale.

Once you do the NIH a few times you can quickly guesstimate a pretty accurate score while doing a few things simultaneously and abbreviating it a bit.

It is pretty amazing how accurately a neurologist can guess the location of the clot based off the NIH exam. It can be very specific.

 

[Tigger]

Once you do the NIH a few times you can quickly guesstimate a pretty accurate score while doing a few things simultaneously and abbreviating it a bit.

It is pretty amazing how accurately a neurologist can guess the location of the clot based off the NIH exam. It can be very specific.

I don't disagree, but the guidance thus far has been specifically to not do this. I guess I don't really have an issue with knowing my role...identify a stroke, recognize its relative severity, and transport the patient to an appropriate facility.