The Role of EMS in Emergency Cardiac & Stroke Care

1. The Role of EMS in Emergency Cardiac & Stroke Care Name, Date County, Agency

2. Objectives • Introduce Washington’s new Emergency Cardiac and Stroke System • Review cardiac & stroke protocol guidelines • Review cardiac & stroke triage tools • Administer stroke F.A.S.T. assessment • Apply triage tools • Discuss cardiac & stroke quality improvement opportunities

3. Emergency Cardiac & Stroke System Why do we need a system? What are the components? How will it work in Washington?

4. Why do we need a system? Systems minimize delays in the chain of survival Deliver the right patient, to the right place, in the right amount of time.

5. Why do we need a system? • People aren’t getting proven treatments • Only 3% strokes get t-PA • Only 35 of 95 hospital administered t-PA • Estimated 39% of heart attacks get PCI • Only 55% of hospitals give lytics under 30 min • OHCA survival rates very low • Variation in care and outcomes across the state • Population at greatest risk increasing rapidly • Time to treatment makes big difference in outcomes • Because we can do better

7. D2N and Mortality McNamara, et al.; American Journal of Cardiology 2007.05.043

9. Systems Work! • National momentum • American Heart Association/American Stroke Association • American College of Cardiology • Centers for Disease Control - CARES • Society for Chest Pain Centers • CMS • Examples • North Carolina RACE • Los Angeles • Minnesota Cardiac Level 1 • Spokane and North Puget Sound Cardiac Level 1 • Cascade HeartRescue

10. System Components Dispatch 911 Neurology / Cardiology

11. Washington’s Approach Emergency Cardiac & Stroke Technical Advisory Committee made recommendations on: • Dispatch guidelines • Standardized EMS protocol guidelines • Standardized EMS triage tools • Voluntary hospital categorization • Quality improvement & data collection • Public education

12. SSHB 2396 Passed in 2010

14. EmergencyCardiac Care Prehospital protocol guidelines Triage tool Hospital levels Partially blocked artery Completely blocked artery

15. Prehospital Protocols • NOTE: Insert your DOH approved local protocols if different from but consistent with the ACS protocol guidelines that follow this slide. You might also want to insert your CPA-ROSC protocols and any other cardiac protocols you have since the triage and destination procedure includes CPA-ROSC.

16. ACS BLS Protocol I. Scene Size-Up/Initial Patient Assessment A) Monitor/support ABC’s B) Be prepared to provide CPR/defibrillation

17. ACS BLS Protocol (cont.) II. Focused History and Physical Exam A) Assess patient for signs and symptoms of Acute Coronary Syndrome (ACS) • Chest discomfort (pressure, crushing pain, tightness, heaviness, cramping, burning, aching sensation), usually in the center of the chest lasting more than a few minutes, or that goes away and comes back. • Epigastric (stomach) discomfort, such as unexplained indigestion, belching, or pain. • Shortness of breath with or without chest discomfort. • Radiating pain or discomfort in 1 or both arms, neck, jaws, shoulders, or back.

18. ACS BLS Protocol (cont.) • Other symptoms may include sweating, nausea, vomiting, or dizziness and weakness. • Women, diabetics, and geriatric patients might not have chest discomfort or pain. Instead they might have nausea/vomiting, back or jaw pain, fatigue/weakness, or generalized complaints.

19. ACS BLS Protocol (cont.) B) If possible ACS patient – request ALS response or arrange ALS rendezvous. Optional in areas without ALS or 12-lead capable ILS: Perform 12-lead ECG according to local operating procedures, and alert receiving facility with results; repeat ECG if signs or symptoms change. C) Limit scene time with goal of ≤ 15 minutes

20. ACS BLS Protocol (cont.) III. Management A) Administer oxygen per protocol B) Administer 160 to 325 mg nonenteric-coated aspirin, crushed or chewed (unless allergy history) C) Assist patient with own nitro Contraindications: • SBP <90 mm Hg. • Severe bradycardia (heart rate < 50/min) or tachycardia (>100/min) • Erectile dysfunction drugs taken within 48 hours. Cautions: • Borderline hypotension (SBP 90 to 100 mm Hg) • Borderline bradycardia (HR<60/min) • Extreme caution in patients who may have RV infarction

21. ACS BLS Protocol (cont.) IV. Ongoing Assessment V. Transport Follow State Prehospital Cardiac Triage Destination Procedure Note: If 12 lead ECG and interpretation (by crew or machine) can be obtained in the field—obtain as soon as possible and alert receiving facility with results

22. ACS ILS Protocol I. Scene Size-Up/Initial Patient Assessment A) Monitor/support ABCs B) Be prepared to provide CPR/Defibrillation II. Focused History and Physical Exam • Assess patient for signs and symptoms of Acute Coronary Syndrome (same as in BLS) • Encourage ILS 12-lead ECG in the field and alert receiving facility with results C) If possible ACS patient – request ALS response 1) Alternative: Arrange ALS rendezvous D) Limit scene time with goal of ≤ 15 minutes

23. ACS ILS Protocol (cont.) III. Management A) Administer oxygen per protocol B) Administer 160 to 325 mg nonenteric-coated aspirin, crushed or chewed (unless allergy history) C) Administer nitro Contraindications: • SBP <90 mm Hg. • Severe bradycardia (heart rate < 50/min) or tachycardia (>100/min) • Erectile dysfunction drugs taken within 48 hours. Cautions: • Borderline hypotension (SBP 90 to 100 mm Hg) • Borderline bradycardia (HR<60/min) • Extreme caution in patients who may have RV infarction D) IV access (do not delay transport to gain IV access)

24. ACS ILS Protocol (cont.) IV. Ongoing Assessment V. Transport A) Follow State Prehospital Cardiac Triage Destination Procedure B) IV, NTG

25. ACS ALS Protocol I. Scene Size-Up/Initial Patient Assessment A) Monitor/support ABCs B) Be prepared to provide CPR/Defibrillation II. Focused History and Physical Exam • Assess patient for signs and symptoms of Acute Coronary Syndrome (same as BLS and ILS) • 12-lead ECG (repeat ECG if signs or symptoms change) • Limit scene time with goal of ≤ 15 minutes

26. ACS ALS Protocol (cont.) III. Management A) Notify receiving hospital with transmission and/or interpretation of ECG B) Administer oxygen C) Administer 160 to 325 mg nonenteric-coated aspirin, crushed or chewed (unless allergy history) D) Administer nitro Contraindications: • SBP <90 mm Hg. • Severe bradycardia (heart rate < 50/min) or tachycardia (>100/min) • Erectile dysfunction drugs taken within 48 hours. Cautions: • Borderline hypotension (SBP 90 to 100 mm Hg) • Borderline bradycardia (HR<60/min) • Extreme caution in patients who may have RV infarction E) IV access F) Administer opiates as needed for pain control G) Complete fibrinolytic checklist (recommended) H) Consider field fibrinolysis if transport time ≥ 60 minutes and acute symptom onset < 3 hours

27. ACS ALS Protocol (cont.) IV. Ongoing Assessment A) Cardiac Bio Markers (optional) B) Repeat ECG every 15 minutes V. Transport A) Follow State Prehospital Cardiac Triage Destination Procedure B) IV, NTG

28. Triaging to “the right place” • Perform PCI 24/7 within 90 minutes • Interventional cardiologists and cath lab team available within 30 minutes 24/7 • Cardiac surgery onsite or transfer agreements • Administer fibrinolytics 24/7 within 30 minutes • ACLS trained providers Level One Level Two

29. Assess Applicability for Triage • Post cardiac arrest with ROSC • -OR- • ≥ 21 years of age with symptoms lasting more than 10 minutes but less than 12 hours suspected to be caused by coronary artery disease: • Chest discomfort (pressure, crushing pain, tightness, heaviness, cramping, burning, aching sensation),usually in the center of the chest lasting more than a few minutes, or that goes away and comes back. • Pain or discomfort in 1 or both arms, neck, jaws, shoulders, or back. • Shortness of breath with or without chest discomfort. • Epigastric (stomach) discomfort, such as unexplained indigestion, belching, or pain. • Other symptoms may include sweating, nausea/vomiting, lightheadedness. • NOTE: Women, diabetics, and geriatric patients might not have chest discomfort or pain. Instead they might have nausea/vomiting, back or jaw pain, fatigue/weakness, or generalized complaints. Cardiac Triage Tool Transport per regional patient care procedures NO If ALS has not been dispatched, upgrade if available. YES • Assess Immediate Criteria • Post cardiac arrest with return of spontaneous circulation • Hypotension or pulmonary edema • EKG positive for STEMI (if available) YES

30. Cardiac Triage Tool (cont.) YES If ALS has not been dispatched, upgrade if available. • Assess High Risk Criteria • In addition to symptoms in Box 1, pt has 4 or more of the following: • Age ≥ 55 • 3 or more CAD risk factors: •  family hx • BP • cholesterol •  Diabetes •  current smoker • Aspirin use in last 7 days • ≥2 anginal events in last 24 hours, including current episode • Known coronary disease • ST deviation ≥ 0.5 (if available) • Elevated cardiac markers • (if available) • Assess Immediate Criteria • Post cardiac arrest with return of spontaneous circulation • Hypotension or pulmonary edema • EKG positive for STEMI (if available) NO YES NO YES If EMS personnel still suspect ACS, contact medical control for destination. If not, transport per regional patient care procedures.

31. Assess High Risk Criteria (4 or more) • 3 or more CAD (coronary artery disease) risk factors: • Age ≥ 55 (epidemiological data in WA State show that incidence of heart attack increases at this age) • Family history: father or brother with heart disease before 55, or mother or sister before 65 • High blood pressure: ≥140/90, or patient/family report, or on blood pressure medication • High cholesterol: patient/family report or on cholesterol medication • Diabetes: patient family report • Current smoker: patient family report • Aspirin use in last 7 days: any aspirin use in last 7 days • ≥2 anginal events in last 24 hours: 2 episodes of symptoms described in first box of the triage tool, including the current event • Known coronary disease: history of angina, heart attack, cardiac arrest, congestive heart failure, balloon angioplasty, stent, or bypass surgery • ST deviation ≥ 0.5 mm (if available): ST depression ≥ 0.5 mm is significant; transient ST elevation ≥ 0.5 mm for < 20 minutes is treated as ST-segment depression and is high risk; ST elevation >1 mm for more than 20 minutes places these patients in the STEMI treatment category • Elevated cardiac markers (if available) CK-MB or Troponin I in the "high probability" range of the device used. Only definitely positive results should be used in triage decisions.

32. No High Risk Criteria—but EMS still suspects ACS Patient • Even if patient does not meet High Risk Criteria (i.e. only 3 boxes positive), EMS crew may still have high index of suspicion that patient is a high risk ACS patient (i.e. patient has had 4 stents and states “this feels just like last heart attack”) • Contact medical control and consult with physician or RN for appropriate patient destination.

33. Assess Transport Time and Determine Destination by Level of Prehospital Care* Cardiac Triage Tool (cont.) YES Unstable patients with life-threatening arrhythmias, severe respiratory distress, or shock unresponsive to EMS treatment should be taken to the closest hospital. YES BLS/ILS ALS Level I Cardiac Hospital w/in 60 minutes Level I Cardiac Hospital w/in 30 minutes YES YES NO NO Go to Level I Cardiac Hospital and alert destination hospital en route ASAP Level II Cardiac Hospital 30 minutes closer than Level I? Go to Level I Cardiac Hospitaland alert destination hospital en route ASAP Level II Cardiac Hospital 60 minutes closer than Level I? NO YES Go to closest Level II Cardiac Hospital and alert destination hospital en route ASAP

34. Asses Transport Time & Determine Destination by Level of Prehospital Care • Slight modifications to the transport times may be made in county operating procedures. • Consider ALS and air transport for all transports greater than 30 minutes. • If there are two or more Level I facilities to choose from within the transport timeframe, patient preference, insurance coverage, physician practice patterns, and local rotation agreements may be considered in determining destination. This also applies if there are two or more Level II facilities to choose from.

35. Determine Destination • The general guideline is to take a patient meeting the triage criteria directly to a Level I cardiac (24/7 Cardiac Cath Lab) hospital within reasonable transport times. For BLS, this is generally within 30 minutes transport time, and for ALS, generally 60 minutes transport time (see next section for further guidance). • Inform the hospital en route so staff can activate the cath lab and call in staff if necessary.

36. Cardiac Destination Examples Insert examples from your area BLS examples: A) minutes to Level 1 – minutes to Level 2 = 29: go to Level 1 B) Minutes to Level 1 – minutes to Level 2 = 35: go to Level 2 ALS examples: A) minutes to Level 1 – minutes to Level 2 = 45: go to Level 1 B) Minutes to Level 1 – minutes to Level 2 = 68: go to Level 2 • If ineligible for fibrinolytics, transport to closest Level 1 hospital even if greater than 60 minutes or rendezvous with air transport. • EMS must inform the hospital en route so staff can initiate cardiac protocols and call in staff if necessary.

37. Emergency Cardiac Hospitals • Cardiac team activation policy and criteria based on EMS pre-arrival notification • Cardiac protocols include use of induced hypothermia for post-cardiac arrest patients. • Participate in regional QI program that includes EMS • Provide training for EMS if requested, particularly in reading ECG for STEMI • No divert policy for emergency cardiac cases

38. Hospital Levels-Emergency Cardiac • Perform PCI 24/7 within 90 minutes • Interventional cardiologists and cath lab team available within 30 minutes 24/7 • Cardiac surgery onsite or transfer agreements • Administer fibrinolytics 24/7 within 30 minutes • ACLS trained providers Level One Level Two

39. Our Local Cardiac Hospitals Level Ones Level Twos

40. Insert Local Destination Examples

41. Acute Stroke Prehospital protocol guidelines Triage tool Hospital levels

42. Signs of a Stroke

43. Stroke Protocol I. Scene Size-Up/Initial Patient Assessment A) Support ABCs B) Check glucose, temperature, SpO2 (if possible) C) Treat hypoglycemia (if possible) D) NPO II. Secondary Survey A) Perform FAST Assessment (Face/Arms/Speech/Time last normal). If one component is abnormal, high probability of stroke. Refer to stroke destination triage tool. Time from last normal will determine destination. B) Limit scene time with goal of ≤ 15 minutes.

44. Stroke Protocol (cont.) III. Transport A) Early hospital notification - specify FAST findings (issue stroke alert & share abnormal physical findings and time last normal). B) Transport according to Washington State Stroke Triage Tool and regional patient care procedures. C) If closest appropriate facility is greater than 30 minutes, consider air transport when appropriate.

45. Stroke Protocol (cont.) IV. Management/Ongoing Assessment en route A) Lay patient flat unless signs of airway compromise, in which case elevate no higher than 20 degrees. B) IV access (as able) • Ideally, 16 or 18 ga IV in unaffected arm (affected arm is acceptable) • Normal saline (avoid glucose-containing and hypotonic solutions) 3) Optional: Blood draw with IV start C) 2nd exam/neuro reassessment D) Optional: initiate tPA checklist

46. Stroke Triage Tool Yes?

47. Stroke Triage Tool

48. FAST Assessment

49. FAST Assessment (cont.)

50. FAST Assessment (cont.)