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F or patients with emergent large- vessel occlusion (ELVO), the treat- ment effect of mechanical throm- bectomy (MT)—the direct removal of the clot at a comprehensive stroke center (CSC)—is powerful and doubles the likeli- hood they'll be independent at 90 days. 1 In addition, the treatment effect is profoundly time-dependent, as for every minute faster EMS professionals usher ELVO patients to the cure (MT), the patients will enjoy one more week of disability-free survival. 2 While the previous articles in this series focus on enabling EMS professionals to recognize and transport suspected ELVO patients directly to CSCs, this article focuses on enabling EMS professionals to profound- ly impact the efficiency of care delivered at the destination hospital, whether it is a CSC or another hospital that does not offer endovascular therapy, such as a primary stroke center (PSC). Prehospital Notification Prehospital notification by first responders (whether electronic or by phone) is critical for initial efficiency at the destination hos- pital. We have educated the first respond- ers with whom we collaborate to notify the receiving hospital with the following information: • Name, gender, and date of birth; • Family contact information; • Clinical severity score (we use the Los Angeles Motor Scale); • Time last known normal; • Systolic blood pressure; • Blood glucose; • Oral anticoagulant use; • Estimated time of arrival (ETA). Providing the name, gender, date of birth and family contact information is empower- ing to the receiving hospital team, as a pre- registration process can begin that would include any information in the EMR. While we believe every stroke patient deserves CT angiography on arrival, alerting the receiving team of the severity score and last-known-normal time can have implica- tions for what imaging is done and what teams are activated, and may perhaps even result in that destination diverting you to a more appropriate destination for your clini- cal circumstances. For example, a wake-up stroke patient with a LAMS score of 4 or 5 will likely obtain no benefit from transport to a center without endovascular capability. Information about systolic blood pres- sure, blood glucose and use of oral antico- agulants can impact IV tPA decision making and door-to-needle efficiency. This informa- tion should always be included in the pre- hospital notification. It is important to note that not all these pieces of information are critical (patient demographics, blood glu- cose etc.), and their absence should not result in delay. Finally, to be most effective, all this infor- mation, including the ETA, should be sent by page to all those expected to care for the patient on arrival so they are present on arrival to escort you and your patient directly to the open and prepared CT scanner. This will allow correct treatment deci- sions to be made for the patient as quickly as possible. Initial hospital efficiency depends entirely on prehospital notification and its quality; EMS professionals are the most important link in the stroke chain of survival. CTA Is to ELVO What EKG Is to STEMI Once a patient has arrived at any hospital, the first and most important step is the imaging. ELVO is an acute vascular syn- drome and a diagnosis that can only be made with CT angiography. Since recent publications have shown that no clinical scale can accurately exclude ELVO, we believe all patients with clinical suspicion for acute ischemic stroke should have a CT and CTA (head and neck) on their first trip to the scanner, regardless of severity and irre- spective of the hospital's capability (stroke designation). Attempting to exclude ELVO in a stroke patient with a clinical severity score alone seems to be impossible. "Neurons over nephrons" should be the mantra. 3 CTA should never be delayed for allergy or nephrotoxicity concerns. In fact, we don't even ask! The risk of death from an ELVO can be as high as 40%, while the risk of a serious contrast reaction is only 0.01%, and no fatalities occurred in a study of 85,000 contrast injections. 4 Recent stud- ies have shown that intravenous contrast rarely if ever causes acute kidney injury, even in patients with poor renal function. 3,5–9 All treatment decisions in stroke hinge on the results of a CT scan. Until we figure out how to dialyze the dead brain and replace it with normal brain, concerns over IV contrast should not preclude CTA. Expect that your patient with suspected ELVO will be taken directly to the CT scanner and have a CT angiogram on that initial trip. CSC Initial Processes For ELVO patients brought to a CSC, the goal is to identify what our colleague Michael Hill at the University of Calgary calls the "good scan occlusion" (is there salvageable brain, and is there a blocked blood vessel?) and then get the vessel open as quickly as pos- sible—within 60–90 minutes of arrival to the CSC. 10 With effective prehospital notification as described above, the code stroke team should greet you on arrival and transport EMSWORLD.com | NOVEMBER 2017 31 By Jason M. Rhodes, MPA, AEMT-C; David M. Faunce, EMT-P; John H. Potvin, BS, NRP; Jason Umbenhauer, AEMT-C, EMS I/C; Nelson Pedro, NRP; Jeffrey Devine, RN; Mayank Goyal, MD, FRCPC; Mahesh V. Jayaraman, MD; and Ryan A. McTaggart, MD EFFICIENT STROKE CARE AT THE HOSPITAL What can EMS do to help ensure timely help for these vulnerable patients?