Stroke FM – Details, episodes & analysis

Welcome to StrokeFM Episode 27: In this exciting episode, we're taking you behind the scenes of our simulation session, where we grappled with angioedema in a code stroke. Explore with us as we delve into the intricacies of diagnosing and managing this life-threatening condition, learn from our successes and challenges, and gain insights from our team of expert cohosts. Whether you're a seasoned medical professional or starting your journey in health, you will want to experience this engaging journey into the heart of medical simulation training. This is a part of our ongoing efforts in a joint collaborative effort between Stroke and Emergency medicine. With that said, there is no duty of care. This is purely an educational podcast.

In this exciting episode, join our expert panel @MirandaLambRN,  @LowylNotario, @emeduc, @neuroccm; we delve into the critical topic of Crisis Resource Management (CRM) in acute stroke care. In our podcast, we will apply these principles to a real-world scenario: managing a stroke emergency in the case of angioedema. The aim is to highlight the practical application of these CRM principles and discuss how they can facilitate consistent, safe, and efficacious care, helping to alleviate human factors and support high-performing teams. To make the transition from simulation to actual patient care as seamless as possible, thereby reducing stress, promoting certainty, and enhancing patient outcomes. So don't miss out. Tune in to our discussion to learn more about the transformative power of CRM in acute stroke care!

StrokeFM is the Official Podcast of the CSC (⁠Canadian Stroke Consortium⁠), Founder and Producer Dr. Houman Khosravani ⁠@neuroccm⁠; Producer and Audio Engineer Dr. Jaime Cazes ⁠@JaimeCazes⁠.

The music for this educational podcast is graciously provided by the musician ⁠breakmastercylinder⁠ ⁠@BrkmstrCylinder⁠ 

As always, you abide by our Disclaimer statement by listening to this podcast. 

#CrisisResourceManagement, #HighPerformingTeam

Read our ⁠CRM manuscript⁠.

In this episode, we interview Dr. Bijoy Menon (PI) and Dr. Rick Swartz (Co-PI), and we delve into the AcT trial, a study conducted to evaluate the efficacy of tenecteplase compared to alteplase for treating acute ischemic stroke. The trial involved 1,600 participants, with a median follow-up duration of 97 days.

The participants, who were all 18 years or older and had suffered an acute ischemic stroke within 4.5 hours of symptom onset, were randomly divided into two groups. Group one (816 patients) received intravenous tenecteplase (0.25 mg/kg, maximum of 25 mg), and group two (784 patients) received intravenous alteplase (0.09 mg/kg bolus, followed by a 60-minute infusion of the remaining 0.81 mg/kg).

The primary outcome measured was the modified Rankin Scale score of 0 or 1, which indicates no significant disability. This was achieved by 36.9% of patients in the tenecteplase group compared to 34.8% in the alteplase group, establishing tenecteplase's noninferiority (p for superiority = 0.19).

Secondary outcomes, such as intracerebral hemorrhage, were similar in both groups, with 3.4% in the tenecteplase group and 3.2% in the alteplase group.

The conclusion drawn from the AcT trial is that tenecteplase was noninferior to alteplase in preserving neurological function in patients with acute ischemic stroke. Due to its ease of administration, tenecteplase may become a preferred treatment option.

This episode is based on the study "Intravenous tenecteplase compared with alteplase for acute ischemic stroke in Canada (AcT): a pragmatic, multicenter, open-label, registry-linked, randomized, controlled, non-inferiority trial" published in Lancet in 2022.

Disclaimer - StrokeFM is an Educational Podcast, by listening you understand that there is no duty of care, please read the full disclaimer.

StrokeFM is the Official Podcast of the CSC (⁠Canadian Stroke Consortium⁠), Founder and Executive Producer Dr. Houman Khosravani ⁠@neuroccm⁠; Audio Engineer and Producer Dr. Jaime Cazes ⁠@JaimeCazes⁠.

The music for this educational podcast is graciously provided by the musician ⁠breakmastercylinder⁠ ⁠@BrkmstrCylinder⁠

Did you ask about thrombolysis? We are here to deliver anxiolysis! In this second of a two-part episode of 2021, we discuss "crisis resource management" (CRM) in acute stroke - a cognitive, mindfulness, and non-technical framework for optimizing clinical performance and working in high-performing teams. CRM is a tool to master four operational domains: that of the self, teamwork, our working environment, and of course, (care for) our patient. Using CRM principles helps make us better clinicians, work more effectively in teams, and maintain a calm sense of vigilance. We re-introduce the concept of a "zero point survey" (Reid et al. 2018) as a starting point before coming on-call for a code stroke and as a tool for better self-awareness and performance. High-performing teams support good clinical outcomes at the resuscitation phase and apply to all subsequent patient care settings. Central to a high-performing team are principles of CRM and their timely application to stroke care. We review our paper in Neurocritical Care titled: "Crisis Resource Management and High-Performing Teams in Hyperacute Stroke Care" with three of the authors: Rajendram, Notario, Khosravani - In this episode we conclude this talk on "how to be a bad-a$$ stroke" resus doc!

• Crisis Resource Management and High-Performing Teams in Hyperacute Stroke Care by: Phavalan Rajendram, Lowyl Notario, Cliff Reid, Charles R. Wira, Jose I. Suarez, Scott D. Weingart & Houman Khosravani (Neurocritical Care, published in 2020)
• Zero point survey: a multidisciplinary idea to STEP UP resuscitation effectiveness Optimizing Crisis Resource Management to Improve Patient Safety and Team Performance
• Cliff's Great talk - Making Things Happen

Did you ask about thrombolysis? We are here to deliver anxiolysis! In this first of a two-part episode of 2021, we discuss "crisis resource management" (CRM) in acute stroke - a cognitive, mindfulness, and non-technical framework for optimizing clinical performance and working in high-performing teams. CRM is a tool to master four operational domains: that of the self, teamwork, our working environment, and of course, (care for) our patient. Using CRM principles helps make us better clinicians, work more effectively in teams, and maintain a calm sense of vigilance. We re-introduce the concept of a "zero point survey" (Reid et al. 2018) as a starting point before coming on-call for a code stroke and as a tool for better self-awareness and performance. High-performing teams support good clinical outcomes at the resuscitation phase and apply to all subsequent patient care settings. Central to a high-performing team are principles of CRM and their timely application to stroke care. We review our paper in Neurocritical Care titled: "Crisis Resource Management and High-Performing Teams in Hyperacute Stroke Care" with three of the authors: Rajendram, Notario, Khosravani

• Crisis Resource Management and High-Performing Teams in Hyperacute Stroke Care by: Phavalan Rajendram, Lowyl Notario, Cliff Reid, Charles R. Wira, Jose I. Suarez, Scott D. Weingart & Houman Khosravani (Neurocritical Care, published in 2020)
• Zero point survey: a multidisciplinary idea to STEP UP resuscitation effectiveness
• Optimizing Crisis Resource Management to Improve Patient Safety and Team Performance

Greetings Stroke FM listeners. We are back in 2021 with an exciting series of Podcasts, follow-up episodes, clinical and non-technical discussions and new future partnerships. Looking forward to releasing episodes as we record them this year and moving onwards! Take care + stay safe!

Key Terms: Thrombolysis, endovascular therapy,

Hosts: Ryan Muir, Houman Khosravani

Summary:

In this episode the hosts discuss the future of stroke by exploring and proposing novel applied modern concepts of endovascular and thrombolytic therapies to innovative and creative ideas for the future.

• Endovascular therapy for distal vessels is discussed
  
• Improving geographic access to endovascular therapy (especially for wide spread countries like Canada)
  
• The role of the NIHSS score in the acute assessment of stroke in the future and the increasing reliance on imaging parameters to guide decision making
  
• The future of thrombolysis
  
• The future of neuroimaging: Evolving understanding of ASPECTS and MRI Brain (Solid state MRI in acute stroke assessments), and potential role for focused ultrasound
  
• Neuroprotection and extending time-windows
  

Key Terms: Transition to residency, Work-life balance, Mentorship, Surviving PGY1

Hosts: Sydney Lee, Jaime Cazes and Houman Khosravani

Summary:

• First few days of residency
  
• Managing expectations
  
• Discovering the rewards of residency
  
• Going from off-service to on-service
  
• Balancing residency with lifestyle
  
• Mentorship
  
• Surviving call
  
• Three take home points
  

1. A positive attitude will take you far
   
2. Reach out to your fellow residents
   
3. Enjoy yourself as much as possible
   

Key Terms: COVID-19, Stroke Orientation, NVU

Hosts: Jane Liao, Houman Khosravani

Summary:

• Purpose of modified procedures - Limit human-human interaction
  
• Handover in separate rooms
  
• Limit hand-off of items (pager, tools) and wipe down after doing so
  
• Virtual meeting apps (Zoom, Google Meet) for rounds/teaching when possible
  
• Have a moderator for meetings focused on keeping discussions concise
  
• Send residents home early if the day's tasks are complete and they are not needed
  
• Assign only one resident to go with the staff to stroke codes as opposed to the whole team
  
• https://www.codestroke.net/covid19
  

Key Terms: Protected Code Stroke, COVID-19, Personal Protective Equipment

Hosts: Phavalan Rajendram, Jaime Cazes, Houman Khosravani

Summary:

• The COVID-19 pandemic poses unique challenges in delivering hyperacute stroke care
  
• The “Protected Code Stroke” (PCS) protocol provides a framework for safely and efficiently delivering hyperacute stroke care
  
• Know when to activate a PCS
  
• Always use PPE with correct donning & doffing techniques
  
• Always appoint a safety leader
  
• Use crisis resource management principles
  

Key Terms: COVID-19, PPE, Pandemic, medical education

Hosts: Jaime Cazes, Houman Khosravani

Summary:

• This episode covers how COVID-19 has impacted healthcare and medical education from the viewpoints of a graduating 4th year medical student and a staff physician.