Gurmeen Kaur, MBBS
@kaurgurmeen
With the COVID-19 pandemic taking more than 50,000 lives in the United States, emergency medical services are being forced to change their triage policies in order to ensure safety of both the patients and the health care personnel involved.
Stroke and STEMI triage systems are among the first to be affected, especially because there is some evidence for the increased incidence of acute ischemic strokes in COVID-19 patients, secondary to the hypercoagulability.
The Society of Vascular and Interventional Neurology has issued a guidance statement highlighting practices that all institutes should be incorporating into their routine stroke workflow — pre-, intra- and post-mechanical thrombectomy. These guidelines serve as pointers that can be used to modify our existing protocols. Because we are going to continue to see the effect of COVID-19 through the summer, especially in highly impacted states like New York, Massachusetts and Illinois, and there is also a potential second wave predicted for fall and winter 2020, it is prudent that all centers adopt these best practice guidelines in their daily stroke triage and workflow.
In the pre-procedure phase, the authors have emphasized early triage of patients with COVID-19 symptoms. In hospitals where rapid testing is available, sending for COVID-19 testing on arrival, even prior to CT, can be helpful in bed placement. While mechanical thrombectomy should be initiated without waiting for COVID-19 results, it is helpful to know the COVID-19 status in order to assign appropriate beds and to plan extubation post procedure. In institutes where it is feasible, having a designated COVID-19 CT and COVID-19 angiosuite can help expedite imaging for the patients who are positive or rule-outs.
If possible, mechanical thrombectomy should be performed under conscious sedation in patients with suspected COVID-19. Additionally, strict donning and doffing protocols should be used for all personnel involved. It is prudent to minimize the number of physicians and nurses required to be in the angiography suite during the procedure.
Recommendations are made for reducing the number of post-procedure checks to a minimum to decrease in-person exposure of health care personnel. This includes using video-based checks when possible and extubation in a negative pressure room.
Acute ischemic stroke patients are a vulnerable group because these patients often present emergently with little known information and limited time to gather that information. These practice guidelines are designed to enhance safe yet efficient triage and treatment of large vessel occlusions and must be reviewed and implemented by everyone in the neuroendovascular field.
