The stroke code is a coordinated system that allows patients with acute stroke to be identified and transferred with advanced notification to the closest stroke referral center with the aim of reducing the time between onset of symptoms and expert assessment of the patient. The stroke code can be activated from primary care center, a local hospital or, more commonly, directly from the Emergency Medical Services. The stroke code activation is coordinated by the EMS central coordinating center who manage the transfer protocol and pre-alert the receptor center. Of the various possible ways the stroke code can be activated, the fastest route is when the patient alerts the EMS and is transferred directly to the stroke hospital, the orange bar in the graph, who also receive a pre-notification of the transfer. This faster transfer is reflected in better patient recovery. In contrast, when the code is activated in a hospital that cannot provide stroke treatment, the green bar, or if patient goes to a stroke center by themselves, yellow bar, these patients take almost 1.5 hours longer to be seen by an expert and the treatment options are considerably reduced. The whole process of stroke code involves multiple professionals. The Emergency Medical Services play an important role in the stroke code protocol. As in the majority of cases, they are the first contact the patient has with the health care system and they also act as a coordinating body for the stroke code transfer circuit. In most cases, a stroke is first identified when the patient or a relative calls the Emergency Medical Services and is confirmed when a care team sees the patient. When a stroke is suspected, the emergency services dispatch center is alerted and staff their collected clinical details and location of the patient and order a priority transfer to the closest stroke center. They also notify the professionals at the center in advance so they can prepare to receive the patient. The specific aims of the Emergency Medical Services are the rapid detection of cases suggestive of a stroke and the activation over the transfer circuits and protocols to notify a receiving center. Having fluid communication between the Emergency Medical Services and the receiving center can cut the pre-hospital and in-hospital times by providing information on the specific profile of each patient. Studies on the stroke code systems have shown that they help achieve a higher rate of thrombolysis, reduce pre-hospital and in-hospital times and improve clinical outcome of the patients. Very simple scales are available that allow identification of patients with acute stroke in the pre-hospital setting. They assess the typical symptoms present in most patients such as facial droop, arm weakness and abnormal speech. The presence of one of these three symptoms should raise suspicion of stroke and the stroke code should be activated for the patient to receive urgent attention. During the transfer of a stroke code patient to a referral hospital, a series of general measures should be carried out. Keep the patient supine at 30 degrees, avoid vomiting and bronchoaspiration, maintain vital signs within appropriate limits to maintain optimal hemodynamic status. Blood pressure should be below 220 over a 110. Subsequently, this must be kept below 185 over 105 if the patient receives thrombolysis. Oxygen sets should be above 95%. Capillary blood glucose should be below 150 milligrams per deciliter. One must rule out hypoglycemia which can mimic the symptoms of a stroke and treat if blood glucose levels are below 60 milligrams per deciliter. Do not give any anti-platelet agents such as aspirin or clopidogrel or any anti-coagulant because until CT head scan is performed, it is impossible to differentiate between ischemic and hemorrhagic stroke. ECG is necessary only if acute coronary syndrome is suspected, but in patients with stroke, they should not be done if it causes delay to transferring the patient. To date, no benefits have been demonstrated for any drug treatment in the pre-hospital setting. There has been some experience with the use of mobile stroke units. These are ambulances that are equipped with CT scans, point-of-care blood testing for rapid coagulation testing and a video conferencing system, as well as a team of specialists. These systems allow a differentiation between ischemic and hemorrhagic stroke while in the ambulance and allow thrombolysis to be started as early as possible without waiting for the patient to get to hospital. This means that thrombolysis can be given more often than earlier. However, their widespread use is limited by the complexity and high financial costs. Various countries are also developing pre-hospital telemedicine systems that allow remote assessment by an expert neurologist. The ambulance is equipped with a tablet that allows a real time video of the patient examination to be viewed along with clinical data. The neurologist can see the patient, confirm a suspected stroke and give instructions to the emergency services crew. Stroke code summary: One, coordination between pre-hospital services and receiving stroke centers, and two, the aim to facilitate rapid access for patients with stroke to the best currently available treatment.
