Stroke Management for the EMS Provider

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Stroke Management for the EMS Provider

• Alameda County Educational Module
• Brenda Krokoski RN (Alta Bates/Summit Stroke
  Center)
• Douglas Van Houten RN (Washington Hospital Stroke
  Center)

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Stroke Management for the EMS Provider

• At the completion of this module, the EMS
  Provider will be able to
• Describe the various types of stroke and their
  etiology.
• Discuss the imperatives for best practice in
  regard to EMS stroke management.
• List 5 or more risk factors for acute stroke.
• Define penumbra and how this concept is
  important in stroke.
• Generally describe the major vessels involved in
  acute ischemic stroke.
• Discuss the therapeutic window for thrombolytic
  therapy in stroke.
• Identify interventions that individual EMS
  providers can make to improve outcomes in stroke.

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Stroke Management for the EMS Provider

• Instructions
• Page through the module to learn the content.
• Complete the post test.

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Is STROKE a health problem in the US today?

• 700,000 strokes every year

• Stroke is the 3rd leading cause of death

• One person dies of stroke every 3 minutes

• Stroke is the leading cause of serious, long term
  disability

• 5 million stroke survivors, but with substantial
  morbidity
• 18 unable to return to work
• 4 require total custodial care

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Is STROKE a health problem in the US today?

• Only 50-70 of stroke survivors regain functional
  independence

• 20 are institutionalized within 3 months

• 22 of men 25 of women die within 1 year of
  their first stroke

• Locally, African-Americans have 50 more strokes
  than Caucasians, and twice as many as Asians and
  Hispanics (Statistics from the American Stroke
  Association)

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African Americans Stroke

• Incidence is nearly double that of white
  Americans
• Suffer more extensive physical impairments
• Twice as likely to die from stroke
• High incidence of risk factors for stroke

• hypertension
• diabetes
• obesity
• smoking
• sickle cell anemia

(National Stroke Association)
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Women Stroke

• Stroke kills more than twice as many American
  women every year as breast cancer
• More women than men die from stroke
• Women over age 30 who smoke and take
  high-estrogen oral contraceptives have a stroke
  risk 22 times higher than average

(National Stroke Association)
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How Bad is a Major Stroke?Elders at Risk for
Stroke (1183, TTO), --Samsa et al, Am Heart J 1998
Worse than death
Equivalent to being well
Equivalent to death
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Is STROKE a health problem in the US today?

• YES, stroke is a major health problem in the US
  today.
• EMS Providers are closely involved with this
  patient population and are a vital component of
  the Stroke Chain of Survival.
• Increased knowledge and personal motivation on
  the part of EMS providers can
• Greatly reduce death and disability due to
  stroke.
• Improve stroke centers ability to provide
  thrombolytic therapy.
• Make a positive impact on communities strides to
  reduce costs for healthcare and improve outcomes.
  

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Goals for EMS Provider Care of Stroke Patients

• Improve knowledge of identification of stroke
  signs and symptoms.
• Develop a rapid assessment process.
• Facilitate transfer of stroke victims to Primary
  Stroke Centers in the quickest and safest manner.
• Pre-notify the Stroke Center, Possible acute
  stroke in route.
• Encourage family members familiar with the
  patient care to either ride with the transfer
  vehicle or drive to the stroke center ASAP to
  provide more patient information.

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Goals for EMS Provider Care of Stroke Patients

• 6. Obtain reliable list of meds taken or bring
  bag of all medications taken.
• Obtain a set of vital signs and finger stick
  blood sugar at the site.
• Reliably identify familys best estimation of
  when the patient was last seen normal.
• Administer the Cincinnati Pre-hospital Stroke
  Scale.
• Provide the receiving facility with a quick,
  complete verbal report that incorporates the
  information obtained since arrival on scene.

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Review Anatomy Physiology of Acute Ischemic
Stroke

• What is acute ischemic stroke?
• What is the major vasculature involved?
• When circulation is suddenly reduced, how quickly
  is brain tissue affected?
• What is penumbra?
• What are the types and etiologies of stroke?
• What about different stroke symptoms?

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What Is Stroke ?
A stroke occurs when blood flow to the brain is
interrupted by a blocked or burst blood vessel.
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(No Transcript)
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• One quarter of cardiac
• output goes to the 5-6
• pound organthe brain.
• The brain needs a
• constant supply of
• Oxygen
• Glucose
• Other nutrients
• Circulation is supplied
• via 2 pairs of arteries
• Internal carotids
• Vertebrals

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The Major Circulation to the Brain
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(No Transcript)
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PENUMBRA (That tissue surrounding the infarct
that is salvageable, but at risk.)
Rapid transfer to the stroke center will allow
for protection of penumbra through emergency
interventions and medical management.
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Cerebrovascular Disease Pathogenesis
Ischemic Stroke (83)
Hemorrhagic Stroke (17)
Atherothrombotic Cerebrovascular Disease (20)
Intracerebral Hemorrhage (59)
Cryptogenic (30)
Subarachnoid Hemorrhage (41)
Lacunar (25) Small vessel disease
Embolism (20)
Albers GW, et al. Chest. 1998114683S-698S. Rosam
ond WD, et al. Stroke. 199930736-743.
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Acute Ischemic Stroke(What do you see?)

• Deficits
• Unilateral (though not always) weakness
• Unilateral sensory deficit
• Visual deficits (blindness, gaze palsy, double)
• Speech (slurred a motor dysfunction)
• Language (aphasia damage to the brains speech
  center)
• Ataxia (lack of coordinated movement)
• Cognitive impairment
• Like real estateLocation, Location, Location

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What Parts of the Brain Are Affected by Stroke?
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What Are the Effects of Stroke?

• Left Brain

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What Are the Effects of Stroke?

• Right Brain

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Stroke Assessment Scale(Cincinnati Pre-hospital
Stroke Scale)
The sky is blue in Cincinnati.
Any abnormality means an abnormal Cincinnati
scale for stroke. Probably accurately
detects stroke 80 of the time.
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Stroke Assessment in the Field

• Administer Cincinnati Scale.
• If abnormal, facilitate a rapid transfer to the
  primary stroke center. (Alta Bates in North
  Alameda CountyWashington Hospital in South
  Alameda County.
• Pre-notify the receiving stroke centerpossible
  acute stroke in route.

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Identify Time Last Seen Normal

• A 75 year old man with HTN and diabetes finishes
  dinner with a friend at 8pm. He drives himself
  the short distance home that night, and a
  daughter stops by the next morning to find him
  still in bed and with right side weakness and
  severe aphasia. When do we assume the stoke
  occurred? (Answer last seen normal at 8pm)
• A 35 year old hypertensive man who is known to be
  non-compliant with meds is found slumped over in
  his car in a job site parking area at 3pm. In
  the ED he was found to have a massive left
  hemispheric ischemic stroke. His wife said he
  left for work at 7am that morning as normal, and
  she had a clear and normal cell phone
  conversation with him at 1230pm. At 1pm a
  co-worker stated the man said he wasnt feeling
  well and was going to his car to rest. At the
  time the co-worker noticed his speech was
  slurred. What time can we use as the time last
  seen normal? (Answer 1230pm)

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Types of Acute Ischemic Strokes

• Middle Cerebral Artery Stroke
• VertebralBasilar Artery Strokes
• Lacunar Strokes

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Types of Strokes(Middle Cerebral Artery MCA)
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CT Scan of Acute Ischemic Stroke (Left MCA
territory stroke)
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Types of Strokes(Middle Cerebral Artery MCA)

• The most common artery occluded in AIScan be
  proximal or from carotid circulation.
• Features
• Motor/Sensory Deficit face, arm, leg
• Speech deficit dysarthria (slurred speech)
• Language deficit if in dominant hemisphere
• Gaze palsy eyes directed towards side of AIS
• Blindness visual field cut (homonymous
  hemianopsia)

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Types of Strokes(VertebralBasilar Artery)

• Features
• Cranial nerve involvement hearing, visual,
  facial, swallowing
• Can have bilateral weakness
• Cerebellar signs ataxia
• Sensory deficits
• Vertigo often nystagmus
• Nausea and vomiting
• Common to have waxing and waning symptoms

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Lacunar Strokes

• These strokes are ischemic in nature.
• Mainly caused by HTN.
• Occurs in the small penetrating arteries of the
  brain.
• Presentation affects the arm, leg, and face,
  sometimes silent. Deficits are equal to all
  areas.

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(No Transcript)
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Conditions That Mimic AIS

• Bells Palsy
• Todds Paralysis
• Hemorrhagic Stroke
• Subdural Hematoma
• Other conditions

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Conditions That Mimic AIS

• Bells Palsy

Bells Palsy is a viral infection of the facial
nerve which causes stroke-like symptoms
unilateral facial droop, sensory deficit,
dysarthria, etc.
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Conditions That Mimic AIS

• Differential dx
• Hx women, pregnancy, viral illness
• Cant close eye completely or raise forehead
• May have facial pain
• No other stroke symptoms
• May have no risk factors for stroke

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Conditions That Mimic AIS

• Todds Paralysis unilateral weakness that
  occurs after a seizure.
• Can involve speech, language, visual and sensory
• May be due to hyperpolarization in the area of
  the seizure
• Resolves within 48 hours
• Key concern in regard to thrombolytic therapy

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Conditions That Mimic AIS

• Hypoglycemia
• Metabolic conditions fever, hyponatremia,
  drugs, etc.
• Psychogenic
• Complex migraines
• Hypertensive crisis

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What are the risks factors for Ischemic Stroke?

• Modifiable Risks
• HTN
• CAD/Carotid Disease/PVD
• Atrial Fibrillation
• Diabetes
• Weight
• High Cholesterol/Diet
• Lack of exercise
• ETOH/Drug abuse
• Coagulopathy- Cancer, Sickle Cell Anemia
• PFO- Patent Foramen Ovale

• Non-Modifiable Risks
• Age-gt55
• Race- African Americans have 2x the risk of death
  and disability. Asians have 1.4x the risk of
  death and disability.
• Sex- 9 greater chance in men. (61 of stroke
  deaths occur in women)
• Previous Stroke or TIA
• Family History of Stroke

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Goals for Treatment in the ED

• EMS rapid identification pre-notification of
  the Emergency Dept.
• Quick evaluation in ED.
• Last seen normal lt 3 hr.
• Door-to-CT scan lt 25 minutes
• CT-to-Radiologist Reading lt 20 minutes
• IV TPA administration lt 15 minutes
• (Door-to-needle within 60 minutes.)

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What can be done for an acute ischemic stroke?

• These patients may be appropriate for clot
  busting drugs. Tissue Plasminogen Activator
  (TPA).
• Requires a rapid, coordinated response.
• IV TPA can only be given within the first 3 hours
  of symptom onset.
• Expected response 60 minutes from door to
  needle.

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Tissue Plasminogen Activator

• Natural body substance. Recombinant TPA converts
  Plasminogen to plasmin, which in turn breaks down
  fibrin and fibrinogen, thereby dissolving the
  clot.
• Dose for Stroke 0.9mg/kg up to a dose not to
  exceed 90mg. 10 of dose as an IV bolus the
  rest over one hour by IV drip.
• IV window of opportunity is lt 3 hours of known
  symptom onset.

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Early Rx was better in the NINDS tPA Trial
Marler JR, et al. Early stroke treatment
associated with better outcome. The NINDS rt-PA
Stroke Study. Neurology 2000551649-1655.
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Transition

• Hemorrhagic Stroke

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Hemorrhagic Stroke(Intracranial HemorrhageICH
Subarachnoid HemorrhageSAH)

• Intracranial Hemorrhage (Hypertensive)
• gt twice as common as SAH
• more likely to result in death or severe
  disability
• 37,000 Americans/year
• 35-52 dead within 1 month (half of deaths in the
  first 2 days)
• Only 10 living independently in 1 month
  improves to only 20 within 6 months

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Hemorrhagic Stroke(Intracranial HemorrhageICH
Subarachnoid HemorrhageSAH)

• Risk factors
• Hypertension
• Advancing age
• Coagulation disorders therapy
• ETOH abuse
• Drug use (meth, cocaine, crack, etc.)
• Ischemic strokehemorrhagic transformation

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Hemorrhagic Stroke(Intracranial HemorrhageICH
Subarachnoid HemorrhageSAH)

• Presenting signs
• Suddensigns over minutes to hours
• Headache
• Nausea and vomiting
• Decreasing LOC
• Extremely elevated blood pressure
• (All of these are signs of increased ICP)

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Hemorrhagic Stroke(Intracranial HemorrhageICH
Subarachnoid HemorrhageSAH)

• Differential Diagnosis

AISoften high BP AISrare decreased LOC AISrare
or vague H.A. AISrare nausea
vomiting AISoften wake up with the
symptoms
ICHusually very high BP ICH50 of the time ?
LOC ICH40 of the time H.A. ICH50 of time
vomiting ICHrarely wake up with
symptoms (15)

• Final diagnosis is by CT scan.

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Weakened blood vessels in a Hypertensive Bleed
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Autopsy of Intracerebral Hemorrhage
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Small hemorrhagic stroke
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Large hemorrhagic stroke
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ICH Goals for Early Management

• Airway management
• Assure adequate oxygenation reduce hypercapnea
  (Remember ?CO2 ? ICP)
• Prevent aspiration (Remember 50 of ICH patients
  vomit and have ALOC)
• Prevent seizures
• Acute mgt Fosphenytoin 500-1000 PE (phenytoin
  equivalents over 3-6 minutes)
• Prevention Phenytoin 500-1000 mg/20-30 min

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ICH Goals for Early Management

• Blood Pressure Management
• Very poor outcomes if BP is allowed to stay very
  highmore bleeding
• Very poor outcomes if BP is allowed to drop
  precipitouslyremoves the brains attempt to
  perfuse a tight brain
• Guidelines
• In general, keep BP about 160/90 or MAP lt130
• In the first 48 hours no BP drop gt 15-25 of
  presenting value

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Hemorrhagic Stroke(Subarachnoid Hemorrhage)

• Acute bleeding around the outside of the brain
  and into the subarachnoid space.
• Usually from an aneurysm or arterio-venous
  malformation.
• Statistics
• 50 are fatal
• 1--15 die before reaching the hospital
• Those who survive are often impaired
• 1-7 of all strokes

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Hemorrhagic Stroke(Subarachnoid Hemorrhage)

• Diagnosis
• Thunderclap headache. It is the worst
  headache of my life!
• Xanthochromic lumbar puncture (blood in the CSF
  not due to traumatic tap)
• Star pattern on CT scan

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Aneurysmal bleed
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Classic Star Pattern of Subarachnoid Hemorrhage
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Magnified view of cerebral aneurysm.
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Subdural Hematoma
(Not a true stroke but symptoms can mimic stroke.)
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Subdural Hematoma

• Symptoms
• Unilateral weakness, sensory deficit
• Facial weakness
• Dysarthria
• Altered level of consciousness
• Onset
• Can be rapid
• Can take months to show symptoms

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Subdural HematomaCauses

• Anticoagulation (Heparin, Coumadin)
• Antithrombotics (Aspirin, Plavix)
• ETOH abuse
• Trauma (could be recent or months ago)
• Advanced age (most common cause)

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Subdural Hematoma
Small bridging veins from the dura mater to the
brain are stretched and can rupture releasing
blood into the subdural space and
causing pressure on that part of the brain. This
leads to the deficits seen.
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Subdural Hematoma on CT Scan
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Subdural HematomaTreatment Options

• Medical Management
• Correct Coags
• Monitor neuro signs
• Surgical Management
• Correct Coags
• Burr hole drainage
• Craniotomy for removal of solid clot

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Summing Up

• The best stroke care is a coordinated approach
  and developed in a stroke center system of care.
• Requires everyone to be on board
• Patients/Families
• EMS
• ED
• Stroke Unit
• Stroke Rehabilitation

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Summing Up

• How well a patient does whether a patient has a
  life-long serious disability whether he/she
  lives or dies may depend on you and how you
  respond.
• A few minutes delay may make a very big
  difference.
• What you do really matters!

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Emergent Stroke Care and the Chain of Survival
Patient Calling EMS ED
Stroke Stroke Knowledge 911
System Staff Team Unit

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Module is CompletedProceed to Post Test
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Post Test

• Which of the following are types of ischemic
  strokes?
• Middle cerebral artery occlusion
• Vertebral-basilar occlusion
• Lacunar stroke
• All of the above
• A vertebral-basilar stroke might have bilateral
  weakness as a symptom. (True or False)
• This quick stroke assessment scale accurately
  identifies stroke 80 of the time.
  ________________

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Post Test

• The family states the patient woke up at 630am
  and exhibited signs of acute stroke. We should
  assume that the stroke started at 630am. (True
  or False)
• List 4 things the EMS Provider should be able to
  tell the Stroke Receiving Center ED about the
  possible stroke patient who just arrived.
• The IV TPA window of opportunity for treatment is
  how long from symptom onset?
• The most common type of hemorrhagic stroke is
  caused by a cerebral aneurysm. (True or False)
• List 5 conditions that can mimic acute ischemic
  stroke.

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Post Test

• Which of the following is not a true hemorrhagic
  stroke?
• Subarachnoid Hemorrhage
• Subdural Hematoma
• Intracerebral Hemorrhage (Hypertensive Bleed)
• 10. The Stroke Receiving Center Emergency Room is
  the stroke system of care. (True or False)

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Post Test (Answers)

• d. all of the above
• True
• Cincinnati Pre-hospital Stroke Scale
• False it is the time last seen normal
• VS FSBS time last seen normal stroke symptoms
  meds the patient takes
• 3 hours
• False Intracerebral Hemorrhage (HTN bleed)
• Bells Palsy Todds Paralysis Subdural
  hematoma hemorrhagic stroke Psychogenic HTN
  Complex Migraine Hypoglycemia etc.
• Subdural Hematoma
• False all entities are equally important links
  in the stroke chain of survival.