2

At the end of this participant you will be able to:

Know the differences between ischemic and hemorrhagic stroke

Recognize signs and symptoms of stroke Be able to use the

› Cincinnati Prehospital Stroke Scale Discuss major principles of prehospital

assessment and treatment for acute stroke Appreciate importance of rapid transport to

Accredited Stroke Center

3

Appreciate importance of notifying ED

before arrival (Calling Stroke Alert) Discuss major principles of ED stroke care Importance of rapid triage and early CT

for stroke victims Understand the potential use of

thrombolytics (IV-tPA) for selected patients with acute ischemic stroke

Appreciate importance of rapid transport from an ED to an Accredited Stroke Center

4

Use of National Institutes of Health Stroke Scale (NIHSS)

Guidelines for managing hypertension in stroke patients

Clinical differences between ischemic and hemorrhagic stroke

Treatment differences between ischemic and hemorrhagic stroke

Appreciate importance of rapid transport from an ED to an Accredited Stroke Center

According to the American Heart Association stroke is the third leading cause of death in U.S. and leading cause of disability

Approximately 700,000 people each year will suffer from a stroke, either for the first time or with a history of stroke; Of those patients, approximately 158,000 will die as a consequence of the stroke.

One-third of strokes occur in patients younger than 65 years.

Men are at higher risk than women. About 85% of strokes are ischemic in nature About 15% of strokes are hemorrhagic in nature EMS plays a large role as early recognition and treatment.

This is key in reducing the mortality rates from strokes.

A stroke or Cerebral Vascular Accident (CVA) or “Brain Attack” is a neurologic deficit that causes a change in the patient’s ability to speak, feel, or move.

When these changes are noted, the EMT should recognize that something has affected the patient’s central nervous system.

This could be a medical or traumatic cause

This power point will be limited to the presentation of a nontraumatic brain injury, or stroke.

Stroke› The symptoms that the

patient presents with is a reflection of the area of the brain that has had a disruption of blood flow.

› Most commonly, strokes affect the regions of the brain that control speech, sensation, and muscle function.

› Paralysis, facial droop, monoplegia, hemiplegia, and speech disturbances are common findings.

Stroke is classified as hemorrhagic or ischemic and further subdivided by etiology

Ischemic stroke› Embolic› Thrombotic› Hypoperfusion

Hemorrhagic stroke› Intracerebral hemorrhage› Nontraumatic subarachnoid

hemorrhage

Ischemic Stroke – This type of stroke is caused by a sudden occlusion of a blood vessel in the brain, a similar mechanism that is seen with a heart attack.

Hemorrhagic Stroke – This type of stroke occurs when a blood vessel in the brain bursts and allows blood to collect in or around the brain tissue.

In either instance, it is the lack of blood flow and oxygen that causes the dysfunction in the brain, and the accompanying signs and symptoms.

› Nausea/vomiting› Dizziness,

weakness› Headache› Impaired vision› Vertigo, tinnitus› Difficulty speaking,

swallowing

› Abnormal gait, weak extremities

› Hemiparesis, quadriparesis

› Sensory loss, seizures

› Pupil abnormalities Dilated Constricted Unreactive Sluggish

Don’t spend a lot of time to determine the specific

cause!Do Prehospital Clinical

Assessment

“Hey you …..

Cincinnati Prehospital Stroke Scale (CPSS)› Assess for

Facial droop Arm drift Abnormal speech

Assess Facial droop (have patient smile) Normal: Both sides of

the face move equally Abnormal: One side of

face does not move as well

Assess Arm drift(have patient hold arms out

for 10 seconds) Normal: Both arms move

equally or not at all Abnormal: One arm

drifts compared to the other, or does not move at all

Assess Abnormal speech(Have the Pt. say)“you can’t teach an old dog new

tricks” Normal: Patient uses correct

words with no slurring Abnormal: Slurred or

inappropriate words, or mute

If positive on one or all of the three tests Transport to the closest

Accredited Stroke Center and call a

STROKE ALERT

CHRISTUS Spohn Shoreline1-361-881-3811

600 Elizabeth St. Corpus Christi, Tx

CCMC Doctors Regional 1-361-761-1467

3315 S. Alameda Corpus Christi, TX

CCMC Bay Area 1-361-

761-36377101 S. Padre Island Dr. Corpus Christi, Tx

Time = Brain!

Assessment and Treatment of a stroke patient by EMS

can make a difference!

Scene evaluation Initial assessment Focused History “SAMPLE history/Vital signs/Check

the blood glucose level” Detailed Physical examination (as

needed) Ongoing Assessment Treatment

Assessment: Scene Size-Up› Dispatch information may alert you to this

emergency if there is knowledge of neurological deficits or altered mental status.

› Look for evidence of trauma, drug use, or alcohol.

› The patient’s clothing may indicate approximately when the symptoms started.

› Call for backup if extrication from the residence will be difficult.

› Remember to take BSI precautions.

Assessment: Initial Assessment› Establish mental status level (AVPU).› In-line immobilization if trauma is suspected or I is unknown.› Open the airway manually if needed, and provide

oropharyngeal suctioning of secretions as necessary.

› Assess breathing adequacy, being particularly attentive for inadequate breathing as evidenced by an abnormal rate, regularity, or depth.

› Determine quality of pulses and perfusion.› Assign patient priority status.

Airway › Ensure an open airway

Breathing› Present› Rate, depth, and adequacy of respirations

Circulation› Check pulse

Disability › Are circulation, sensation, and motor

function intact in all extremities?› What is the patient’s mental status?

Can the patient answer questions appropriately?

› GCS score

SAMPLE history, continued› OPQRST

Onset Provocation/palliative measures Quality Region/Radiation Severity Time Associated Symptoms Pertinent Negatives

Assessment: SAMPLE History› Along with the normal SAMPLE questions, consider

the following: When did the symptoms begin? Is there any recent history of trauma to the head? Does the patient have a history of strokes? Was there any known seizure activity prior to

arrival? What was the patient doing at symptom onset? Is there a history of possible diabetes? Any history or presence of a stiff neck or

headache? Any dizziness, nausea, vomiting, or weakness? Has the patient experienced any slurred speech?

SAMPLE history› Past medical history of interest

Hypertension Hypercholesterolemia Coronary artery disease Diabetes Atrial fibrillation, valve replacement,

recent acute myocardial infarction (AMI) History of smoking Transient ischemic attack (TIA)Do not assume that a patient is unconscious or has

an altered mental status simply because he or she does not respond to your questions.

Assessment: Detailed Physical Exam› Do not delay transport to obtain a physical

exam.› Sensory and motor function should be

assessed in all extremities.› Document and report any alterations from

earlier assessment findings, to include the patient’s mental status, speech, sensory capabilities, and motor function.

Assessment: Ongoing Assessment› Perform an ongoing assessment every 5

minutes.› Stroke patients deteriorate rapidly, watch

for airway, breathing, circulation, and mental status changes.

› Repeat and record the baseline vital signs.› Communicate any changes in the patient’s

condition to the receiving medical facility.

Maintain the ABC Place in recovery position Have suction available Treat underline cause Ongoing assessment

Maintain scene and personal safety Support airway, breathing, circulation

› Consider need for BLS/ALS airway. Oropharyngeal (OPA), nasopharygeal (NPA) Endotracheal intubation

Ensure adequate ventilation.› BVM ventilation if needed › Oxygen 2-4 lpm/NC or 15 lpm/NRB › Monitor oxygen saturation with pulse oximetry

keeping Spo2 >92% Continuous Cardiac Monitoring/12 lead

ECG Cardiac dysrhythmia and AMI can occur with

stroke.

IV Access x 2 of NS/LR (This should not delay transport)

› Administer fluids, if patient is hypotensive. Note: Over administration of IV fluids can create or

worsen existing cerebral edema.

Blood Glucose Level › Correct hypoglycemia with glucose administration.› DO NOT administer glucose if hypoglycemia is not

identified. Monitor V/S every 5 minutes. Keep patient warm.

Elevate head, if no hypotension.› If high BP SYS >200 or DIAS >110 treat with

LABETALOL 10 mg IV over 1–2 min may repeat q 10 min to max 300mg

› Nitroglycerin may be used (Check with your Protocol)

EMS Treatment Guidelines› Follow the CBRAC 2010 Stroke Algorithm

Place patient in position of comfort.› Protect paralyzed extremities since the patient

cannot move the extremity, ensure that it is protected from injury.

Reassure patient. Rapid transport to an Accredited Stroke Center

EMS Treatment Guidelines: CBRAC 2010 Stroke Algorithm

CBRAC STROKE ALGORITHM These are guidelines; they do not supersede the Medical Directors order set.

Critical EMS Assessment and Actions Support ABCs Oxygen 2-3 L NP or 15L NRB keep spo2 >92% Perform Prehospital Stroke Assessment Early Notification to Stroke Center

Establish SYMPTOM ONSET < 4.0 hours

RAPID TRANSPORT TO THE APPROPRIATE FACILITY

ACTIVATE/Transport closest Accredited Stroke Center if <30 minutes by ground or air transport; CALL STROKE ALERT CHRISTUS Spohn Shoreline 1.361.881.3811 CCMC Bay Area 1.361.761.3637 CCMC Doctor’s Regional 1.361.761.1467 ACTIVATE/Transport closest facility capable of treating stroke with t-PA if >30 minutes

HALO Flight (Corpus Christi) 1.800.776.4256 AirLIFE (San Antonio) 1.210.233.5800 PHI (Victoria) 1.877.435.9744 Valley Air (Harlingen) 1.800.679.0911

In Transit: Continuous Cardiac Monitoring Blood Glucose Level IV Access x2 (Should not delay transport)

CINCINNATI PREHOSPITAL STROKE SCALE Facial Droop/Smile Normal Abnormal TX for H-BP for SYS >200 or DIAS >110 Arm Drift Normal Abnormal LABETALOL 10 mg IV over 1–2 min Speech may repeat q 10 min to max 300mg Say “you can’t teach an old dog new tricks” Normal Abnormal

Time = Brain!

Transport to and Treatment at an established Stroke Center

can make a difference in pt outcome!

Decision Criteria: The bypass protocol is intended to ensure that patients with a witnessed acute stroke be transported to an accredited stroke center.

Exceptions to the bypass protocol requiring the patient to be transported to the NEAREST facility are:› Inability to establish and/or maintain an airway or

in the event of a cardiac arrest. › If transport time to the indicated accredited stroke

center exceeds 30 minutes; the patient should be transported to the nearest facility capable of treating stroke with Activase (t-PA) if indicated, then transferred to an accredited stroke facility.

The activation of the Bypass Protocol for the symptomatic acute stroke patient should be initiated upon the recognition of confirmed witnessed changes in patient condition as to “Last Known Well” in less than 4 hours.

If “Last Known Well” temporarily unknown due to patients inability to talk or the lack of a witness, transport to an accredited stroke center and activate a stroke alert.

Hand off of the acute stroke patient to advanced life support “Mobile Intensive Care Unit” or Air Transport will be initiated in the following circumstances:

Basic life support unit is first responder only and/or unable to leave service area

If air transport/pick-up total time is less than ground transport time.

HALO Flight (Corpus Christi) 1-800-776-4256 AirLIFE (San Antonio) 1-210-233-5800 PHI (Victoria) 1-877-435-9744 Valley Air (Harlingen) 1-800-679-0911

If >30 minutes by ground to an accredited stroke center or no air medical

then transport to the closest facility

capable of treating stroke pts. with (t-PA)

Continue airway maintenance and administration of supplemental oxygen.

Obtain IV access if not done prehospital› Central venous catheter

Blood glucose determination Cardiac monitoring, 12-Lead ECG Foley catheter

Lab studies› Complete blood count (CBC) with

platelet count› Coagulation profile› Serum glucose› Electrolytes, cardiac enzymes

NIH Stroke Scale Imaging studies

› Noncontrast CT of the brain Differentiates between hemorrhagic and

ischemic stroke› Chest X-Ray

Treatment for ischemic stroke may include› Anticoagulants › Antiplatelet agents› Fibrinolytics

Recombinant tissue-type plasminogen activator (rtPA)

Patients with ischemic stroke and hypertension may receive› Labetalol› Enalaprilat › Nicardipine› Nitroglycerin

Treatment of intracerebral hemorrhage› Severe hypertension (MAP >130 mmHg)

may be treated. Labetalol Enalapril Nicardipine Nitroprusside

› Increased ICP treated with Hyperventilation Mannitol, furosemide

› Surgical intervention dependent on patient neurological status plus size and location of hemorrhage

Treatment of subarachnoid hemorrhage› Head elevated to 30 degrees› Maintenance of blood pressure to

prehemorrhagic levels› Seizure prophylaxis› Ventriculostomy › Surgical clipping of ruptured aneurysm

Door to Triage by Doctor – 10 minutes Door to CT Scan – 25 minutes Door to CT Read/Lab Results – 45

minutes Door to (t-PA) – 60 minutes

Inclusion criteria› Older than 18 years› Clinical diagnosis of ischemic stroke› Time of onset well established to be less

than four hours

Exclusion criteria› Past medical history of

Intracranial hemorrhage, aneurysm, or arteriovenous malformation

Internal bleeding within preceding 21 days

Head trauma, intracranial surgery, CVA within past three months

› Warnings: Major surgery within past 14 days Recent myocardial infarction Lumbar puncture within past seven days Recent arterial puncture

Exclusion criteria› Known bleeding disorder

Platelet count <100,000/mm3

Current use of oral anticoagulants and/or prothrombin time (PT) >15 seconds

Heparin used in past 48 hours and/or elevated partial thromboplastin time (PTT)

› Evidence of intracranial hemorrhage on noncontrast CT scan

› High clinical suspicion of SAH even with normal CT scan

(If all exclusion criteria “NO” the patient is a potential candidate for IV-tPA)

Some exclusion criteria are “warnings”

Any EXCLUSION will be done by the

NEUROLOGIST”

“Hey you …..

All post t-PA patients should be sent by Critical Care Transport (MICU)

Document vital signs prior to transport and verify that SBP <180, DBP <100. If BP above limits, sending hospital should stabilize prior to transport

Obtain contact method for family or caregiver (preferably cell phone) to allow contact during transport or upon patient arrival

Obtain and record Vitals Signs and Neurological checks (CPSS) every 15 minutes

Perform and record baseline GCS Continuous cardiac monitoring/12 Leads Strict NPO – this includes all PO medications

Verify total dose and time of IV t-PA bolus (if t-PA is completed prior to transfer)

If IV t-PA dose administration will continue en route:

Verify estimated time of completion. Verify with the sending hospital that the excess

t- PA has been withdrawn and discarded (for example, if the total dose of t-PA to be given is 70mg, then verify the remaining 30cc has been wasted since a 100mg bottle of t-PA contains 100cc of fluid)

If SBP >180 or DBP >100, and if antihypertensive medication started at sending facility, then adjust as follows:

If Labetalol IV drip started at the sending hospital, increase by 2mg/min every 10 minutes (to a maximum of 5mg/min) until SBP <180 and DBP <100; If SBP <150 or DBP <80 or HR <60, turn off drip and call receiving hospital for further instructions.

If Nicardipine IV drip was started at the sending hospital, may increase dose by 2.5mg/hr every 5 minutes. To a maximum of 15mg/hr until SBP <180 and DBP <100; If SBP <150 or DBP <80 or HR <60, turn off drip and call receiving hospital for further instructions.

For any acute worsening of neurologic condition, or if patient develops severe headache, acute hypertension or vomiting (suggestive of intracerebral hemorrhage) or profuse bleeding not controlled by pressure:

1. Discontinue t-PA infusion (if still being administered) 2. Call receiving facility for further instructions including

decision to adjust blood pressure medication and/or divert to nearest hospital.

3. Continue to monitor vitals and neuro checks every 5 mins.

Rapid Assessment, Management and Transport by EMS to an Accredited Stroke

Center can help reduce mortality and morbidity,

and produce maximal potential for rehabilitation and recovery.

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