Download Stroke Management for the EMS Provider

Stroke Management for the
EMS Provider
October 2014 CME
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
Discuss
Identify
describe the major vessels involved in acute ischemic stroke.
the “therapeutic window” for thrombolytic therapy in stroke.
interventions that individual EMS providers can make to
improve outcomes in stroke.
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
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)
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 highestrogen oral contraceptives have a stroke risk
22 times higher than average
(National Stroke Association)
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.
Goals for EMS Provider Care of
Stroke Patients
1.
2.
3.
4.
5.
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.
Goals for EMS Provider Care of
Stroke Patients
6.
7.
8.
9.
10.
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 family’s 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.
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?
What Is Stroke ?
A stroke occurs when blood flow
to the brain is interrupted by
a blocked or burst blood vessel.
What is Stroke?
 No oxygen, nerve cells die in minutes
 In first three hours, some cells
can be saved (up to 35% recovery)
 Thrombolytics (‘clot-busting’) drugs
dissolve clots; prevent more strokes:



Administered via IV pump
Heparin (mixed results)
t-PA, “Activase”
Activase” (good results)
Copyright 2004 MEDRAD, Inc. All rights reserved.
One quarter of cardiac
output goes to the 5-6
pound organ—the brain.
The brain needs a
constant supply of:
•Oxygen
•Glucose
•Other nutrients
Circulation is supplied
via 2 pairs of arteries:
•Internal carotids
•Vertebrals
The Major Circulation to the Brain
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.
Cerebrovascular Disease:
Pathogenesis
Hemorrhagic Stroke (17%)
Intracerebral
Hemorrhage (59%)
Ischemic Stroke (83%)
Atherothrombotic
Cerebrovascular
Disease (20%)
Cryptogenic (30%)
Subarachnoid Hemorrhage (41%)
Lacunar (25%)
Small vessel disease
Albers GW, et al. Chest. 1998;114:683S-698S.
Rosamond WD, et al. Stroke. 1999;30:736-743.
Embolism (20%)
Acute Ischemic Stroke

Deficits:








(What do you see?)
Unilateral (though not always) weakness
Unilateral sensory deficit
Visual deficits (blindness, gaze palsy, double)
Speech (slurred – a motor dysfunction)
Language (aphasia – damage to the brain’s
speech center)
Ataxia (lack of coordinated movement)
Cognitive impairment
Like real estate—Location, Location, Location
What Parts of
the Brain Are
Affected by Stroke?
What Are the Effects
of Stroke?

Left Brain
What Are the Effects
of Stroke?

Right Brain
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.
Act F.A.S.T for stroke

The National Stroke Association recommends
using the FAST method for recognizing and
responding to stroke symptoms.
F (face)
 A (arms)
 S (speech)
 T (time)

Stroke Assessment in the Field



Administer Cincinnati Scale.
If abnormal, facilitate a rapid transfer to
an approved stroke center.
Pre-notify the receiving stroke center—
”possible acute stroke in route”.
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
12:30pm. At 1pm a co-worker stated the man said he wasn’t 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: 12:30pm)
Types of Acute Ischemic Strokes



Middle Cerebral Artery Stroke
Vertebral—Basilar Artery Strokes
Lacunar Strokes
Types of Strokes
(Middle Cerebral Artery – MCA)
CT Scan of Acute Ischemic Stroke
(Left MCA territory stroke)
Types of Strokes


(Middle Cerebral Artery – MCA)
The most common artery occluded in AIS—
can 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)
Types of Strokes

(Vertebral—Basilar 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
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.
Conditions That Mimic AIS




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Bell’s Palsy
Todd’s Paralysis
Hemorrhagic Stroke
Subdural Hematoma
Other conditions
Conditions That Mimic AIS

Bell’s Palsy
Bell’s Palsy is a viral infection of the facial nerve which causes stroke-like
symptoms: unilateral facial droop, sensory deficit, dysarthria, etc.
Conditions That Mimic AIS

Differential dx:





Hx: women, pregnancy,
viral illness
Can’t close eye completely
or raise forehead
May have facial pain
No other stroke symptoms
May have no risk factors for
stroke
Conditions That Mimic AIS

Todd’s 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
Conditions That Mimic AIS




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Hypoglycemia
Metabolic conditions – fever, hyponatremia,
drugs, etc.
Psychogenic
Complex migraines
Hypertensive crisis
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

Non-Modifiable Risks



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Age->55
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
Goals for Treatment in the ED



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EMS rapid identification & pre-notification of the
Emergency Dept.
Quick evaluation in ED.
Last seen normal < 3 hr.
Door-to-CT scan
< 25 minutes
CT-to-Radiologist Reading
< 20 minutes
IV TPA administration
< 15 minutes
(Door-to-needle within 60 minutes.)
What can be done for an acute
ischemic stroke?



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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.”
Tissue Plasminogen Activator


Natural body substance. Recombinant TPA
converts Plasminogen to plasmin, which in turn
breaks down fibrin and fibrinogen, thereby
dissolving the clot.
IV window of opportunity is < 3 hours of known
symptom onset.
Transition
Hemorrhagic Stroke
Hemorrhagic Stroke
(Intracranial Hemorrhage—ICH & Subarachnoid Hemorrhage—SAH)

Intracranial Hemorrhage (Hypertensive):





> 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
Hemorrhagic Stroke
(Intracranial Hemorrhage—ICH & Subarachnoid Hemorrhage—SAH)

Risk factors:






Hypertension
Advancing age
Coagulation disorders & therapy
ETOH abuse
Drug use (meth, cocaine, crack, etc.)
Ischemic stroke—hemorrhagic transformation
Hemorrhagic Stroke
(Intracranial Hemorrhage—ICH & Subarachnoid Hemorrhage—SAH)

Presenting signs:




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Sudden—signs over minutes to hours
Headache
Nausea and vomiting
Decreasing LOC
Extremely elevated blood pressure
(All of these are signs of increased ICP)
Hemorrhagic Stroke
(Intracranial Hemorrhage—ICH & Subarachnoid Hemorrhage—SAH)

Differential Diagnosis:
AIS—often high BP
AIS—rare decreased LOC
AIS—rare or vague H.A.
AIS—rare nausea & vomiting
AIS—often wake up with the
symptoms
• Final
ICH—usually very high BP
ICH—50% of the time ↓ LOC
ICH—40% of the time H.A.
ICH—50% of time vomiting
ICH—rarely wake up with
symptoms (15%)
diagnosis is by CT scan.
Weakened blood vessels in a
Hypertensive Bleed
Autopsy of Intracerebral Hemorrhage
Small hemorrhagic stroke
Large hemorrhagic stroke
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)
Seizures


Versed – If seizure activity > 2-3 minutes
administer 2.5mg IV. May repeat 2.5mg once
in 5 minutes
Versed may be given IM if no IV established
Oxygenation



Oxygen is a free radical, meaning that it is a highly
reactive species owing to its two unpaired electrons.
From a physics perspective, free radicals have
potential to do harm in the body
Normally, the body fends off free radical attacks using
antioxidants. With aging and in cases of trauma,
stroke, heart attack or other tissue injury, the balance
of free radicals to antioxidants shifts
Cell damage occurs when free radicals outnumber
antioxidants, a condition called oxidative stress
Oxygenation



Tissue damage is directly proportionate to the quantity of
free radicals present at the site of injury. Supplemental
oxygen administration during the initial moments of a
stroke may well increase tissue injury by flooding the injury
site with free radicals.
Oxygen saturations should be measured on every patient.
Administer oxygen to keep saturations between 94 and 96
percent. Rarely does a patient need oxygen saturations
above 97 percent.
ICH: Goals for Early Management

Blood Pressure Management:



Very poor outcomes if BP is allowed to stay very
high—more bleeding
Very poor outcomes if BP is allowed to drop
precipitously—removes the brain’s attempt to
perfuse a “tight” brain
Guidelines:


In general, keep BP about 160/90 or MAP <130
In the first 48 hours: no BP drop > 15-25% of
presenting value
Hemorrhagic Stroke



(Subarachnoid Hemorrhage)
Acute bleeding around the outside of the
brain and into the subarachnoid space.
Usually from an aneurysm or arteriovenous malformation.
Statistics:




50% are fatal
1--15% die before reaching the hospital
Those who survive are often impaired
1-7% of all strokes
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
Aneurysmal bleed
Classic “Star Pattern” of Subarachnoid Hemorrhage
Subdural Hematoma
(Not a true stroke
but symptoms can
mimic stroke.)
Subdural Hematoma

Symptoms:




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Unilateral weakness, sensory deficit
Facial weakness
Dysarthria
Altered level of consciousness
Onset:


Can be rapid
Can take months to show symptoms
Subdural Hematoma
Causes

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


Anticoagulation (Heparin, Coumadin)
Antithrombotics (Aspirin, Plavix)
ETOH abuse
Trauma (could be recent or months ago)
Advanced age (most common cause)
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.
Subdural Hematoma on CT Scan
Subdural Hematoma
Treatment Options

Medical Management:



Correct Coags
Monitor neuro signs
Surgical Management:



Correct Coags
Burr hole drainage
Craniotomy for removal of solid clot
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
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!
Emergent Stroke Care and the
Chain of Survival
Patient
Calling
Knowledge 911
EMS
System
ED
Staff
Stroke
Team
Stroke
Unit
EMS
Treatment
SMO Code 38
“Suspected
Stroke”
“Initiate rapid transport.”
ESRH – Emergent Stroke Ready Hospital
PSC – Primary Stroke Center
Stroke Centers

On Oct 22, 2013, the Illinois Legislature’s
Joint Committee on Administrative Rules
formally approved the Administrative Rule
for the 2009 Illinois Primary Stroke Center
Law.

The 2009 Primary Stroke Center Law was
designed to improve stroke care in two
complementary ways:


Help hospitals to improve the quality of their inpatient stroke care systems
It would ensure that regional emergency medical
services (EMS) medical directors draft and
implement stroke care protocols to better identify
stroke patients in the field and take them directly
to the nearest designated stroke center for
treatment, bypassing a less-specialized hospital if
necessary.
Silver Cross Hospital EMS
System

Within SCEMSS, there are 3 IDPH
approved PSC or ESRH facilities:




Silver Cross Hospital – PSC
Presence St Joseph Medical Center – PSC
South Suburban Hospital – PSC
Other associate/participating facilities
within SCEMSS have IDPH applications
pending approval
Patient advocacy…
Per CODE 38
 If the Cincinnati Stroke Scale is positive;
 And “last known normal” is less than 3
hours;

Transport to the closest Primary Stroke
Center or Emergent Stroke Ready Hospital
Code 38 – Suspected Stroke

Initial Medical Care


Cincinnati Stroke Scale



If Positive, begin transport to nearest MOST
APPROPRIATE facility
Initiate rapid transport
12-Lead EKG


Obtain blood glucose reading and treat
appropriately
“If available” refers to the ability of your cardiac monitor
to perform a 12-lead EKG. If you have 12-lead
capabilities, you must perform one.
Other SMO CODE’s as indicated


Coma of Unknown Origin
Seizures
Run of the month…
Atrial Fibrillation
1) P waves are absent.
2) There are fibrillation (f)
waves instead of P waves.
The f waves result in
an oscillating irregular
baseline.
3) The R-R intervals are not
equal resulting in an
irregular rhythm
(irregularly irregular)
Atrial rate 400-600bpm
Ventricular rate 75-175bpm
Clinical significance




Atrial fibrillation patients usually have a ventricular rate of 75-175
beats/minute
A lower ventricular rate should suggest AV block or the use of
medications decreasing the ventricular rate (digoxin, beta blocker,
verapamil, diltiazem, amiodarone)
High ventricular response may cause syncope or even death in
these patients
Since the R-R intervals continuously change in atrial fibrillation
patients, the heart rate on the monitor also changes continuously.
In such patients, the instantaneous heart rates depicted on the
monitor usually does not give the average ventricular rate of that
patient



Since there is no atrial contraction, the presence of atrial fibrillation
decreases cardiac output by 20-25%
Atrial fibrillation results in “atrial statis” which predisposes to
the thrombus formation in the atria. This results in increased risk of
systemic embolism
Unless contraindicated, patients with atrial fibrillation are generally advised
to be on blood thinners


In patients with a very high ventricular rate, it may be difficult to recognize
the irregularity of the R-R intervals at first glance


Coumadin (warfarin sodium) is the most common medication prescribed for A-Fib
Adenosine is often used in the clinical setting to slow the rate to
differentiate between SVT/V-Tach. A-fib will not respond to the effects of
adenosine. THIS IS NOT PART OF REGION VII SMO’s
In some patients, atrial fibrillation is not persistent. (Transient A-Fib)
Assessment/Treatment

Symptomatic A-Fib patients – Signs of
hypoperfusion with elevated heart rate,
altered mental status

Consider Synchronized Cardioversion

Region VII – Code 83, “Synchronized Cardioversion”
Code 83 - “Synchronized Cardioversion”

Consider use of Versed for pain management and/or sedation




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



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
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2.5mg to 5mg, slow IVP
Constantly assess pulse oximetry and be prepared to place advanced airway if
necessary!
Place patient in safe environment, away from pooled water and metal surfaces
Apply monitor-defibrillator electrode pads to patient chest or appropriate conductive
medium paddles
Turn on defibrillator
Set energy level
Activate “synchronous” mode
Charge capacitor
Ensure proper placement of electrodes on chest: Apical and high parasternal
If using hand-held paddles, apply firm pressure and maintain until machine discharges
Assure that no personnel are in direct contact with the patient (Call “clear”)
Deliver shock by depressing discharge button. Hold button down until machine discharges
Reassess patient
Drug of the Month
Dextrose 50%
Dextrose 50%
Adult
Dose/Route
25 gm/50ml of
50% solution
IVP
Peds
Dose/Route
> 8 years
2 mL/kg of
50% solution
1 – 8 years
2 mL/kg of
25% solution
Infants under
2months
4 mL/kg of
12.5%
solution
Action
Increase blood
glucose
concentration
Indications
Hypoglycemia
ContraIndications
Adverse
Reactions
Intracranial and
intraspinal
hemorrhage,
hypovolemia,
hypotension 2°
tachydysrhythm
ias, delerium
tremens.
Hyperglycemia,
warmth /
burning from
IV injection,
diuresis,
thrombophlebit
is,
tissue necrosis
if IV infiltration.
The End…
Thanks for all you do !!!