Download MDPH/OEMS Stroke Point of Entry

St. Elizabeth Healthcare
Pre-hospital Care
Stroke Assessment
Debbie Szurlinski, EMT-P
EMS Coordinator
Update 2010
Purpose
To provide EMTs and Paramedics with the
fundamental knowledge needed to
recognize and manage potential stroke in
the pre-hospital setting and make
appropriate transport and hospital
notification decisions based on the Stroke
POE Plan.
Objectives
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Identify the different categories of strokes
List common signs & symptoms of stroke
Provide several risk factors for stroke
Explain the importance of rapid stroke therapy
Describe pre-hospital assessment and care
Describe the Regional Stroke POE plan
Discuss appropriate treatment and transport
modalities
Describe detailed stroke documentation
Stroke Background
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Third leading cause of death in the U.S.
Approx. 700,000 people suffer strokes
each year
Incidence increases with age
Mortality from stroke increases with age
Frequent cause of disability
Pre-hospital care has been primarily
supportive
Stroke in the Pre-Hospital Setting
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Stroke must be suspected quickly by EMT’s and
Paramedics in the field.
Extensive neurological neurological exams are
impractical in the pre-hospital setting
After assessment, notify hospital,rapid transport
without delay to closest certified stroke facility
Cincinnati Pre-hospital Stroke
Scale
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Patients with 1 of these three
finding- (as a new event)- have 72%
probability of ischemic stroke
If all (3) findings are present
probability of an acute stroke is more
than 85%
Immediately contact medical control
and destination ED and provide prearrival notification
Stroke Assessment
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One of the most important aspects of your
patient assessment must be the time of
onset of first symptom
Document time the patient was last seen
acting normal
The onset time has the most important
implications for potential therapy.
Early notification to STROKE facility is
essential
Careful assessment of a stroke is a must,
signs of stroke can be very subtle
Conditions that mimic Stroke
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Hypoglycemia
Electrolyte imbalances (esp. Sodium)
Epidural or subdural hematoma
Brain abscess or tumor
Post-seizure
Migraine
Etiology Overview
Atheromatous
Atheromatous
Source: Brady CD, Paramedic Care: Principles & Practice Vol.3 ©2001
Stroke Risk Factors
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High blood pressure
Atrial fibrillation, CHF
High cholesterol
Diabetes (twice the risk)
Smoking (50% higher risk)
Alcohol or Drug Abuse
Inactivity or Obesity
Clotting problems (OCP, Sickle Cell)
Stroke Risk Factors (con’t)
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Prior Stroke History
Heredity
Age (risk increases with age)
Gender
• more common in men
• more women die from stroke
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Race (greater risk among African
Americans)
Transient Ischemic Attacks
(TIA’s)
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Temporary interruption of blood supply
to brain
Carotid artery disease a common cause
Stroke-like neurological deficit
symptoms
• abrupt onset
• Symptoms resolve in less than 24 hours,
usually within minutes.
• No long-term effects, but high stroke risk
TIA’s, (con’t)
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One third of TIA patients will suffer an
acute stroke
Evaluate through history taking:
• History of HTN, prior stroke, or TIA
• Symptoms and their progression
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Impossible (at this time) in pre-hospital
setting to determine if a neurological event
is due to TIA or stroke
Ischemic Stroke
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About 80% of all strokes
Occurs when a cerebral artery is blocked
by a clot or other foreign matter
Causes ischemia (inadequate blood
supply to tissue)
Progresses to infarction (death of tissues)
Classified as:
• Embolic Stroke
• Thrombotic Stroke
Ischemic Stroke
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Embolic
• The occlusion is caused by an embolus (solid, liquid,
or gaseous mass) carried to a blood vessel from
another area
• Most common emboli are blood clots
• Risk factors for blood clots include Atrial Fibrillation
and diseased or damaged carotid or vertebral arteries
• Rare causes of emboli include air, tumor tissue, and
fat
• Occurs suddenly & may rarely be accompanied by
headache
Source: http://www.irishhealth.com/?level=4&con=8
Ischemic Strokes
Thrombotic
• The occlusion is caused by a cerebral
thrombus; a blood clot which develops
gradually in a previously diseased artery and
obstructs it
• Caused by atherosclerosis:
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atheromatous plaque deposits form on the inner
walls of arteries, resulting in narrowing and
reduction of blood flow
platelets adhere to the roughened surface of the
plaque deposit and a blood clot is created
Ischemic Strokes
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Thrombotic (con’t)
• Signs & symptoms may develop more
gradually
• Often occurs at night with patient
awakening from sleep with symptoms
Source: http://www.strokecenter.org/pat/ais.htm
Hemorrhagic Strokes
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About 20% of all strokes
Onset usually sudden with severe headache
Classified as:
• Intracerebral hemorrhage (within the brain)
• Subarachnoid hemorrhage (in the fluid filled spaces
around the blood vessels outside the brain)
Intracerebral hemorrhage
•Most occur in the hypertensive patient
when a small vessel within the brain tissue
ruptures
•Hemorrhage inside the brain often tears
and separates brain tissue
Intracerebral Hemorrhage
Often caused by a ruptured blood vessel within
the brain tissue of the hypertensive patient.
Hemorrhagic Strokes
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Subarachnoid hemorrhage
• Most often result from congenital blood vessel
abnormalities (e.g., aneurysm) or head trauma
•Herniation of brain tissue may occur
•Blood in the subarachnoid space may impair
drainage of cerebrospinal fluid and cause a
rise in intracranial pressure
Source: http://medic.med.uth.tmc.edu/edprog/Path/NeuroIIb.htm
What can be done?
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Rapid recognition and prompt transport to Hospital.
A Primary Stroke service provider is a DPH designated
facility that offers emergency diagnostic and therapeutic
services provided by a multidisciplinary team and
available 24 hours per day, 7 days per week to patients
presenting with symptoms of acute stroke.
GCNKSS and Massachusetts DPH.
Stroke Chain of Survival
Time-Sensitive Therapy
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Transport to PSC within 2 hours of
symptom onset if possible
EMS must determine the exact time of
onset as accurately as possible and also
note the time the patient was last seen
acting normal
Time = Brain Tissue
Team Approach
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Detection
• Importance of early recognition by lay public
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Dispatch (9-1-1)
• Obtains pertinent info; identifies urgency
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Delivery (EMS)
• Evaluates, obtains symptom onset, minimizes
on scene time; immediate transport and prenotification to PSS as soon as possible!
Team Approach
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Door (Primary Stroke Service)
• Alerts stroke team, performs patient exam &
assessment, rapid CT scan
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Data
• Reviews all pertinent patient information
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Decision
• Determines appropriate therapy
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Drug
• Administers appropriate therapy
Stroke
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Once the diagnosis of stroke is
suspected, time in the field must
be minimized.
The presence of a patient with acute
stroke is a “load and go”
A more extensive examination or
initiation of supportive therapies
should be accomplished en-route to
the hospital.
Stroke: Signs & Symptoms
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Paralysis on one side
Facial Droop
Limb Weakness
Paresthesias/Sensory loss
(numbness or tingling)
Ataxia
• Gait Disturbance
• Uncoordinated fine motor movements
Signs & Symptoms
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Speech Disturbance
Vision Problems
Headache
Confusion/Agitation
Dizziness/Vertigo
CINCINNATI STROKE SCALE
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Identifies patients with strokes.
Evaluates three major physical
findings.
 Facial droop
 Motor arm weakness
 Speech abnormalities
FACIAL DROP
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FACIAL DROOP
• Patient shows teeth or smiles
NORMAL
ABNORMAL
Speech Disturbance
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Aphasia
• Inability to speak
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Dysphasia
• Difficulty speaking
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Dysarthria
• Impairment of the tongue muscles essential to
speech
Vision Problems
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Nystagmus
• Involuntary jerking of the eyes
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Diplopia
• Double vision
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Monocular blindness
• Blindness in one eye
Arm Drift
• Have the patient close his / her eyes
and hold both arms out
• Normal-both arms move the same way.
or both arms do not move at all
• Abnormal- one arm does not move or
one arm drifts down compared to the
other arm.
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Other findings such as pronater grip may be
helful.
Pre-hospital Care
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Scene safety & BSI
Maintain airway & assist ventilations as
indicated (do not hyperventilate)
Provide 2 lpm O2 NC unless in
respiratory distress
Provide C-Spine immobilization if
indicated
Obtain Vital Signs & SAMPLE history
Collect or document ALL medications
Pre-hospital Care, continued
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Record onset time and phone access to
witness
Do not allow patient to exert themselves
Follow appropriate ALS / BLS protocols
Do not administer aspirin unless evidence
of acute coronary syndrome
Complete and then document results of
• Cincinnati Stroke Scale
Pre-hospital Care
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Notify receiving facility ASAP
Monitor/record VS every 5 minutes if unstable,
or every 15 minutes if stable
Position the patient, protecting paralyzed
extremities
Secure patient to stretcher and transport rapidly
without excessive movement or noise
Use treatment eligibility checklist en-route &
include information in documentation
Stroke: Documentation
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SAMPLE
Age, Sex, Race/Ethnicity
Onset time and last seen at baseline
Assessment and care provided (BLS/ALS)
Receiving Primary Stroke Service (PSS)
Trip times (dispatch, patient contact, hospital
notified, hospital arrival)
Eligibility checklist (include all information)
Pre-hospital Care: ALS
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Contact medical control prior to
administering any drugs.
IV access & 12 lead should not delay
transport
Scenario 1
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67 year old female at home
Chief complaint dizziness
History of NIDDM
Scenario 1 examined
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There could be other causes of dizziness,
do not rule out stroke. Review other
causes.
Older patients and those with Diabetes are
at increased risk of ischemic stroke.
Discuss the other findings that might make
you think this patient is experiencing a
stroke.
Scenario 2
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54 year old male at minor MVA
Chief complaint sudden onset headache
History of hypertension
Scenario 2 examined
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The MVA may have caused the headache,
but maybe the headache caused the MVA.
Remember to consider all the possibilities.
Patients with hypertension are at
increased risk of ischemic stroke and
intracerebral hemorrhage.
Headache is unusual in ischemic stroke,
but is the hallmark of hemorrhagic stroke.
Stroke POE Plan
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GOAL: Rapid transport to the closest PSS
facility within 2 hours of symptom onset.
Choose most appropriate mode of
transport (ground, air) and destination to
achieve this.
Documentation
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Complete a Pre-hospital Stroke Assessment
Sheet
Remember to leave a copy of the Patient Care
Report at the hospital
The EMS patient care report is a CRITICAL part
of the patient’s medical record and contains vital
information pertinent to continuing care at the
hospital and to providing follow-up information to
EMS.
Summary
Early detection of CVA / TIA in the prehospital care setting can have a
dramatic effect of the mortality and
morbidity of patients. Using the
Cincinnati Stroke Scale pre-hospital
personnel can quickly and accurately
access the neurological status of a
patient presenting with signs and
symptoms of a CVA / TIA
References
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Bledsoe, B., Porter, R., Cherry, R. (2003). Neurology.
In Brady,
Essentials of Paramedic Care (pp. 1356-1361, 1827-1828). Upper Saddle River, NJ:
Pearson
Education, Inc.
Dambinova, S. (2004). Diagnostic Potential of New
Brain Markers for
TIA/Stroke Assessment. Business Briefing:Medical Device Manufacturing &
Technology, 1-4.
(2004). Acute Stroke. In EMS Pre-hospital Treatment
Protocols (V. 5.1, Protocol
3.11). MDPH/OEMS.
www.ninds.nih.gov
www.strokeassociation.org
www.stopstroke.org
Internet References
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www.ninds.nih.gov
www.strokeassociation.org
www.stopstroke.org