1. 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)

2. 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.

3. Stroke Management for the EMS Provider
Instructions:
Page through the module to learn the content.
Complete the post test.

4. 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

5. 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)

6. 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
Stroke is a leading cause of adult disability. Over the course of a lifetime, four out of every five American families will be touched by stroke.
Stroke can be a preventable disease. I’ll discuss specific ways you can prevent stroke later in the presentation.
Every 45 seconds someone suffers a stroke, every 3 minutes someone dies from a stroke.
Twice as many women die from stroke every year than from breast cancer.
hypertension
diabetes
obesity
smoking
sickle cell anemia
(National Stroke Association)

7. 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
Stroke is a leading cause of adult disability. Over the course of a lifetime, four out of every five American families will be touched by stroke.
Stroke can be a preventable disease. I’ll discuss specific ways you can prevent stroke later in the presentation.
Every 45 seconds someone suffers a stroke, every 3 minutes someone dies from a stroke.
Twice as many women die from stroke every year than from breast cancer.
(National Stroke Association)

8. How Bad is a Major Stroke
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

9. 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.

10. 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.

11. 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 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.

12. 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?

13. What Is Stroke ?
A stroke occurs when blood flow to the brain is interrupted by a blocked or burst blood vessel.

15. 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

16. The Major Circulation to the Brain

18. through emergency interventions and medical management.
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.

19. Cerebrovascular Disease: Pathogenesis
Hemorrhagic Stroke (17%)
Ischemic Stroke (83%)
Atherothrombotic
Cerebrovascular
Disease (20%)
Intracerebral
Hemorrhage (59%)
Cryptogenic (30%)
Subarachnoid Hemorrhage (41%)
Lacunar (25%)
Small vessel disease
Embolism (20%)
Albers GW, et al. Chest. 1998;114:683S-698S.
Rosamond WD, et al. Stroke. 1999;30:

20. 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 brain’s speech center)
Ataxia (lack of coordinated movement)
Cognitive impairment
Like real estate—Location, Location, Location

21. What Parts of the Brain Are Affected by Stroke?
The brain is an extremely complex organ that controls various body functions. If a stroke occurs such that blood flow is restricted from reaching the region that controls a particular body function, for example, the leg, then the result will be muscle weakness causing a limp or some related motor disability.
If the stroke occurs toward the back of the brain, it is likely that some disability involving vision will result.
The effects of a stroke depend primarily on the location of the obstruction and the extent of brain tissue affected.

22. What Are the Effects of Stroke?
Left Brain
If the stroke occurs in the left side of the brain, the right side of the body (and the left side of the face) will be affected, producing any or all of the following:
Paralysis on the right side of the body
Speech/language problems
Slow, cautious behavioral style
Memory loss

23. What Are the Effects of Stroke?
Right Brain
The effects of a stroke depend on a number of factors including the location of the obstruction and the extent of brain tissue affected.
However, because the brain is structured such that one side controls the opposite side of the body, a stroke affecting one side will result in neurological complications on the opposite side of the body as well.
For example, if the stroke occurs in the right side of the brain, the left side of the body (and the right side of the face) will be affected, which could produce any or all of the following:
• Paralysis on the left side of the body
• Vision problems
• Quick, inquisitive behavioral style
• Memory loss

24. 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.

25. Stroke Assessment in the Field
Administer Cincinnati Scale.
If abnormal, facilitate a rapid transfer to the primary stroke center. (Alta Bates in North Alameda County—Washington Hospital in South Alameda County.
Pre-notify the receiving stroke center—”possible acute stroke in route”.

26. 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)

27. Types of Acute Ischemic Strokes
Middle Cerebral Artery Stroke
Vertebral—Basilar Artery Strokes
Lacunar Strokes

28. Types of Strokes (Middle Cerebral Artery – MCA)

29. CT Scan of Acute Ischemic Stroke (Left MCA territory stroke)

30. 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)

31. 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

32. 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.

34. Conditions That Mimic AIS
Bell’s Palsy
Todd’s Paralysis
Hemorrhagic Stroke
Subdural Hematoma
Other conditions

35. 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.

36. 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

37. 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

38. Conditions That Mimic AIS
Hypoglycemia
Metabolic conditions – fever, hyponatremia, drugs, etc.
Psychogenic
Complex migraines
Hypertensive crisis

39. 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->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

40. Goals for Treatment in the ED
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.)

41. 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.”

42. 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 < 3 hours of known symptom onset.

43. Early Rx was better in the NINDS tPA Trial
Minutes From Stroke Onset To Start of Treatment 60 70 80 90
100
110
120
130
140
150
160
170
180
Odds Ratio For Favorable Outcome at 3 Months 1 2 3 4 5 6 7 8
Marler JR, et al. Early stroke treatment associated with better outcome. The NINDS rt-PA Stroke Study. Neurology 2000;55:

44. Transition
Hemorrhagic Stroke

45. 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

46. 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

47. Hemorrhagic Stroke (Intracranial Hemorrhage—ICH & Subarachnoid Hemorrhage—SAH)
Presenting signs:
Sudden—signs over minutes to hours
Headache
Nausea and vomiting
Decreasing LOC
Extremely elevated blood pressure
(All of these are signs of increased ICP)

48. 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
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%)
Final diagnosis is by CT scan.

49. Weakened blood vessels in a Hypertensive Bleed

50. Autopsy of Intracerebral Hemorrhage

51. Small hemorrhagic stroke

52. Large hemorrhagic stroke

53. 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 PE (phenytoin equivalents over 3-6 minutes)
Prevention: Phenytoin mg/20-30 min

54. 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

55. 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

56. 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

57. Aneurysmal bleed

58. Classic “Star Pattern” of Subarachnoid Hemorrhage
SAH

59. Magnified view
of cerebral
aneurysm.

60. Subdural Hematoma
(Not a true stroke
but symptoms can
mimic stroke.)

61. Subdural Hematoma Symptoms: Onset:
Unilateral weakness, sensory deficit
Facial weakness
Dysarthria
Altered level of consciousness
Onset:
Can be rapid
Can take months to show symptoms

62. Subdural Hematoma Causes
Anticoagulation (Heparin, Coumadin)
Antithrombotics (Aspirin, Plavix)
ETOH abuse
Trauma (could be recent or months ago)
Advanced age (most common cause)

63. 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.

64. Subdural Hematoma on CT Scan

65. Subdural Hematoma Treatment Options
Medical Management:
Correct Coags
Monitor neuro signs
Surgical Management:
Burr hole drainage
Craniotomy for removal of solid clot

66. 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

67. 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!

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

69. Module is Completed Proceed to Post Test

70. 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. ________________

71. Post Test
The family states the patient woke up at 6:30am and exhibited signs of acute stroke. We should assume that the stroke started at 6:30am. (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.

72. 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)

73. 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)
Bell’s Palsy; Todd’s 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.