1. Stroke Management for the EMS Provider
October 2014 CME

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. 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

4. 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)

5. 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)

6. 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.

7. 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.

8. 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.

9. 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?

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

12. 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

13. The Major Circulation to the Brain

14. 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.

15. 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:

16. 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

17. 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.

18. 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

19. 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

20. 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.

21. Act F.A.S.T for stroke F (face) A (arms) S (speech) T (time)
The National Stroke Association recommends using the FAST method for recognizing and responding to stroke symptoms.
F (face)
A (arms)
S (speech)
T (time)

22. 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”.

23. 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)

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

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

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

27. 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)

28. 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

29. 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.

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

32. 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.

33. 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

34. 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

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

36. 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
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

37. 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.)

38. 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.”

39. 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.

40. Transition
Hemorrhagic Stroke

41. 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

42. 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

43. 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)

44. 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.

45. Weakened blood vessels in a Hypertensive Bleed

46. Autopsy of Intracerebral Hemorrhage

47. Small hemorrhagic stroke

48. Large hemorrhagic stroke

49. 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

50. 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

51. 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.

52. 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

53. 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

54. 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

55. Aneurysmal bleed

56. Classic “Star Pattern” of Subarachnoid Hemorrhage
SAH

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

58. 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

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

60. 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.

61. Subdural Hematoma on CT Scan

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

63. 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

64. 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!

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

66. EMS Treatment
SMO Code 38
“Suspected Stroke”

67. “Initiate rapid transport.”
ESRH – Emergent Stroke Ready Hospital
PSC – Primary Stroke Center

68. 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.

69. The 2009 Primary Stroke Center Law was designed to improve stroke care in two complementary ways:
Help hospitals to improve the quality of their in-patient 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.

70. 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

71. 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

72. Code 38 – Suspected Stroke
Initial Medical Care
Obtain blood glucose reading and treat appropriately
Cincinnati Stroke Scale
If Positive, begin transport to nearest MOST APPROPRIATE facility
Initiate rapid transport
12-Lead EKG
“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

73. Run of the month…
Atrial Fibrillation

74. P waves are absent. 
There are fibrillation (f) waves instead of P waves. The f waves result in an oscillating irregular baseline. 
The R-R intervals are not equal resulting in an irregular rhythm (irregularly irregular)
Atrial rate bpm
Ventricular rate bpm

75. Clinical significance
Atrial fibrillation patients usually have a ventricular rate of  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  

76. 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
Coumadin (warfarin sodium) is the most common medication prescribed for A-Fib
In patients with a very high ventricular rate, it may be difficult to recognize the irregularity of the R-R intervals at first glance 
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)

77. 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”

78. Code 83 - “Synchronized Cardioversion”
Consider use of Versed for pain management and/or sedation
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

79. Drug of the Month
Dextrose 50%

80. Dextrose 50% Adult Dose/Route Peds Dose/Route Action Indications
Contra-Indications
Adverse Reactions
25 gm/50ml of 50% solution IVP
> 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
Increase blood glucose concentration
Hypoglycemia
Intracranial and intraspinal
hemorrhage, hypovolemia,
hypotension 2°
tachydysrhythmias, delerium
tremens.
Hyperglycemia, warmth /
burning from IV injection,
diuresis, thrombophlebitis,
tissue necrosis if IV infiltration.

81. The End…
Thanks for all you do !!!