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Massachusetts Department of Public Health Office of Emergency Medical Services Stroke Point of Entry.

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Presentation on theme: "Massachusetts Department of Public Health Office of Emergency Medical Services Stroke Point of Entry."— Presentation transcript:

1 Massachusetts Department of Public Health Office of Emergency Medical Services Stroke Point of Entry

2 Purpose To provide EMTs 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. Photo source: UMass Memorial LifeFlightUMass Memorial LifeFlight

3 Objectives Identify the two major categories of strokeIdentify the two major categories of stroke List common signs & symptoms of strokeList common signs & symptoms of stroke Provide several risk factors for strokeProvide several risk factors for stroke Explain the importance of rapid stroke therapyExplain the importance of rapid stroke therapy Describe pre-hospital assessment and care, including the BOSS and thrombolytic checklistDescribe pre-hospital assessment and care, including the BOSS and thrombolytic checklist Describe the MA and Regional Stroke POE planDescribe the MA and Regional Stroke POE plan Discuss appropriate treatment and transport modalitiesDiscuss appropriate treatment and transport modalities Describe detailed stroke documentationDescribe detailed stroke documentation

4 Background Third leading cause of death in the U.S.Third leading cause of death in the U.S. Approx. 700,000 people suffer strokes each yearApprox. 700,000 people suffer strokes each year Incidence increases with ageIncidence increases with age Mortality from stroke increases with ageMortality from stroke increases with age Frequent cause of disabilityFrequent cause of disability Pre-hospital care has been primarily supportivePre-hospital care has been primarily supportive

5 Stroke: What is it? Injury or death of brain tissue due to oxygen deprivation; usually due to an interruption of blood flowInjury or death of brain tissue due to oxygen deprivation; usually due to an interruption of blood flow Also referred to as “Brain Attack” or “Cerebrovascular Accident” (CVA)Also referred to as “Brain Attack” or “Cerebrovascular Accident” (CVA) A true emergency!A true emergency!

6 Etiology Overview Source: Brady CD, Paramedic Care: Principles & Practice Vol.3 ©2001Brady CD, Paramedic Care: Principles & Practice Vol.3 ©2001 Atheromatous

7 Ischemic Stroke About 80% of all strokesAbout 80% of all strokes Occurs when a cerebral artery is blocked by a clot or other foreign matterOccurs when a cerebral artery is blocked by a clot or other foreign matter Causes ischemia (inadequate blood supply to tissue)Causes ischemia (inadequate blood supply to tissue) Progresses to infarction (death of tissues)Progresses to infarction (death of tissues) Classified as:Classified as: –Embolic Stroke –Thrombotic Stroke

8 Ischemic Stroke EmbolicEmbolic –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

9 Embolic Stroke Source:

10 Ischemic Strokes ThromboticThrombotic –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: atheromatous plaque deposits form on the inner walls of arteries, resulting in narrowing and reduction of blood flowatheromatous 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 createdplatelets adhere to the roughened surface of the plaque deposit and a blood clot is created

11 Ischemic Strokes Thrombotic, continued:Thrombotic, continued: –Signs & symptoms may develop more gradually –Often occurs at night with patient awakening from sleep with symptoms

12 Thrombotic Stroke Source:

13 Hemorrhagic Strokes About 20% of all strokesAbout 20% of all strokes Onset usually sudden with severe headacheOnset usually sudden with severe headache Classified as:Classified as: –Intracerebral hemorrhage (within the brain) –Subarachnoid hemorrhage (in the fluid filled spaces around the blood vessels outside the brain)

14 Hemorrhagic Strokes Intracerebral hemorrhageIntracerebral 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

15 Intracerebral Hemorrhage Often caused by a ruptured blood vessel within the brain tissue of the hypertensive patient. Source:

16 Hemorrhagic Strokes Subarachnoid hemorrhageSubarachnoid hemorrhage –Most often result from congenital blood vessel abnormalities (e.g., aneurysm) or head trauma

17 Subarachnoid Hemorrhage Often result from congenital abnormalities (e.g., aneurysms) or from head trauma Source:

18 Cerebral Aneurysm dilation, bulging or ballooning out of part of the wall of a vein or artery in the brain.dilation, bulging or ballooning out of part of the wall of a vein or artery in the brain. Source:

19 Hemorrhagic Strokes Subarachnoid hemorrhageSubarachnoid hemorrhage –Blood in the subarachnoid space may impair drainage of cerebrospinal fluid and cause a rise in intracranial pressure –Herniation of brain tissue may occur

20 Herniation Protrusion of brain tissue through the base of skull (shown as “e”) from pressure due to mass lesion Source:

21 What can be done? Rapid recognition and prompt transport to a Primary Stroke Service (PSS) providerRapid recognition and prompt transport to a Primary Stroke Service (PSS) provider 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.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.

22 Stroke: What can be done? Tissue plasminogen activator (tPA) and other thrombolytic (clot dissolving) agents used for heart attack, are also effective against certain ISCHEMIC strokes

23 Stroke: What can be done? A multi-center, randomized clinical trial conducted by The National Institute of Neurological Disorders and Stroke (NINDS) found that selected stroke patients who received t-PA within three hours of the onset of stroke symptoms were at least 30 percent more likely than placebo patients to recover from their stroke with little or no disability after three months.

24 Time Sensitive Treatment Must receive treatment within three (3) hours of onset of symptomsMust receive treatment within three (3) hours of onset of symptoms EMS must determine the exact time of onset as accurately as possible and also note the time the patient was last seen wellEMS must determine the exact time of onset as accurately as possible and also note the time the patient was last seen well Transport to PSC within 2 hours of symptom onset if possibleTransport to PSC within 2 hours of symptom onset if possible Time = Brain TissueTime = Brain Tissue

25 Team Approach DetectionDetection –Importance of early recognition by lay public Dispatch (9-1-1)Dispatch (9-1-1) –Obtains pertinent info; identifies urgency Delivery (EMS)Delivery (EMS) –Evaluates, obtains symptom onset, minimizes on scene time; immediate transport and pre-notification to PSS as s oon as possible!

26 Team Approach Door (Primary Stroke Service)Door (Primary Stroke Service) –Alerts stroke team, performs patient exam & assessment, rapid CT scan DataData –Reviews all pertinent patient information DecisionDecision –determines if thrombolytic therapy candidate DrugDrug –administers treatment <60 min of arrival

27 Therapies & New Developments Thrombolytic AgentsThrombolytic Agents Cytoprotective AgentsCytoprotective Agents Platelet Inhibitor DrugsPlatelet Inhibitor Drugs Neuroradiological InterventionNeuroradiological Intervention Ultrasound-aided TherapyUltrasound-aided Therapy In vitro diagnostic testsIn vitro diagnostic tests –may allow rapid detection of ischemic stroke in the field, at the bedside or in the ED!

28 Stroke Risk Factors High blood pressureHigh blood pressure Atrial fibrillation, CHFAtrial fibrillation, CHF High cholesterolHigh cholesterol Diabetes (twice the risk)Diabetes (twice the risk) Smoking (50% higher risk)Smoking (50% higher risk) Alcohol or Drug AbuseAlcohol or Drug Abuse Inactivity or ObesityInactivity or Obesity Clotting problems (OCP, Sickle Cell)Clotting problems (OCP, Sickle Cell)

29 Stroke Risk Factors, continued Prior Stroke HistoryPrior Stroke History HeredityHeredity Age (risk increases with age)Age (risk increases with age) GenderGender –more common in men –more women die from stroke Race (greater risk among African Americans)Race (greater risk among African Americans)

30 Paralysis on one side Facial Droop Limb Weakness Paresthesias/Sensory loss (numbness or tingling) Ataxia – –Gait Disturbance – –Uncoordinated fine motor movements Stroke: Signs & Symptoms

31 Signs & Symptoms, continued Speech Disturbance Vision ProblemsVision Problems HeadacheHeadache Confusion/AgitationConfusion/Agitation Dizziness/VertigoDizziness/Vertigo

32 Speech Disturbance AphasiaAphasia –Inability to speak DysphasiaDysphasia –Difficulty speaking DysarthriaDysarthria –Impairment of the tongue muscles essential to speech

33 Vision Problems NystagmusNystagmus –Involuntary jerking of the eyes DiplopiaDiplopia –Double vision Monocular blindnessMonocular blindness –Blindness in one eye

34 Temporary interruption of blood supply to brainTemporary interruption of blood supply to brain Carotid artery disease a common causeCarotid artery disease a common cause Stroke-like neurological deficit symptomsStroke-like neurological deficit symptoms –abrupt onset –Symptoms resolve in less than 24 hours, usually within minutes. –No long-term effects, but high stroke risk Transient Ischemic Attacks (TIAs)

35 TIAs, continued One third of TIA patients will suffer an acute strokeOne third of TIA patients will suffer an acute stroke Evaluate through history taking:Evaluate through history taking: –History of HTN, prior stroke, or TIA –Symptoms and their progression Impossible (at this time) in pre-hospital setting to determine if a neurological event is due to TIA or strokeImpossible (at this time) in pre-hospital setting to determine if a neurological event is due to TIA or stroke

36 Conditions that mimic Stroke HypoglycemiaHypoglycemia Electrolyte imbalances (esp. Sodium)Electrolyte imbalances (esp. Sodium) Epidural or subdural hematomaEpidural or subdural hematoma Brain abscess or tumorBrain abscess or tumor Post-seizurePost-seizure MigraineMigraine

37 Scene safety & BSIScene safety & BSI Maintain airway & assist ventilations as indicated (do not hyperventilate)Maintain airway & assist ventilations as indicated (do not hyperventilate) Provide 2 lpm O 2 NC unless in resp. distressProvide 2 lpm O 2 NC unless in resp. distress Provide C-Spine immobilization if indicatedProvide C-Spine immobilization if indicated Obtain Vital Signs & SAMPLE historyObtain Vital Signs & SAMPLE history Collect or document ALL medicationsCollect or document ALL medications Pre-hospital Care

38 Pre-hospital Care, continued Record onset time and phone access to witnessRecord onset time and phone access to witness Do not allow patient to exert themselvesDo not allow patient to exert themselves Do not administer aspirin unless evidence of acute coronary syndromeDo not administer aspirin unless evidence of acute coronary syndrome Complete and then document results of Boston Operation Stroke Scale (BOSS)Complete and then document results of Boston Operation Stroke Scale (BOSS) –(Refer to Protocols Appendix Q) –ONE positive finding is strongly predictive of stroke

39 Boston Stroke Scale (BOSS) FACIAL DROOPFACIAL DROOP –Patient shows teeth or smiles NORMALABNORMAL

40 BOSS Scale ARM DRIFTARM DRIFT –Patient closes eyes & extends arms for 10 seconds NORMALABNORMAL

41 BOSS Scale SPEECHSPEECH –Patient repeats “The sky is blue in Boston” Normal: States correctly without slurring on first attempt Abnormal: Slurs words, says the wrong words or is unable to speak on first attempt (mute)

42 Pre-hospital Care, continued Determine blood glucose level if allowed; get medical control permission to administer glucose even if glucose level is lowDetermine blood glucose level if allowed; get medical control permission to administer glucose even if glucose level is low If unconscious or seizing, transport on left sideIf unconscious or seizing, transport on left side If BP drops below 100 systolic, treat for shockIf BP drops below 100 systolic, treat for shock Initiate transport by ground to nearby PSS using BLS or ALS; activate ALS in patients with respiratory or hemodynamic compromiseInitiate transport by ground to nearby PSS using BLS or ALS; activate ALS in patients with respiratory or hemodynamic compromise

43 Pre-hospital Care, continued Notify receiving facility ASAPNotify receiving facility ASAP Monitor/record VS every 5 minutes if unstable, or every 15 minutes if stableMonitor/record VS every 5 minutes if unstable, or every 15 minutes if stable Position the patient, protecting paralyzed extremitiesPosition the patient, protecting paralyzed extremities Secure patient to stretcher and transport rapidly without excessive movement or noiseSecure patient to stretcher and transport rapidly without excessive movement or noise Use Thrombolytic Checklist en-route & include information in documentationUse Thrombolytic Checklist en-route & include information in documentation

44 Pre-hospital Care: ALS Contact medical control prior to administration of D50 or D5WContact medical control prior to administration of D50 or D5W IV access & 12 lead should not delay transportIV access & 12 lead should not delay transport

45 Stroke POE Plan EMS Operational Definition of Acute StrokeEMS Operational Definition of Acute Stroke –Onset of symptoms < 2hr duration (or since last seen at baseline) according to the BOSS scale OR other concerning neurologic signs consistent with stroke, such as: Eye movement abnormalitiesEye movement abnormalities Weakness affecting the legWeakness affecting the leg Double visionDouble vision Sudden onset dizziness AND unable to walkSudden onset dizziness AND unable to walk

46 Stroke POE Plan Following the Mass EMS Pre-hospital Treatment Protocols for Acute Stroke (3.11), determine possibility of stroke based on BOSS scale (Protocols, Appendix Q) and assessmentFollowing the Mass EMS Pre-hospital Treatment Protocols for Acute Stroke (3.11), determine possibility of stroke based on BOSS scale (Protocols, Appendix Q) and assessment Establish time of onset and last time seen at baselineEstablish time of onset and last time seen at baseline

47 Stroke POE Plan If stroke symptoms present & time fromIf stroke symptoms present & time from onset of symptoms to hospital arrival will be < 2 hours, transport patient to nearest appropriate DPH designated provider of Primary Stroke Service (PSS) Notify receiving facility ASAPNotify receiving facility ASAP

48 Stroke POE Plan GOAL: To transport patient to PSS within 2 hours of symptom onset.GOAL: To transport patient to PSS within 2 hours of symptom onset. Choose most appropriate mode of transport (ground, air) and destination to achieve this.Choose most appropriate mode of transport (ground, air) and destination to achieve this. Photo Source: Boston MedFlightBoston MedFlight

49 Stroke POE Plan It may be more appropriate to transport to the nearest hospital for acute stabilization if:It may be more appropriate to transport to the nearest hospital for acute stabilization if: –Compromised airway –Hemodynamically unstable –Depressed level of consciousness –Documented or suspected severe hypoglycemia (diaphoretic & known diabetic)

50 Stroke POE Plan If CT Scan capability is unavailable at the nearest PSS (e.g., “Cautionary Status”), the patient should be transported to the next nearest appropriate PSSIf CT Scan capability is unavailable at the nearest PSS (e.g., “Cautionary Status”), the patient should be transported to the next nearest appropriate PSS If the patient will arrive at the PSS more than 2 hours after symptom onset, transport to the nearest hospital.If the patient will arrive at the PSS more than 2 hours after symptom onset, transport to the nearest hospital. These time guidelines may be revised as new therapies extend the stroke treatment time frameThese time guidelines may be revised as new therapies extend the stroke treatment time frame

51 Stroke: Documentation SAMPLESAMPLE Age, Sex, Race/EthnicityAge, Sex, Race/Ethnicity Onset time and last seen at baselineOnset time and last seen at baseline Assessment and care provided (BLS/ALS)Assessment and care provided (BLS/ALS) Receiving Primary Stroke Service (PSS)Receiving Primary Stroke Service (PSS) Trip times (dispatch, patient contact, hospital notified, hospital arrival)Trip times (dispatch, patient contact, hospital notified, hospital arrival) Thrombolytic Checklist (include all information)Thrombolytic Checklist (include all information)

52 Documentation Remember to leave a copy of the Patient Care Report at the hospital per:Remember to leave a copy of the Patient Care Report at the hospital per: 105 CMR (C)(2) 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.

53 Summary Two major categories of strokeTwo major categories of stroke Common signs & symptoms of strokeCommon signs & symptoms of stroke Risk factors for strokeRisk factors for stroke The importance of rapid stroke therapyThe importance of rapid stroke therapy Pre-hospital assessment and care, the (BOSS) and thrombolytic checklistPre-hospital assessment and care, the (BOSS) and thrombolytic checklist Stroke POE planStroke POE plan Stroke documentationStroke documentation

54 Scenario 1 67 year old female at home67 year old female at home Chief complaint dizzinessChief complaint dizziness History of NIDDMHistory of NIDDM

55 Scenario 1 examined There are many causes of dizziness that are not stroke-related. Review these together.There are many causes of dizziness that are not stroke-related. Review these together. Older patients and those with Diabetes are at increased risk of ischemic stroke.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.Discuss the other findings that might make you think this patient is experiencing a stroke.

56 Scenario 2 54 year old male at minor MVA54 year old male at minor MVA Chief complaint sudden onset headacheChief complaint sudden onset headache History of hypertensionHistory of hypertension

57 Scenario 2 examined The MVA may have caused the headache, but maybe the headache caused the MVA. Remember to consider all the possibilities.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.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.Headache is unusual in ischemic stroke, but is the hallmark of hemorrhagic stroke.

58 Scenario 3 72 year old male at fast food restaurant72 year old male at fast food restaurant Wife reports patient “acting funny” and slurring wordsWife reports patient “acting funny” and slurring words History of TIAHistory of TIA

59 Scenario 3 examined Older patients and those with prior cerebrovascular disease are at increased risk of ischemic stroke.Older patients and those with prior cerebrovascular disease are at increased risk of ischemic stroke. “Acting funny” may indicate impaired language or cognitive function. Slurred speech may be aphasia or dysarthria.“Acting funny” may indicate impaired language or cognitive function. Slurred speech may be aphasia or dysarthria. Discuss what to do next to determine if this patient meets the POE criteria.Discuss what to do next to determine if this patient meets the POE criteria.

60 Questions? Ask your training officerAsk your training officer Consult your service Medical DirectorConsult your service Medical Director Call your Regional office or visit their websiteCall your Regional office or visit their website Contact OEMS at (617) or visit OEMS at (617) or visit

61 References Bledsoe, B., Porter, R., Cherry, R. (2003). Neurology. In Brady, Essentials of Paramedic Care (pp , ). Upper Saddle River, NJ: Pearson Education, Inc.Bledsoe, B., Porter, R., Cherry, R. (2003). Neurology. In Brady, Essentials of Paramedic Care (pp , ). 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.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.(2004). Acute Stroke. In EMS Pre-hospital Treatment Protocols (V. 5.1, Protocol 3.11). MDPH/OEMS. Internet References Note: The Department of Public Health’s Office of Emergency Medical Services provides links to the referenced web sites as a public service. The Office of Emergency Medical Services does not exercise control over the content of these web sites. A link's presence here should not be construed as an endorsement of its contents by the Office of Emergency Medical Services.

62 Online Resources American College of NeurologyAmerican College of NeurologyAmerican College of NeurologyAmerican College of Neurology Centers for Disease Control and PreventionCenters for Disease Control and PreventionCenters for Disease Control and PreventionCenters for Disease Control and Prevention National Center for Health StatisticsNational Center for Health StatisticsNational Center for Health StatisticsNational Center for Health Statistics National Institutes of HealthNational Institutes of HealthNational Institutes of HealthNational Institutes of Health National Library of MedicineNational Library of MedicineNational Library of MedicineNational Library of Medicine National Women’s Health Information CenterNational Women’s Health Information CenterNational Women’s Health Information CenterNational Women’s Health Information Center Society of Interventional RadiologistsSociety of Interventional RadiologistsSociety of Interventional RadiologistsSociety of Interventional Radiologists Stroke ArticlesStroke ArticlesStroke ArticlesStroke Articles Think Neurology Now Month in MassachusettsThink Neurology Now Month in MassachusettsThink Neurology Now Month in MassachusettsThink Neurology Now Month in Massachusetts


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