Presentation on theme: "Stroke Management for the EMS Provider"— Presentation transcript:
1Stroke Management for the EMS Provider Alameda County Educational ModuleBrenda Krokoski RN (Alta Bates/Summit Stroke Center)Douglas Van Houten RN (Washington Hospital Stroke Center)
2Stroke 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.
3Stroke Management for the EMS Provider Instructions:Page through the module to learn the content.Complete the post test.
4Is STROKE a health problem in the US today? 700,000 strokes every yearStroke is the 3rd leading cause of deathOne person dies of stroke every 3 minutesStroke is the leading cause of serious, long term disability5 million stroke survivors, but with substantial morbidity:18% unable to return to work4% require total custodial care
5Is STROKE a health problem in the US today? Only 50-70% of stroke survivors regain functional independence20% are institutionalized within 3 months22% of men & 25% of women die within 1 year of their first strokeLocally, African-Americans have 50% more strokes than Caucasians, and twice as many as Asians and Hispanics (Statistics from the American Stroke Association)
6African Americans & Stroke Incidence is nearly double that of white AmericansSuffer more extensive physical impairmentsTwice as likely to die from strokeHigh incidence of risk factors for strokeStroke 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.hypertensiondiabetesobesitysmokingsickle cell anemia(National Stroke Association)
7Women & StrokeStroke kills more than twice as many American women every year as breast cancerMore women than men die from strokeWomen over age 30 who smoke and take high-estrogen oral contraceptives have a stroke risk 22 times higher than averageStroke 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)
8How Bad is a Major Stroke How Bad is a Major Stroke? Elders at Risk for Stroke (1183, TTO), --Samsa et al, Am Heart J 1998Worse than deathEquivalent to being wellEquivalent to death
9Is 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.
10Goals 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.
11Goals 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.
12Review: 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?
13What Is Stroke ?A stroke occurs when blood flow to the brain is interrupted by a blocked or burst blood vessel.
15One quarter of cardiacoutput goes to the 5-6pound organ—the brain.The brain needs aconstant supply of:OxygenGlucoseOther nutrientsCirculation is suppliedvia 2 pairs of arteries:Internal carotidsVertebrals
18through 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 penumbrathrough emergency interventions and medical management.
20Acute Ischemic Stroke (What do you see?) Deficits:Unilateral (though not always) weaknessUnilateral sensory deficitVisual 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 impairmentLike real estate—Location, Location, Location
21What 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.
22What Are the Effects of Stroke? Left BrainIf 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 bodySpeech/language problemsSlow, cautious behavioral styleMemory loss
23What Are the Effects of Stroke? Right BrainThe 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
24Stroke Assessment Scale (Cincinnati Pre-hospital Stroke Scale) “The sky is blue in Cincinnati.”Any abnormality means anabnormal Cincinnati scalefor stroke.Probably accurately detectsstroke 80% of the time.
25Stroke 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”.
26Identify 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)
29CT Scan of Acute Ischemic Stroke (Left MCA territory stroke)
30Types 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, legSpeech deficit – dysarthria (slurred speech)Language deficit – if in dominant hemisphereGaze palsy – eyes directed towards side of AISBlindness – visual field cut (homonymous hemianopsia)
31Types of Strokes (Vertebral—Basilar Artery) Features:Cranial nerve involvement – hearing, visual, facial, swallowingCan have bilateral weaknessCerebellar signs – ataxiaSensory deficitsVertigo – often nystagmusNausea and vomitingCommon to have waxing and waning symptoms
32Lacunar 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.
34Conditions That Mimic AIS Bell’s PalsyTodd’s ParalysisHemorrhagic StrokeSubdural HematomaOther conditions
35Conditions That Mimic AIS Bell’s PalsyBell’s Palsy is a viral infection of the facial nerve which causes stroke-likesymptoms: unilateral facial droop, sensory deficit, dysarthria, etc.
36Conditions That Mimic AIS Differential dx:Hx: women, pregnancy, viral illnessCan’t close eye completely or raise foreheadMay have facial painNo other stroke symptomsMay have no risk factors for stroke
37Conditions That Mimic AIS Todd’s Paralysis: unilateral weakness that occurs after a seizure.Can involve speech, language, visual and sensoryMay be due to hyperpolarization in the area of the seizureResolves within 48 hoursKey concern in regard to thrombolytic therapy
39What are the risks factors for Ischemic Stroke? Modifiable RisksHTNCAD/Carotid Disease/PVDAtrial FibrillationDiabetesWeightHigh Cholesterol/DietLack of exerciseETOH/Drug abuseCoagulopathy- Cancer, Sickle Cell AnemiaPFO- Patent Foramen OvaleNon-Modifiable RisksAge->55Race- 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 TIAFamily History of Stroke
40Goals 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 minutesCT-to-Radiologist Reading < 20 minutesIV TPA administration < 15 minutes(Door-to-needle within 60 minutes.)
41What 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.”
42Tissue 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.
43Early Rx was better in the NINDS tPA Trial Minutes From Stroke Onset To Start of Treatment60708090100110120130140150160170180Odds Ratio For Favorable Outcome at 3 Months12345678Marler JR, et al. Early stroke treatment associated with better outcome. The NINDS rt-PA Stroke Study. Neurology 2000;55:
45Hemorrhagic Stroke (Intracranial Hemorrhage—ICH & Subarachnoid Hemorrhage—SAH) Intracranial Hemorrhage (Hypertensive):> twice as common as SAHmore likely to result in death or severe disability37,000 Americans/year35-52% 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
47Hemorrhagic Stroke (Intracranial Hemorrhage—ICH & Subarachnoid Hemorrhage—SAH) Presenting signs:Sudden—signs over minutes to hoursHeadacheNausea and vomitingDecreasing LOCExtremely elevated blood pressure(All of these are signs of increased ICP)
48Hemorrhagic Stroke (Intracranial Hemorrhage—ICH & Subarachnoid Hemorrhage—SAH) Differential Diagnosis:AIS—often high BPAIS—rare decreased LOCAIS—rare or vague H.A.AIS—rare nausea & vomitingAIS—often wake up with thesymptomsICH—usually very high BPICH—50% of the time ↓ LOCICH—40% of the time H.A.ICH—50% of time vomitingICH—rarely wake up withsymptoms (15%)Final diagnosis is by CT scan.
53ICH: Goals for Early Management Airway managementAssure adequate oxygenation & reduce hypercapnea (Remember: ↑CO2 = ↑ ICP)Prevent aspiration (Remember: 50% of ICH patients vomit and have ALOC)Prevent seizuresAcute mgt: Fosphenytoin PE (phenytoin equivalents over 3-6 minutes)Prevention: Phenytoin mg/20-30 min
54ICH: Goals for Early Management Blood Pressure Management:Very poor outcomes if BP is allowed to stay very high—more bleedingVery poor outcomes if BP is allowed to drop precipitously—removes the brain’s attempt to perfuse a “tight” brainGuidelines:In general, keep BP about 160/90 or MAP <130In the first 48 hours: no BP drop > 15-25% of presenting value
55Hemorrhagic 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 fatal1--15% die before reaching the hospitalThose who survive are often impaired1-7% of all strokes
56Hemorrhagic 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
60Subdural Hematoma(Not a true strokebut symptoms canmimic stroke.)
61Subdural Hematoma Symptoms: Onset: Unilateral weakness, sensory deficitFacial weaknessDysarthriaAltered level of consciousnessOnset:Can be rapidCan take months to show symptoms
62Subdural Hematoma Causes Anticoagulation (Heparin, Coumadin)Antithrombotics (Aspirin, Plavix)ETOH abuseTrauma (could be recent or months ago)Advanced age (most common cause)
63Subdural HematomaSmall bridging veins from the dura mater to the brain are stretchedand can rupture releasing blood into the subdural space and causingpressure on that part of the brain. This leads to the deficits seen.
65Subdural Hematoma Treatment Options Medical Management:Correct CoagsMonitor neuro signsSurgical Management:Burr hole drainageCraniotomy for removal of solid clot
66Summing UpThe best stroke care is a coordinated approach and developed in a stroke center system of care.Requires everyone to be on board:Patients/FamiliesEMSEDStroke UnitStroke Rehabilitation
67Summing UpHow 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!
68Emergent Stroke Care and the Chain of Survival Patient Calling EMS ED Stroke StrokeKnowledge System Staff Team Unit
70Post Test Which of the following are types of ischemic strokes? Middle cerebral artery occlusionVertebral-basilar occlusionLacunar strokeAll of the aboveA 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. ________________
71Post TestThe 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.
72Post Test Which of the following is not a true hemorrhagic stroke? Subarachnoid HemorrhageSubdural HematomaIntracerebral Hemorrhage (Hypertensive Bleed)10. The Stroke Receiving Center Emergency Room is the stroke system of care. (True or False)
73Post Test (Answers) d. –all of the above True Cincinnati Pre-hospital Stroke ScaleFalse –it is the time “last seen normal”VS; FSBS; time last seen normal; stroke symptoms; meds the patient takes3 hoursFalse –Intracerebral Hemorrhage (HTN bleed)Bell’s Palsy; Todd’s Paralysis; Subdural hematoma; hemorrhagic stroke; Psychogenic; HTN; Complex Migraine; Hypoglycemia; etc.Subdural HematomaFalse –all entities are equally important links in the stroke chain of survival.