Presentation on theme: "Stroke Management for the EMS Provider"— Presentation transcript:
1Stroke Management for the EMS Provider October 2014 CME
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.
3Is 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
4Is 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)
5Women & 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)
6Is 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.
7Goals 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.
8Goals 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.
9Review: 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?
10What Is Stroke ?A stroke occurs when blood flow to the brain is interrupted by a blocked or burst blood vessel.
12One 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
14through 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.
16Acute 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
17What 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.
18What 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
19What 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
20Stroke 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.
21Act 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)
22Stroke 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”.
23Identify 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)
26CT Scan of Acute Ischemic Stroke (Left MCA territory stroke)
27Types 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)
28Types 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
29Lacunar 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.
31Conditions That Mimic AIS Bell’s PalsyTodd’s ParalysisHemorrhagic StrokeSubdural HematomaOther conditions
32Conditions 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.
33Conditions 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
34Conditions 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
36What are the risks factors for Ischemic Stroke? Modifiable RisksHTNCAD/Carotid Disease/PVDAtrial FibrillationDiabetesWeightHigh Cholesterol/DietLack of exerciseETOH/Drug abuseCoagulopathy- Cancer, Sickle Cell AnemiaNon-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
37Goals 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.)
38What 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.”
39Tissue 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.
41Hemorrhagic 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
43Hemorrhagic 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)
44Hemorrhagic 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.
49ICH: Goals for Early Management Airway managementAssure adequate oxygenation & reduce hypercapnea (Remember: ↑CO2 = ↑ ICP)Prevent aspiration (Remember: 50% of ICH patients vomit and have ALOC)SeizuresVersed – If seizure activity > 2-3 minutes administer 2.5mg IV. May repeat 2.5mg once in 5 minutesVersed may be given IM if no IV established
50OxygenationOxygen 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 bodyNormally, 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 shiftsCell damage occurs when free radicals outnumber antioxidants, a condition called oxidative stress
51OxygenationTissue 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.
52ICH: 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
53Hemorrhagic 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
54Hemorrhagic 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
56Classic “Star Pattern” of Subarachnoid Hemorrhage SAH
57Subdural Hematoma(Not a true strokebut symptoms canmimic stroke.)
58Subdural Hematoma Symptoms: Onset: Unilateral weakness, sensory deficitFacial weaknessDysarthriaAltered level of consciousnessOnset:Can be rapidCan take months to show symptoms
59Subdural Hematoma Causes Anticoagulation (Heparin, Coumadin)Antithrombotics (Aspirin, Plavix)ETOH abuseTrauma (could be recent or months ago)Advanced age (most common cause)
60Subdural 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.
62Subdural Hematoma Treatment Options Medical Management:Correct CoagsMonitor neuro signsSurgical Management:Burr hole drainageCraniotomy for removal of solid clot
63Summing 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
64Summing 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!
65Emergent Stroke Care and the Chain of Survival Patient Calling EMS ED Stroke StrokeKnowledge System Staff Team Unit
68Stroke CentersOn 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.
69The 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 systemsIt 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.
70Silver Cross Hospital EMS System Within SCEMSS, there are 3 IDPH approved PSC or ESRH facilities:Silver Cross Hospital – PSCPresence St Joseph Medical Center – PSCSouth Suburban Hospital – PSCOther associate/participating facilities within SCEMSS have IDPH applications pending approval
71Patient 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
72Code 38 – Suspected Stroke Initial Medical CareObtain blood glucose reading and treat appropriatelyCincinnati Stroke ScaleIf Positive, begin transport to nearest MOST APPROPRIATE facilityInitiate rapid transport12-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 indicatedComa of Unknown OriginSeizures
74P 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 bpmVentricular rate bpm
75Clinical significance Atrial fibrillation patients usually have a ventricular rate of beats/minuteA 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 patientsSince 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
76Since 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 embolismUnless contraindicated, patients with atrial fibrillation are generally advised to be on blood thinnersCoumadin (warfarin sodium) is the most common medication prescribed for A-FibIn 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’sIn some patients, atrial fibrillation is not persistent. (Transient A-Fib)
77Assessment/Treatment Symptomatic A-Fib patients – Signs of hypoperfusion with elevated heart rate, altered mental statusConsider Synchronized CardioversionRegion VII – Code 83, “Synchronized Cardioversion”
78Code 83 - “Synchronized Cardioversion” Consider use of Versed for pain management and/or sedation2.5mg to 5mg, slow IVPConstantly assess pulse oximetry and be prepared to place advanced airway if necessary!Place patient in safe environment, away from pooled water and metal surfacesApply monitor-defibrillator electrode pads to patient chest or appropriate conductive medium paddlesTurn on defibrillatorSet energy levelActivate “synchronous” modeCharge capacitorEnsure proper placement of electrodes on chest: Apical and high parasternalIf using hand-held paddles, apply firm pressure and maintain until machine dischargesAssure that no personnel are in direct contact with the patient (Call “clear”)Deliver shock by depressing discharge button. Hold button down until machine dischargesReassess patient