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Ray Taylor Ray Taylor Valencia Community College Valencia Community College Department of Emergency Medical Services Department of Emergency Medical Services.

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Presentation on theme: "Ray Taylor Ray Taylor Valencia Community College Valencia Community College Department of Emergency Medical Services Department of Emergency Medical Services."— Presentation transcript:

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2 Ray Taylor Ray Taylor Valencia Community College Valencia Community College Department of Emergency Medical Services Department of Emergency Medical Services

3 Overview v Background v Anatomy/Physiology v Major Stroke Syndromes v Assessment and Evaluation v Diagnosis v Prehospital Case Studies v Summary

4 Questions

5 Question v Hemorrhagic stroke accounts for what percent of all strokes?  A. Less than 5%  B. 15% - 20%  C. 50%  D. 80%

6 Question v Which one of the following events causes the majority of ischemic strokes?  A. Ventricular fibrillation  B. Thromboembolism  C. Atrial fibrillation  D. Intracerebral hemorrhage

7 Question v In a patient suspected of having an acute brain attack, which one of the following is the best way to differentiate between an ischemic or hemorrhagic cause?  A. The history  B. The physical examination  C. A CT scan of the brain  D. An MRI scan of the brain

8 Question v A patient has sudden weakness of the left arm and leg. EMS is called and the patient’s blood pressure is found to be 250/150mmHg. The most appropriate action to be taken by EMS is to monitor and record the blood pressure and:  A. Administer labetalol 15mg IV  B. Administer nifedipine 10mg SL  C. Administer NTG SL  D. Do not administer any antihypertensive agent

9 Question v Which one of the following pairings is incorrect?  A. Left brain dysfunction – right sided weakness  B. Brainstem dysfunction – slurred speech  C. Cerebellum dysfunction – dyscoordination  D. Subarachnoid hemorrhage – inappropriate speech

10 Question v Which one of the following is true regarding the “ischemic penumbra”?  A. It is brain tissue with irreversible ischemia  B. It is unaffected by the use of TPA  C. It is worsened by hypotension  D. Can be seen on a CT scan of the brain

11 Question v All of the following are true statements regarding stroke, except:  A. It is the leading cause of disability in the US  B. It is a preventable condition  C. Death from stroke may be reduced by the treatment with TPA  D. Its incidence increases with age

12 Question v All of the following are signs of a brainstem stroke, except:  A. Aphasia  B. Hemisensory loss  C. Nausea and vomiting  D. Vertigo

13 Question v All of the following assessments are components of the initial on-site prehospital stroke examination, except:  A. Reflexes  B. Speech  C. Facial symmetry  D. Arm strength

14 Background (USA) v #1 Disability v #3 Killer  500,000/year o20% mortality v 50 million dollars per year v Old therapy  rehabilitation  reduce risk of future strokes v Current therapy  acute interventions  reduce brain area of ischemia o Blood sugar o Blood pressure

15 Background Median Hours to ED Arrival (EMS vs Car) Goal Kothari.(Cincinnati) Ann Emerg Med 1999; 33: 1. 2nd Goal

16 Background Median Time (Hours) Spent Evaluating Stroke Patients (Prehospital = time at home + EMS [small part]) Kothari (Cincinnati). Ann Emerg Med 1999; 33: 1.

17 Background - Who is Eligible O’Connor RE. Ann Emerg Med 1999; 33: 9-14

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19 Anatomy & Physiology v Anterior Cerebral Artery  leg > arm - opposite side of ischemia  sensory deficits = motor deficit sites  frontal lobe - impaired judgement/insight v Middle Cerebral Artery  face/arm > leg: ignore side/site of deficit  sensory = motor deficit sites  aphasia = speech v Posterior cerebral  vision/mentation v Vertebrobasilar  vertigo/gait/cranial nerves (face/eyes/tongue)  syncope***

20 Anatomy & Physiology v Ischemic Stroke  low flow o occluded blood vessel (carotid) o embolic - clot travels from heart  80% v Hemorrhagic Stroke  20%  bleed into brain - stop v TIA  temporary deficit - < minutes  high risk of future stroke

21 Ischemic Stroke Clot occluding artery Most common cause: thromboembolism Possible sources of clot: v Heart v Large artery (to brain) v Small artery (in brain)

22 Ischemic Stroke: Modifiable Risk Factors v Hypertension (systolic and diastolic) v Cigarette smoking v Prior stroke/ TIA v Heart disease v Diabetes mellitus, hyperlipidemia v Hypercoagulable states v Carotid bruit v Cocaine, excess alcohol

23 Ischemic Stroke: Nonmodifiable Risk Factors v Advanced age v Male gender v African-American heritage v Family history of early stroke or MI

24 Intracerebral Hemorrhage Bleeding into brain Most common cause: chronic hypertension Other causes: v Vessel malformation v Tumor, bleeding abnormalities

25 Subarachnoid Hemorrhage Bleeding around brain Most common cause: aneurysm rupture Other causes: v Vessel malformation v Tumor, bleeding abnormalities

26 Transient Ischemic Attack (TIA) v Reversible focal dysfunction, usually lasts mins v Among TIA pts who go to ED:  5% have stroke in next 2 days  25% have recurrent event in next 3 months v Decrease stroke risk with proper therapy:  artery source—antiplatelet (ASA), surgery  heart source—anticoagulation (warfarin)

27 Background Risk of Stroke Following A Transient Ischemic Attack

28 Penumbra Core Time Is Brain: Save The Penumbra Clot in Artery

29 Time is Brain: Save the Penumbra v In first few hours of ischemic stroke, brain tissue can still be saved v Zone of reversible ischemia (“penumbra”) surrounds core of irreversible infarction v Patient symptoms due to both infarcted core and ischemic penumbra v One cannot determine by exam how much brain can still be saved

30 Time is Brain: Save the Penumbra v Thrombolytic (fibrinolytic) agent t-PA can limit brain damage safely if given w/in 3 h—it reduces risk of disability due to ischemic stroke by 30% v Administer t-PA only if:  clinical diagnosis confirmed by CT scan  within 3 hours of onset  age 18 or older  no other contraindications

31 Major Stroke Syndromes LEFT HEMISPHERE RIGHT HEMISPHERE BRAINSTEMCEREBELLUMHEMORRHAGE

32 Left (Dominant) Hemisphere: Typical Signs (Right Side and Aphasia) Aphasia Left Gaze Preference Right Hemiparesis Right Hemisensory Loss Right Visual Field Deficit

33 Right (Nondominant) Hemisphere: Typical Signs (Left Side) Right Gaze Preference Left Hemiparesis Left Hemisensory Loss Left Hemi-inattention Left Visual Field Deficit

34 Brainstem: Typical Signs (Both Sides) Quadriparesis Sensory Loss in All 4 Limbs Crossed Signs (1 side of face and contralateral body Hemiparesis Hemisensory Loss

35 Brainstem: Typical Signs (continued) Oropharyngeal Weakness: Dysarthria, Dysphagia Eye Movement Abnormalities: Diplopia Dysconjugate Gaze Gaze Palsy Decreased LOC Nausea, Vomiting Hiccups, Abnormal Respirations Vertigo, Tinnitus

36 Cerebellum: Typical Signs (Coordination) Ipsilateral Limb Ataxia (dyscoordination) Truncal or Gait Ataxia (imbalance)

37 Symptoms Suggestive of Hemorrhage Subarachnoid Hemorrhage: Intolerance to Light Neck Stiffness / Pain Intracerebral Hemorrhage: Focal Signs Such as Hemiparesis Both Subarachnoid and Intracerebral Hemorrhage: Headache Nausea, Vomiting Decreased LOC

38 The Focused Neurologic Assessment and Evaluation The Focused Neurologic Assessment and Evaluation

39 Cincinnati and LA Prehospital Stroke Scales Perform on scene during Primary Survey under “D” – Disability: v Speech v Facial Droop v Arm Drift v Grip “Speech, Droop, Drift, Grip!”

40 Speech: Repeat Phrase v “You can’t teach an old dog new tricks.” v Abnormal:  Wrong or inappropriate words (aphasia)  Slurred words (dysarthria) or unable to speak (Aphasia = left hemisphere Dysarthria = cranial nerves)

41 Facial Droop (Cranial Nerves): Show Teeth or Smile v Abnormal:  One side of face does not move as well as the other side Right-sided droop © AHA 1997

42 Arm Drift (Motor): Close Eyes, Hold Out Arms v Abnormal:  One arm does not move or drifts down Right-sided drift © AHA 1997

43 Prehospital Stroke Scale v Grip  Normal right and left  Abnormal right or absent right  Abnormal left or absent left  Comparison of sides

44 Prehospital Stroke Identification Smith. Prehospital Emerg Care 1998; 2: 170. Kidwell (Los Angelos) Stroke 2000; 31: 71. Kothari (Cincinnati). Ann Emerg Med 1999; 33: 373.

45 Cincinnati Prehospital Stroke Scale Normal Patient Click picture to play video

46 CRANIAL NERVES MENTAL STATUS Miami Emergency Neurologic Deficit Exam Expanded Prehospital Stroke Exam CHECK IF ABNORMAL LIMBS n Level of Consciousness (AVPU) n Speech “You can’t teach an old dog new tricks.” (repeat) Abnormal = wrong words, slurred speech, no speech Abnormal = wrong words, slurred speech, no speech n Questions (age, month) n Commands (close, open eyes) n Facial Droop (show teeth or smile) RT LT Abnormal - one side does not move as well as other Abnormal - one side does not move as well as other n Visual Fields (four quadrants) n Horizontal Gaze (side to side) n Motor–Arm Drift (close eyes and hold out both arms) RT LT Abnormal–arm can’t move or drifts down Abnormal–arm can’t move or drifts down Leg Drift (open eyes and lift each leg separately) n Sensory–Arm and Leg (close eyes and touch, pinch) n Coordination–Arm and Leg (finger to nose, heel to shin)

47 Miami Emergency Neurologic Deficit Exam Normal Patient Click picture to play video

48 Cincinnati Prehospital Stroke Scale Left Hemispheric Stroke Click picture to play video

49 Miami Emergency Neurologic Deficit Exam Left Hemispheric Stroke Click picture to play video

50 Diagnosis and Management v Prehospital  Exclude masqueraders o hypoglycemia/hyperglycemia o drugs/toxins o trauma o hypoxia  Neurologic screen o Cincinnati/LA prehospital stroke scale onot meant to be 100% accurate

51 Management - Glucose Neurologic Effects of Lo glucose vs. Very Hi glucose on Infarcted Brain (Rabbit Model) Thoralf. Stroke 1999; 30:

52 Management - Glucose Pulsinelli. Am J Med 1983; 74: 540.

53 Management - Blood Pressure Relationship of CNS tissue perfusion (SPECT scan) to drop in BP after treatment Lisk. Arch Neurol 1993; 50: 855.

54 Acute Stroke Patients: Indications for Antihypertensive Therapy In general: v Consider: absolute level of BP?  If BP: >185/>110 mm Hg = fibrinolytic therapy contraindicated v Consider: other than BP, is patient candidate for fibrinolytics?  If patient is candidate for fibrinolytics: treat initial BP >185/>110 mm Hg v Consider: response to initial efforts to lower BP in ED?  If treatment brings BP down to <185/110 mm Hg: give fibrinolytics v Consider: ischemic vs hemorrhagic stroke?  Treat BP in the / mm Hg range the same  The obvious: no fibrinolytics for hemorrhagic stroke

55 Treatment of High BP in Acute Stroke Patients BP Level >185/>110 mm Hg During/after fibrinolytic treatment BP may rise: DBP >140 mm Hg >230/ mm Hg / mm Hg Fibrinolytic Candidate Nitropaste or labetalol IV if BP remains elevated: no fibrinolytics Nitroprusside infusion Labetalol, then prn nitroprusside Labetalol Not a Fibrinolytic Candidate No acute therapy indicated Nitroprusside infusion Labetalol Acute therapy only if hypertensive urgency also present

56 Diagnosis and Management v ED Diagnosis  History and Physical in ED  Supplemented with CT o normal in 1 st hours  Thrombolytic Therapy

57 Emergent CT Scan v Is necessary to rule out nonstroke cause of symptoms v Is necessary to differentiate ischemic vs. hemorrhagic stroke v Exam alone cannot distinguish stroke vs. nonstroke or ischemia vs. hemorrhage

58 Noncontrast CT Scan: Ischemic Stroke (Left Hemisphere) R 4 Hours L Subtle blurring and compression of sulci R 4 Days L Obvious dark changes of infarction

59 Noncontrast CT Scan: Hemorrhagic Strokes “Ball” of white blood in thalamus R L White blood in cisterns & 4th ventricle Intracerebral HemorrhageSubarachnoid Hemorrhage

60 What Pathology Does This Scan Show? Scan A

61 What Pathology Does This Scan Show? Hypodense area: Ischemic area with edema, swelling Indicates >3 hours old No fibrinolytics! Left Right

62 What Pathology Does This Scan Show? Scan B

63 What Pathology Does This Scan Show? Scan B (White areas indicate hyperdensity = blood) Large left frontal intracerebral hemorrhage. I ntraventricular bleeding is also present No fibrinolytics! Left Right

64 What Pathology Does This Scan Show? Scan C

65 What Pathology Does This Scan Show? Scan C Acute subarachnoid hemorrhage Diffuse areas of white (hyperdense) images Blood visible in ventricles and multiple areas on surface of brain

66 Management - Thrombolytics Percent of Patients with Minimal/No deficit at 3 months NINDS. New Engl J Med 1995; 333: 1581.

67 Fibrinolytic Therapy: Yes/No Checklist Inclusion Criteria (all “Yes” boxes must be checked before fibrinolytics are given) Yes  Age 18 years or older  Clinical diagnosis of ischemic stroke causing a measurable neurologic deficit  Time of symptom onset well established to be <180 minutes before treatment would begin

68 Fibrinolytic Therapy: Yes/No Checklist Exclusion Criteria (all “No” boxes must be checked before fibrinolytics are given): No  Evidence of intracranial hemorrhage on noncontrast head CT  Only minor or rapidly improving stroke symptoms  High suspicion of subarachnoid hemorrhage even if CT is normal  Active internal bleeding (eg, gastrointestinal bleeding or urinary bleeding within last 21 days)  Known bleeding diathesis, including but not limited to — Platelet count < mm 3 — Patients who received heparin in last 48 hours; have elevated PTT — Recent anticoagulant use (eg, coumadin); have elevated PT

69 Fibrinolytic Therapy: Yes/No Checklist Exclusion Criteria (cont’d) (all “No” boxes must be checked before fibrinolytics are given): No  <3 mo ago: intracranial surgery, head trauma, previous stroke  <14 days ago: major surgery or serious trauma  <7 days ago: lumbar puncture  Recent arterial puncture at noncompressible site  History of intracranial hemorrhage, AV malformation, or aneurysm  Witnessed seizure at start of stroke  Recent acute myocardial infarction  SBP >185 mm Hg/DBP >110 mm Hg; confirmed several times  BP must be treated aggressively to bring within these limits

70 Management - thrombolytics v Requirements - all within 3 hours  Recognition/identification o potentially eligible patients  History o Awaken with weakness does NOT count) o Exclusion criteria  Exam o detailed o NIH stroke scale  CT scan o must be read by neuro-radiologist (subtle exclusions)  Consent

71 Management - other options v New neuroprotective agents v Selective intra-arterial  thrombolytics  angioplasty?  Stents/coils?  EXTENDS window to 4-6 hours

72 Immediate assessment: <10 minutes from arrival Assess ABCs, vital signs Provide oxygen by nasal cannula Obtain IV access; obtain blood samples (CBC, electolytes, coagulation studies) Check blood sugar; treat if indicated Obtain 12-lead ECG, check for arrhythmias Perform general neurological screening assessment Alert Stroke Team: neurologist, radiologist, CT technician Immediate neurological assessment: <25 minutes from arrival Review patient history Establish onset (<3 hours required for fibrinolytics) Perform physical examination Perform neurological examination: Determine level of consciousness ( Glasgow Coma Scale ) Determine level of stroke severity ( NIH Stroke Scale or Hunt and Hess Scale ) Order urgent noncontrast CT scan (door-to–CT scan performed: goal <25 minutes from arrival) Read CT scan (door-to–CT read: goal <45 minutes from arrival) Perform lateral cervical spine x-ray (if patient comatose/history of trauma) Acute Stroke Algorithm EMS assessments and actions Immediate assessments performed by EMS personnel include Cincinnati Prehospital Stroke Scale (includes difficulty speaking, arm weakness, facial droop) Los Angeles Prehospital Stroke Screen Alert hospital to possible stroke patient Rapid transport to hospital Suspected Stroke Detection Dispatch Delivery Door

73 Case-Based Prehospital Scenarios

74 Case 1:On scene Click picture to play video

75 Case 1:Transport (patient is 60 / month is December) Click picture to play video

76 Case 1:Discussion 1.Is this more likely a stroke or stroke mimic? 2.What are the physical findings? 3. Where in the brain is the abnormality? 4.Is the radio report complete? 5.Is this patient a candidate for t-PA?

77 Case 2:On Scene Click picture to play video

78 Case 2:Transport (patient is 45 / month is December) Click picture to play video

79 Case 2:Radio Report Click picture to play video

80 Case 2:Discussion 1.Is this more likely a stroke or stroke mimic? 2.What are the physical findings? 3. Where in the brain is the abnormality? 4.Is the radio report complete? 5.Is this patient a candidate for t-PA?

81 Case 3:On Scene Click picture to play video

82 Case 3:Transport (patient is 48 / month is October) Click picture to play video

83 Case 3:Radio Report Click picture to play video

84 Case 3:Discussion 1.Is this more likely a stroke or stroke mimic? 2.What are the physical findings? 3. Where in the brain is the abnormality? 4.Is the radio report complete? 5.Is this patient a candidate for t-PA?

85 Case 4: On Scene Click picture to play video

86 Case 4:Transport (patient is 69 / month is December) Click picture to play video

87 Case 4: Radio Report Click picture to play video

88 Case 4: Discussion 1.Is this more likely a stroke or stroke mimic? 2.What are the physical findings? 3. Where in the brain is the abnormality? 4.Is the radio report complete? 5.Is this patient a candidate for t-PA?

89 Summary Key Evaluation Targets for Stroke Patient: Potential Fibrinolytic Candidate? Door-to–doctor first sees patient…….…………10 min Door-to–CT completed…….…………………..25 min Door-to–CT read...…………..…………………45 min Door-to–fibrinolytic therapy starts…………….. 60 min Neurologic expertise available*…..……………15 min Neurosurgical expertise available* …………… 2 hours Admitted to monitored bed..……...…………… 3 hours Maximum Intervals Recommended by NINDS

90 Thank You I’M OUTTA HERE


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