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Start Show Start Show Notes. 2 The following presentation is taken from the American Heart Association’s Advanced Cardiac Life Support : Principles and.

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Presentation on theme: "Start Show Start Show Notes. 2 The following presentation is taken from the American Heart Association’s Advanced Cardiac Life Support : Principles and."— Presentation transcript:

1 Start Show Start Show Notes

2 2 The following presentation is taken from the American Heart Association’s Advanced Cardiac Life Support : Principles and Practice, Chapter 18, Acute Stroke: Current Treatments and Paradigms Please use this publication as a reference. Please use this publication as a reference.

3 3 Stroke An Educational Program for Pre-Hospital Personnel Developed by: EMS Committee Operation Stroke – American Stroke Association Phoenix, Arizona

4 4 Stroke Overview Introduction, Definition, Types and Risks

5 5 How Serious Is Stroke in the US? About 700,000 strokes occur each About 700,000 strokes occur each year. year. Over 167,000 deaths each year. Over 167,000 deaths each year. #3 killer. #3 killer. A leading cause of serious long-term A leading cause of serious long-term disability in adults. disability in adults. 4.7 million stroke survivors. 4.7 million stroke survivors.

6 6 Introduction New emerging therapies offer hope, however the following MUST occur: Education of at-risk patients. Education of at-risk patients. Early recognition of stroke signs. Early recognition of stroke signs. Prompt transport to the hospital. Prompt transport to the hospital. Rapid hospital triage and evaluation. Rapid hospital triage and evaluation.

7 7 Introduction With rapid, aggressive prehospital stroke care, at-risk patients can be appropriately managed and quickly assessed for fibrinolytic therapy that may significantly improve their outcome.

8 8 Definition of Stroke A stroke is a neurological impairment caused by a disruption in blood supply to a region of the brain.

9 9 Classification of Stroke Two major categories: Ischemic strokes, caused when a blood vessel supplying the brain is occluded by a clot. Responsible for 75% of all strokes.Ischemic strokes, caused when a blood vessel supplying the brain is occluded by a clot. Responsible for 75% of all strokes. Hemorrhagic strokes, caused when a cerebral artery ruptures.Hemorrhagic strokes, caused when a cerebral artery ruptures. Both forms are life threatening.

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11 11 Hemorrhagic Stroke Hypertension is the most common cause of intracerebral hemorrhage.Hypertension is the most common cause of intracerebral hemorrhage. Other causes:Other causes: Aneurysms and Aneurysms and Arteriovenous malformations. Arteriovenous malformations.

12 12 Risk Factors for Stroke Although some strokes occur without warning, most stroke victims have prior risk factors. Major strokes can be prevented in many cases, but only if early signs and symptoms are heeded.

13 13 Well-Documented Modifiable Risk Factors HypertensionHypertension SmokingSmoking DiabetesDiabetes Asymptomatic Carotid StenosisAsymptomatic Carotid Stenosis Atrial Fibrillation Hyperlipidemia Sickle Cell Disease Other cardiac diseases Goldstein et al. Circulation. 2001:103:163

14 14 Less Well Documented Potentially Modifiable Risk Factors ObesityObesity Physical InactivityPhysical Inactivity Poor Diet/NutritionPoor Diet/Nutrition Alcohol AbuseAlcohol Abuse Drug AbuseDrug Abuse Hypercoagulability Hormone Replacement Therapy Oral Contraceptive Use Inflammatory Process Goldstein et al. Circulation. 2001:103:163

15 15 Non-modifiable Risk Factors AgeAge SexSex Race/EthnicityRace/Ethnicity Family HistoryFamily History

16 16 Stroke Diagnosis Signs and Symptoms of Stroke

17 17 Signs and Symptoms of Stroke Consider in anyone who has: Sudden numbness or weakness of face, arm, or leg, especially on one side of the body Sudden confusion, trouble speaking or understanding

18 18 Signs and Symptoms of Stroke Sudden trouble seeing in one or both eyesSudden trouble seeing in one or both eyes Sudden trouble walking, dizziness, loss of balance or coordinationSudden trouble walking, dizziness, loss of balance or coordination Sudden severe headache with no known causeSudden severe headache with no known cause

19 19 Signs and Symptoms of Stroke THIS IS A LIFE THREATENING EMERGENCY! Emergency healthcare providers must: Recognize the importance of these symptoms.Recognize the importance of these symptoms. Respond quickly with medical and / or surgicalRespond quickly with medical and / or surgical interventions. interventions.

20 20 Stroke Signs and Symptoms: Hemorrhagic Stroke May present similar to Ischemic stroke. Distinguishing Features: Appear more seriously ill Deteriorate more rapidly Severe headache Alteration in consciousness Nausea and/or vomiting Neck pain Intolerance of noise or light

21 21 Transient Ischemic Attack “Temporary” or “mini” stroke. The signs and symptoms of a TIA are similar to those of a completed stroke; however, they typically last only a few minutes to several hours before resolving.The signs and symptoms of a TIA are similar to those of a completed stroke; however, they typically last only a few minutes to several hours before resolving.

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23 23 Transient Ischemic Attack TIA is the most important forecaster of impending stroke.TIA is the most important forecaster of impending stroke.

24 24 Stroke Patient Management The Stroke Chain of Survival and Recovery

25 25 Seven Step Stroke Chain of Survival and Recovery Pre-arrival: Post-arrival: 1.Detection 4. Door 2.Dispatch 5. Data 3.Delivery6. Decision 7. Drug

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27 27 1. Detection: Early Recognition Early treatment of stroke depends on the victim, family members, or other bystanders detecting the event.Early treatment of stroke depends on the victim, family members, or other bystanders detecting the event. Mild signs or symptoms may go unnoticed or be denied by the patient or bystander.Mild signs or symptoms may go unnoticed or be denied by the patient or bystander.

28 28 2. Dispatch: Early EMS Activation and Dispatch Instructions Stroke victims and their families must be taught to activate the EMS system as soon as they detect stroke signs or symptoms.Stroke victims and their families must be taught to activate the EMS system as soon as they detect stroke signs or symptoms. EMS dispatchers must appropriately prioritize the call to ensure a rapid response within the EMS system.EMS dispatchers must appropriately prioritize the call to ensure a rapid response within the EMS system.

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30 30 3. Delivery: Pre-hospital Transport and Management The goals : Rapid identification of the strokeRapid identification of the stroke Support of vital functionsSupport of vital functions Rapid transport of the victim to the receiving facilityRapid transport of the victim to the receiving facility Pre-arrival notification of the receiving facilityPre-arrival notification of the receiving facility

31 31 3. Delivery: Pre-hospital Transport and Management The Cincinnati Pre-hospital Stroke Scale 1.Facial Droop (have patient show teeth or smile): Normal - Both sides of face move Normal - Both sides of face move equally well. equally well. Abnormal - One side of face does not Abnormal - One side of face does not move as well as the other side. move as well as the other side.

32 32 3. Delivery: Pre-hospital Transport and Management The Cincinnati Pre-hospital Stroke Scale 2. Arm Drift (patient closes eyes and holds both arms out): Normal - Both arms move the same or both Normal - Both arms move the same or both arms do not move at all (other findings, arms do not move at all (other findings, such as pronator grip, may be helpful). such as pronator grip, may be helpful). Abnormal - One arm does not move or one Abnormal - One arm does not move or one arm drifts down compared with the other. arm drifts down compared with the other.

33 33 3. Delivery: Pre-hospital Transport and Management The Cincinnati Pre-hospital Stroke Scale 3. Speech (have the patient say "you can't teach an old dog new tricks"): Normal - Patient uses correct words with Normal - Patient uses correct words with no slurring. no slurring. Abnormal - Patient slurs words, uses Abnormal - Patient slurs words, uses inappropriate words, or is unable to speak. inappropriate words, or is unable to speak.

34 34 3. Delivery: Pre-hospital Transport and Management The presence of acute stroke is an indication for "load and go“.The presence of acute stroke is an indication for "load and go“. Establish the time of onset of stroke signs and symptoms!Establish the time of onset of stroke signs and symptoms! This timing will have important implications for potential therapy. If the time of onset of symptoms is viewed as time "zero," all assessments and therapies can be related to that time.This timing will have important implications for potential therapy. If the time of onset of symptoms is viewed as time "zero," all assessments and therapies can be related to that time.

35 35 3. Delivery: Pre-hospital Transport and Management Once stroke is diagnosed, pre-hospital treatment includes management of the ABCs of critical care (Airway, Breathing, and Circulation) and close monitoring of vital signs.

36 36 3. Delivery: Pre-hospital Transport and Management Airway: Paralysis of the muscles of the throat, tongue, or mouth can lead to partial or complete upper-airway obstruction.Paralysis of the muscles of the throat, tongue, or mouth can lead to partial or complete upper-airway obstruction. Saliva pools or vomit may be aspirated.Saliva pools or vomit may be aspirated.

37 37 3. Delivery: Pre-hospital Transport and Management Breathing: Breathing abnormalities are uncommon, except in patients with severe stroke, and rescue breathing is seldom needed.Breathing abnormalities are uncommon, except in patients with severe stroke, and rescue breathing is seldom needed. Abnormal respirations, however, are prominent in comatose patients and portend serious brain injury.Abnormal respirations, however, are prominent in comatose patients and portend serious brain injury.

38 38 3. Delivery: Pre-hospital Transport and Management Circulation: Monitor both blood pressure and cardiac rhythm as part of the early assessment and treatment of a stroke patient.Monitor both blood pressure and cardiac rhythm as part of the early assessment and treatment of a stroke patient. Hypotension or shock is rarely due to stroke, so other causes should be sought.Hypotension or shock is rarely due to stroke, so other causes should be sought.

39 39 3. Delivery: Pre-hospital Transport and Management Circulation: Hypertension is often present in stroke patients, but it typically subsides and does not require treatment.Hypertension is often present in stroke patients, but it typically subsides and does not require treatment. Treatment of hypertension in the field is not recommended!Treatment of hypertension in the field is not recommended!

40 40 3. Delivery: Pre-hospital Transport and Management Other Supportive Measures: Intravenous access.Intravenous access. Management of seizures, and diagnosis and treatment of hypoglycemia, can be initiated en route to the hospital if necessary.Management of seizures, and diagnosis and treatment of hypoglycemia, can be initiated en route to the hospital if necessary. Isotonic fluids (Normal Saline or Lactated Ringer's solution) are used for intravenous therapy; hypotonic fluids are contraindicated.Isotonic fluids (Normal Saline or Lactated Ringer's solution) are used for intravenous therapy; hypotonic fluids are contraindicated.

41 41 3. Delivery: Pre-hospital Transport and Management Early Notification: Early notification enables personnel to prepare for the imminent arrival of any seriously ill or injured patient.Early notification enables personnel to prepare for the imminent arrival of any seriously ill or injured patient. In many hospitals this notification shortens the time to evaluation of, and critical interventions for, stroke patients.In many hospitals this notification shortens the time to evaluation of, and critical interventions for, stroke patients.

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43 43 4. Door: Emergency Department Triage Even if a potential stroke victim arrives in the emergency department in a timely fashion, too often hours may elapse before appropriate neurological consultation and diagnostic studies are performed.

44 44 5. Data: Emergency Evaluation and Management ABCs should be reassessed and rechecked frequently.

45 45 5. Data: Emergency Evaluation and Management An emergency neurological stroke assessment should be done quickly focusing on four key issues: An emergency neurological stroke assessment should be done quickly focusing on four key issues: 1.Level of consciousness 2.Type of stroke (hemorrhagic versus nonhemorrhagic) 3.Location of stroke (carotid versus vertebrobasilar) 4.Severity of stroke

46 46 5. Data: Emergency Evaluation and Management Obtaining the exact time of stroke or onset of symptoms from family or people at the scene is critical.Obtaining the exact time of stroke or onset of symptoms from family or people at the scene is critical.

47 47 Emergency Diagnostic Studies Currently, CT is the single most important diagnostic test.Currently, CT is the single most important diagnostic test. Goal: CT scan obtained and read within 45 minutes of the stroke victim's arrival at the emergency department.Goal: CT scan obtained and read within 45 minutes of the stroke victim's arrival at the emergency department.

48 48 Emergency Diagnostic Studies Anticoagulants and fibrinolytic agents should be withheld until CT has ruled out a brain hemorrhage.Anticoagulants and fibrinolytic agents should be withheld until CT has ruled out a brain hemorrhage. Hemorrhagic Stroke

49 49 Differential Diagnosis: Unrecognized seizuresUnrecognized seizures Confusional statesConfusional states SyncopeSyncope Toxic or metabolic disordersToxic or metabolic disorders HypoglycemiaHypoglycemia Brain tumorsBrain tumors Subdural hematomaSubdural hematoma Adams et al. Stroke. 2003;34:1056

50 50 6. Decision: Specific Stroke Therapies General care includes, but is not limited to: Prevention of aspirationPrevention of aspiration Management of hypertensionManagement of hypertension Management of hyper/hypo-glycemiaManagement of hyper/hypo-glycemia Management of seizuresManagement of seizures Management of intra-cranial pressure (ICP)Management of intra-cranial pressure (ICP) Acute Stroke, 2003 American Heart Association

51 51 7. Drugs: Fibrinolytic Therapy for Ischemic Stroke Intravenous tPA represents the first FDA- approved therapy for acute ischemic stroke.Intravenous tPA represents the first FDA- approved therapy for acute ischemic stroke. In the NINDS trial, patients treated with tPA within 3 hours of onset of symptoms were at least 30% more likely to have minimal or no disability at 3 months compared with those treated with placebo.In the NINDS trial, patients treated with tPA within 3 hours of onset of symptoms were at least 30% more likely to have minimal or no disability at 3 months compared with those treated with placebo.

52 52 7. Drugs: Fibrinolytic Therapy for Ischemic Stroke However, there were 10-fold increases in the risk of fatal intracranial hemorrhage in the treated group (3% vs 0.3%) and the frequency of all symptomatic hemorrhage (6.4% vs. 0.6%).However, there were 10-fold increases in the risk of fatal intracranial hemorrhage in the treated group (3% vs 0.3%) and the frequency of all symptomatic hemorrhage (6.4% vs. 0.6%). This increase in symptomatic hemorrhage did not lead to an overall increase in mortality in the treated group.This increase in symptomatic hemorrhage did not lead to an overall increase in mortality in the treated group.

53 53 7. Drugs: Fibrinolytic Therapy for Ischemic Stroke Careful patient selection and strict adherence to the treatment protocol are essential!

54 54 7. Drugs: Fibrinolytic Therapy for Ischemic Stroke Because of the time criteria and risk associated with fibrinolytic therapy, it is important for hospitals to develop specific strategies and protocols that will achieve rapid initiation of therapy.

55 55 NINDS-Recommended Stroke Evaluation Targets for Potential Fibrinolytic Candidates* Door to doctor 10 minutes Door to CT † completion 25 minutes Door to CT read 45 minutes Door to treatment 60 minutes Access to neurological expertise ‡ 15 minutes Access to neurosurgical expertise ‡ 2 hours Admit to monitored bed 3 hours *Target times will not be achieved in all cases, but they represent a reasonable goal. † CT indicates computed tomography. ‡ By phone or in person. Time Target

56 56 Management of Hemorrhagic Stroke Optimal management: Prevention of continued bleeding.Prevention of continued bleeding. Appropriate management of ICP.Appropriate management of ICP. Timely neurosurgical decompression when warranted.Timely neurosurgical decompression when warranted. Large intracerebral or cerebellar hematomas often require surgical intervention.

57 57 Summary: Pre-hospital Critical Actions and Management This is what should happen:  Recognize the signs of stroke and TIA  Rapid neuro exam (Cincinnati Stroke Scale or similar).  Determine time of symptom onset (if possible).  Provide rapid transport to an ED capable of caring for acute stroke (pre-notify).  Perform finger-stick to assess serum glucose levels.

58 58 Summary: Pre-hospital UNACCEPTABLE Actions Failure to recognize signs and symptoms of stroke/TIAFailure to recognize signs and symptoms of stroke/TIA Failure to attempt to determine symptom onset.Failure to attempt to determine symptom onset. Delay in transport.Delay in transport. Transporting a potential stroke patient to an ED not capable of treating acute ischemic stroke with fibrinolytic therapy.Transporting a potential stroke patient to an ED not capable of treating acute ischemic stroke with fibrinolytic therapy.

59 59 Summary: Pre-hospital UNACCEPTABLE Actions Attempts to treat hypertension in the field.Attempts to treat hypertension in the field. Failure to notify receiving ED.Failure to notify receiving ED.

60 60 Conclusion: Now, fibrinolytic and other emerging therapies offer practitioners the opportunity to limit neurological insult and improve outcome in stroke patients.

61 61 Conclusion: The challenge with these therapies is that they require administration within hours of stroke onset, making the following measures imperative: Education of at-risk patientsEducation of at-risk patients Early recognition of stroke signsEarly recognition of stroke signs Prompt transport to the hospitalPrompt transport to the hospital Rapid hospital triage and evaluationRapid hospital triage and evaluation

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