1. BRAIN ATTACK Understanding and Managing Acute Stroke in the Pre-hospital Setting EMS Education – Stroke Carolyn Walker RN, BN January 2011

2. What’s New in Prehospital care of Acute Stroke? Change is Everywhere! New approach to EMS delivery in Alberta New EMS Provincial Medical Control Protocols

3. New Approach to EMS delivery in Alberta EMS services prior to April 2009 Private, Municipal, Hospital based/Regional EMS services since April 2009 Governance and Policy – Alberta Health and Wellness Operations and Support – Alberta Health Services >550 ambulances in system across Alberta 300 are AHS 250 are owned and operated by approx. 50 contracted services

4. New EMS Provincial Medical Control Protocols Implemented Dec 1, 2010 for both ground and air Developed by a provincial committee Ensure evidence based practices Ensure consistent standards of care throughout Alberta Clearly defined clinical treatment pathways STROKE MANAGEMENT PROTOCOL

5. EMS = Prehospital care Neurological emergencies Introduction Used with permission by Genetech Acute Stroke Syndromes Acute Ischemic Stroke

6. Define stroke Describe acute ischemic stroke Discuss EMS assessment and management of the suspected stroke patient Describe provincial stroke management protocol Identify requirements for direct transport to the nearest Primary or Comprehensive Stroke Centre Explain the importance of rapid reperfusion Describe how reperfusion is achieved Objectives

7. 65 year old female Collapsed Unable to move right side Unable to speak Case Study

8. Stroke Syndrome – sudden vascular event leading to focal neurological dysfunction Hemorrhagic -15% (ICH & SAH ) Ischemic- 85% (Thrombotic & Embolic) Ischemic Stroke – 65% Transient Ischemic Attack – 20% - symptoms resolve - no brain cell death - 20-40% of strokes are proceeded by TIA “… proficient … recognize, assess, manage, treat, triage, and transport stroke patients” NAEMSP Define Stroke Used with permission by National Stroke Association

9. Cerebral Perfusion and Acute Ischemic Stroke Mechanisms of ischemic stroke Multi-factorial Risk Factors Recent prior TIA/ stroke Diabetes Atrial fibrillation Smoking HTN - 70% of all strokes 32 000 brain cells/ second “Time is Brain” Cerebral Blood Flow Used with permission by National Stroke Association

10. EMS Assessment Primary Assessment o Sudden onset of: Weakness or numbness on one side of the body and/or face Difficulty with speech or understanding Double vision or loss of vision o Focused neurological assessment Vital signs BGL Medical history o Last seen normal o Co-morbid diseases – cardiac disease, diabetes, HTN, dyslipidemia o Risk factors – smoking, obesity, alcohol o Hemorrhage risk – recent trauma, surgery or bleeding problems o Neuro history – TIA, Stroke, TBI ECG – Atrial Fibrillation Used with permission by The City of Calgary EMS

11. Stroke Management Protocol When was patient last seen normal?

12. EMS Stroke Screen Form

13. Stroke Screen Form

14. EMS Assessment - Neurological – Level of Consciousness o A – alert o V – verbal o P – painful o U – unconscious Speech impairment -Aphasia and dysarthia Facial symetry - facial droop? Arm weakness o Limb drift o Hemiplegia vs. hemiparesis Leg weakness o Limb drift Vision abnormalities Hand Grip Strength - non-specific Used with permission by AHS EMS

15. Stroke Screen Form

16. Positive Stroke Screen Criteria: Stroke screen criteria are positive when the following 3 criteria are met: Blood glucose > 3.0 mmol/L Interval from “last seen normal” to arrival at nearest PSC or CSC is < 4.5 hours (Calgary only- awoke with symptoms OR last seen normal to arrival < 6 hours) One or more disabling findings are present

17. Case Study Assessment Aphasic Hemiparesis - right arm Weakness - right leg Facial weakness Medical History o Childhood Rheumatic fever o Mitral valve replacement Medications o Previous coumadin o ASA Used with permission by AHS EMS

18. Airway management - ETI Oxygen – SPO2 > 95% Positioning – supine to 30 degrees IV – minimum1 large bore N/S at 100mL/hr -no dextrose IV solutions NO CT Scan = No Thrombolytics = No ASA = No Anti-hypertensives EMS Treatment Used with permission The City of Calgary EMS

20. Access to Tertiary care Minimize total ischemic time Treatment window for t-PA <4.5 hours Scene time < 10 mins Rapid transport (with family/ witness if able or phone # to contact) Early Notification Prehospital recognition = Time to reperfusion Used with permission by Calgary EMS “Time is Brain ”

21. Communication and Transport Decision: Hyperacute - Metro - EMS Crew identifies hyperacute stroke, reviews stroke screen form, contacts ADCC (Ambulance Destination Co-ordination Centre) - ADCC advises on location and sets up information patch to ED - Awaiting ED notified by crew, clinical details, lytic screen - ED will contact stroke team to prepare for CT

22. Bypass Decision: Rural/Suburban - Bypass protocol in place, determines closest PSC location - Contacts ADCC if coming into Edmonton for direction to CSC - Transport to local PSC or to CSC with pre-notification - Consultation with Stroke team/Telestroke

23. Partners in Acute Ischemic Stroke Used with permission by Libin Cardiovascular Institute of Alberta Primary Stroke Centre (PSC) criteria: CT scan availability Door to CT time less than 20 minutes with a pre-alert Stroke expertise on-site or available by Telestroke link r-tPA treatment availability May not be available 24/7 due to CT/physician availability Serves surrounding communities in which it is the nearest PSC Comprehensive Stroke Centre (CSC) criteria: CT scan availability Door to CT time less than 20 minutes with a pre-alert Stroke team on-site Neurological expertise on-site Neurointerventional expertise on-site Central hub of stroke Neurologist expertise in a telestroke network Be aware of PSC and CSC in your area

24. Alberta Stroke Centre Locations 2 Comprehensive Stroke Centres Calgary - Foothills Medical Centre Edmonton - University of Alberta Hosp *Grey Nuns Hosp in Edmonton 14 Primary Stroke Centers

25. Reperfusion: t-PA (Activase), Mechanical Devices TIME IS BRAIN!! Mechanical Thrombectomy Devices: - MERCI device: Mechanical Embolus Removal in Cerebral Ischemia - Penumbra device Alteplase binds to fibrin in a thrombus: - converts plasminogen to plasmin - initiates local fibrinolysis with minimal systemic effects.

26. National and Provincial Stroke Statistics Prevalence in Canada 3rd leading cause of death 14,000 deaths/ year 50,000 strokes per year or 1 every 10 minutes 300,000 Canadians live with a disability due to stroke Leading cause of adult disability Alberta Provincial Stroke Strategy : 2003-2008 20% decline in stroke occurrence from 2003/4 -2007/8 4500 stroke patients admitted to Alberta hospitals 4000 stroke patients ED visits EMS is involved in majority of TIAs / Strokes

27. EMS in Stroke Management “… proficient … recognize, assess, manage, treat, triage, and transport stroke patients” NAEMSP "EMS providers are critical to the management of the acute stroke patient. Early recognition of stroke in-the-field, stabilization and transport to a Primary or Comprehensive Stroke Centre as rapidly as possible are mandatory for acute stroke treatment and good outcomes.“ Dr. Michael Hill, Stroke Neurologist, APSS

28. Thank you Alberta Provincial Stroke Strategy AHS Emergency Medical Services – Calgary Zone Greg Vogelaar Calgary Stroke Program: Dr. Michael Hill Darren Knapp Paramedic/Quality Assurance Strategist AHS Emergency Medical Services - Edmonton Zone

29. References 1.2005 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Part 9: Adult stroke. Circulation. 2005;112:111-120. 2.Canadian Stroke Network and the Heart and Stroke Foundation of Canada: Canadian Stroke Strategy. Canadian Best Practice Recommendations for Stroke Care: 2006. Ottawa, 2006. 3.Canadian best practice recommendations for stroke care (updated 2010) Patrice Lindsay, BScN PhD, Mark Bayley, MD, Chelsea Hellings, BScH, Michael Hill, MSc MD, Elizabeth Woodbury, BCom MHA, Stephen Phillips, MBBS (Canadian Stroke Strategy Best Practices and Standards Writing Group on behalf of the Canadian Stroke Strategy, a joint initiative of the Canadian Stroke Network and the Heart and Stroke Foundation of Canada*). FINAL v.25 October 21, 2010 4.EMS MANAGEMENT OF ACUTE STROKE– PREHOSPITAL TRIAGE (RESOURCE DOCUMENT TO NAEMSP POSITION STATEMENT) 5.T. J. Crocco, J. C. Grotta, E. C. Jauch, S. E. Kasner, R. U. Kothari, B. R. Larmon, J. L. Saver,M. R. Sayre, S. M. Davis. ABSTRACT. PREHOSPITAL EMERGENCY CARE 2007;11:313–317 6.Demchuk AM., Calgary Stroke Program – Thrombolysis Update 2008 mostly a 3 to 4.5 hours post stroke story. December 2007 – Lecture presentation 7.Kidwell CS, Alger J, Saver JL. Beyond mismatch: Evolving paradigms in imaging the ischemic penumbra with multimodal magnetic resonance imaging. Stroke. 2003; 34: 2729–2735 8.Saver JL. Time is brain--quantified Stroke. 2006 Jan;37(1):263-6. Epub 2005 Dec 8Saver JL 9.Koeing KL Benefits of Pre-hospital Notification for Stroke Patients. Journal Watch Emergency Medicine Nov 7, 2008 10.Alberta Provincial Stroke Strategy: Pre-Hospital Care February 2009 11. Government of Alberta Health and Wellness: Alberta Health Services: Emergency Medical Services: Provincial Medical Control Protocols: Adult and Pediatric, December 1, 2010.