1. IDPH EMS Region Five
Stroke Education

2. Time is Brain!!!!!

3. Time is Brain !!!!
Stroke refers to any spontaneous damage to the brain caused by an abnormality of the blood supply by means of a clot or bleed.
Strokes should be treated emergently.
During a stroke, up to 2 million brain cells die every minute. For every hour a stroke continues, up to 200 million nerve cells die and the brain ages 4 years. Intravenous tPA (Activase / alteplase) should be given within 180 minutes of the onset of ischemic stroke, so do not delay transport and minimize scene time. It is recommended to limit scene time to 10 minutes.
TIME IS BRAIN!

4. Cerebrovascular Accident (CVA)
Pathophysiology
Thrombosis (brain itself)
Embolus (head, neck or heart)
Hemorrhage (within brain)
Ischemia (systemic blood flow)

5. Predisposing Factors: Modifiable
Hypertension
Cigarette smoking
Diabetes Mellitus
Heart disease
Hyperlipidemia
Cardiovascular disease
Chronic atrial fibrillation
Sickle cell disease
Polycythemia
Hypercoagulability
Birth control pill use
Cocaine use

6. Predisposing Factors: Unmodifiable
Age
Gender
Race
Prior stroke
Heredity

7. CVA Mechanisms

8. CVA Origin
Thrombus
Embolus
Aneurysm
Arrhythmia
Hypovolemia

9. Ischemic Stroke Blood vessel occlusion Thrombosis Embolism
Plaque fragments from carotids
Chronic atrial fibrillation
Fat particles
IV substance abuse particulates
Systemic hypoperfusion
Pump failure
Hypovolemia

10. Ischemic Stroke Syndromes
Transient Ischemic Attack (TIA)
Neurological deficits that resolve in 24 hours or less (most in 30 minutes)
Commonly result from carotid artery disease
Same symptoms as CVA
Often warning sign of impeding CVA
5% risk of stroke per year

11. Ischemic Stroke Syndromes
Dominant Hemisphere Infarction
Contralateral weakness, numbness
Contralateral blurring of vision of half the visual field in both eyes
Difficulty pronouncing words (dysarthria)
Difficulty speaking or understanding speech (dysphasia or aphasia)

12. Ischemic Stroke Syndromes
Nondominant Hemisphere Infarction
Contralateral weakness, numbness
Contralateral visual field cut
Neglect of contralateral extremities
Dysarthria
Usually NOT dysphasic or aphasic

13. Hemorrhagic Stroke

14. Hemorrhagic Stroke Syndromes
Intracerebral Hemorrhage
Headache, nausea, vomiting precede deficits
Patients commonly have decreased LOC with extreme hypertension
Contralateral hemiplegia, hemianesthesia
Possible aphasia, extremity neglect depending on hemisphere involved

15. Hemorrhagic Stroke Syndromes
Subarachnoid Hemorrhage

16. Brain can show injury in only three ways:
CVA Presentation
Brain can show injury in only three ways:
Decreased LOC
Seizures
Localizing signs
Hemiparesis or hemiplegia
Dysphasia (Receptive or expressive)
Visual disturbances
Gait disturbances
Inappropriate affect
Bizarre behavior
Incontinence

17. Cincinnati Stroke Scale
To facilitate accuracy in diagnosing stroke and to expedite transport, a rapid neurological examination tool is recommended.
The most common prehospital exam used is the Cincinnati Stroke Scale (CSS).
One new onset positive sign on the CSS indicates a 72% probability of stroke. Three new onset positive signs on the CSS indicates a greater than 85% probability of stroke.

19. Cincinnati Stroke Scale:
Facial Droop (ask the patient to show their teeth or smile)
Normal – Both sides of the face move equally/symmetrically.
Abnormal – One side of the face does not move as well as the other.

20. Cincinnati Stroke Scale:
Arm Drift (ask the patient to close their eyes and hold both arms out straight with palms up for 10 seconds).
Normal – Both arms move the same.
Abnormal –One arm turns over, drifts down compared to the other arm, or is flaccid.

21. Cincinnati Stroke Scale:
Speech (ask the patient to say, “You can’t teach an old dog new tricks”)
Normal – The patient says the phrase correctly with no slurring/slowing of words.
Abnormal – The patient slurs words, uses the wrong words or is unable to speak.

22. Cincinnati Stroke Scale:
Time (ask the patient/witness when the symptoms started)
Time of Onset: the time symptoms actually begin.
Last Known Well Time: the last time the patient was known to be without symptoms (asymptomatic).

23. CRITICAL THINKING ELEMENTS:
EMS personnel should ask family members or bystanders the stroke symptom onset time if the patient is unable to provide that information. Consider transporting a witness or obtaining witness’ contact information.
Maintain the head/neck in neutral alignment. Elevate the head of the cot 30 degrees if the systolic BP is >100mmHg (this will facilitate venous drainage and help reduce ICP).
Be alert for airway problems (swallowing difficulty, vomiting/aspiration)
Bradycardia may be present in a suspected stroke patient due to increased ICP. DO NOT give Atropine if the patient’s BP is normal or elevated.
Spinal immobilization should be provided if the patient sustained a fall or other trauma. Monitor and maintain the patient’s airway.
87% of strokes are ischemic and should be considered for tPA, while 13% of strokes are hemorrhagic.

24. Assessment Signs & Symptoms Ischemic S&S usually of slower onset
Hemiparesis or hemiplegia
Numbness or decreased sensation of face or unilateral
Altered LOC or coma
Convulsions
Visual disturbances
Slurred or inappropriate speech
Headache or dizziness

25. Assessment Signs & Symptoms Cerebral Embolus with rapid onset
Emboli from valvular HD or Afib
rapid onset
Often with an identifiable cause (e.g. Afib, Valvular heart disease, recent long bone fracture)

26. Cerebral hemorrhage associated with rapid onset
Assessment
Signs & Symptoms
Cerebral hemorrhage associated with rapid onset
high mortality rate
Often with severe HA (“Worst headache ever”)
N/V
Rapid decrease in LOC or seizure
Coma, Cushing’s and Herniation

27. Assessment Past Medical History Associated Altered LOC or Seizure?
Onset/Precipitating factors?
Initial symptoms and progression? Dizziness, Severe HA, N/V
Previous CVA or TIA?
Previous neurological deficits?
Concomitant illnesses?
Sickle Cell Disease
Atrial fibrillation
Risk factors for stroke & thrombus formation?
BCP, Smoking
HTN, CVD

28. Assessment Physical Exam Mental Status & Behavior
Extremity Motor & Sensory
Gait
Pupils & Vision
Cincinnati Prehospital Stroke Scale
Evidence of Cushing’s Syndrome (Reflex)or Herniation
Blood glucose level

29. Basic Objective Improve cerebral blood flow and oxygenation
CVA Management
Basic Objective
Improve cerebral blood flow and oxygenation

30. CVA Management Airway Breathing If no gag reflex, intubate
Otherwise, position to ensure drainage of secretions
Suction as needed
Breathing
Oxygen via NRB
Ventilate with BVM and O2 if rate or tidal volume inadequate

31. CVA Management Circulation Check blood glucose level
Hypoglycemia may mimic CVA
Treat hypoglycemia with D50W
Establish IV Access
Draw blood samples
TKO
avoid solutions with glucose (Hypertonic)
Monitor ECG
10% of CVAs are associated with cardiac event
12 Lead ECG if suspected ischemia

32. CVA Management
Do not assume patient cannot understand because they cannot talk
Position appropriately:
If hypertensive, semireclined (head slightly elevated)
If normotensive, on affected side
If hypotensive, supine

33. CVA Management
Increased Blood pressure treated ONLY if strongly suggestive of ischemic stroke
If systolic >220 or diastolic >120 consider gradual blood pressure reduction
Labetalol
Nitropaste
Nitroprusside
Controlled reduction
Return to pre-CVA levels, NOT to “normal”

34. CVA Management Thrombolytic agents
Consider for all patients with ischemic CVA presenting within 3 hours of onset
Early recognition of ischemic stroke and administration of thrombolytics can prevent/limit loss of neurologic function
Requires CT scan!!!

35. CVA Management Think like AMI of the Brain Therapy Mainstays
Time is Muscle….. Time is Brain
Therapy Mainstays
Oxygenation/Ventilation
IV Access
Rapid assessment & differential
Treat associated conditions (hypoglycemia, hypoxia, hypotension)
Rapid Transport to appropriate facility
CT Scan & Thrombolytics vs. CT Scan & Neurosurgery

36. Definitions
Primary Stroke Center (PSC) – a hospital that is currently certified by The Joint Commission (TJC) or Healthcare Facilities Accreditation Program (HFAP) as a Primary Stroke Center.

37. Definitions
Emergent Stroke Ready Hospital (ESRH) – a hospital which provides emergency care with a commitment to Stroke with recognition by Illinois Department of Public Health that has the following capabilities:
CT availability with in-house technician availability 24/7/365
Lab availability 24/7/365
Ability to rapidly evaluate an acute stroke patient to identify patients who would benefit from thrombolytic administration
Ability and willingness to administer thrombolytic agents to eligible acute Stroke patients
Accepts all patients regardless of bed availability

38. Definitions
Non-Stroke Hospital – No recognized organized treatment for acute stroke.

39. INTERHOSPITAL TRANSPORT GUIDELINES FOR CONFIRMED STROKE PATIENTS
TPA (Activase / alteplase) Transfers
Patients with a tPA infusion in progress must be accompanied by a Registered Nurse.
Patients that have completed a tPA infusion must be transported by an ILS/ALS ambulance.
It is preferred to complete tPA before transferring patient.
Hemorrhagic Transfers
Keep head of cot elevated at least 30 degrees (if stable) and head positioned midline.
Vital Signs and Neuro checks every 15 minutes
Notify Medical Control immediately of
SBP > 180 mmHg
DBP > 105 mmHg
Deterioration in level of consciousness
Bleeding at any location
Severe headache 

40. Time is Brain !!!!!!!