MACK HUTCHISON, BS, AS, NREMT-P QUALITY MANAGER

HISTORY OF EMS The good Samaritan rendered aid to a man laying on the side of the road. Napoleon’s chief physician was the first to develop Pre-Hospital care in The United States first recognized the need for Pre-Hospital care after the first year of the Civil War.

HISTORY OF EMS 1971, the hit television show “Emergency” caught the attention of the public prompting growing concern for their health. 1985, Trauma became a concern for EMS

STROKE FACTS Every 45 seconds someone in America has a stroke. About 700,000 Americans will have a new or recurrent stroke this year and over 163,000 of them will die (making it the third leading cause of death in the USA). There are approximately 266,000 stroke survivors with permanent disabilities.

MORE STROKE FACTS Fewer than one in five Americans can identify even one stroke symptom. The economic impact of stroke is estimated to cost $40-$70 billion per year. A stroke can be devastating, that's why it's so important to minimize your risk. “CALL 911”

CASE PRESENTATION After returning home from the supermarket, a woman finds her 67-year-old husband in the kitchen with slurred speech and left-sided weakness. He was acting normally when she left the house earlier that evening. She immediately calls her friend across the street to ask for help. The friend arrives a few minutes later only to find that the patient’s symptoms are getting worse. They decide to call 911. EMS personnel arrive within 5 minutes of the call. Paramedics evaluate the patient and are concerned that the patient may be having a stroke. What are the important elements of the pre-hospital management of potential stroke patients?

STROKE PRESENTATION OBJECTIVES: Describe the importance of rapid detection of CVA/TIA symptoms in the pre-hospital setting Describe why extensive neurological examinations are inappropriate in the pre- hospital setting Describe all points of the LA Stroke Scale

PRE-HOSPITAL MANAGEMENT OF STROKE Detection Dispatch Delivery Door

PRE-HOSPITAL EMERGENCY CARE 1999 A lack of awareness/understanding of TIAs A common sentiment that strokes could be managed non-emergently Less than half of survey participants were aware of the 3-hour time window for IV tPA.

TIME OF SYMPTOM ONSET Question multiple sources Actual time of symptoms vs. symptoms noticed How normal were they? Symptom onset: stuttering vs. acute Baseline level of neurological function

LA PRE-HOSPITAL STROKE SCREEN (LAPSS) 1. Age over 45 years 2. No prior history of seizure disorder 3. New onset of neurologic symptoms in last 24 hours 4. Patient was ambulatory at baseline (prior to event) 5. Blood glucose between 60 and 400

ELECTRONIC LA STROKE SCALE

LAPSS Exam: look for obvious asymmetry Normal Right Left Facial smile/grimace: __ __ Droop __ Droop Grip: __ __ Weak Grip __ Weak Grip __ No Grip __ No Grip Arm weakness: __ __ Drifts Down __ Drifts Down __ Falls Rapidly __ Falls Rapidly 6. Based on exam, patient has only unilateral weakness: Y/N ___

PRE-HOSPITAL CARE Airway, Breathing, Circulation Assess vital signs Neurologic exam Check serum blood sugar Determine time of onset Oxygen, IV, Monitor Notify the ED quickly

WHAT NOT TO DO Do not delay transport. Do not give large volumes of fluid (unless the patient is in shock). Do not give dextrose (unless hypoglycemic). Do not lower blood pressure. Do not forget to determine time of onset.

CASE OUTCOME When the paramedics arrived, their first action was to evaluate the patient’s airway, breathing, and circulation status. Since these were found to be adequate, the patient’s vital signs were then assessed. The results were as follows: blood pressure = 180/96, heart rate = 106, and respiratory rate = 22. While one paramedic then acquired some history from the patient’s wife, the other paramedic performed a concise physical examination which included a Glasgow Coma Score (GCS) and a pre-hospital stroke scale assessment.

CASE OUTCOME (CONT’D)……. Based upon the wife’s account, her husband was acting normally 45 minutes earlier when she went grocery shopping. He has never had symptoms like this before and is otherwise a very healthy person. She did not know what to do, so she called her friend across the street. By the time she arrived, he was getting worse, so she called 911. By this time, the second paramedic has determined that the patient has a GCS of 13 (E4 V3 M6). The pre- hospital stroke scale reveals the presence of left- sided facial droop, left-sided arm drift, and slurred speech.

CASE OUTCOME (CONT’D)…….. The paramedics then measure the patient’s blood sugar and oxygen saturation. Both are found to be normal. They explain to the patient’s wife that her husband appears to be having a stroke. Time is critical, and they encourage her to come with them since her assistance may be needed. The patient is promptly transferred to the ambulance. While enroute to the hospital, an IV is established, and the patient is placed on a cardiac monitor and low flow oxygen. The receiving hospital is contacted during the patient’s transport. Upon their arrival at the Emergency Department, the staff have already vacated a room and the physician begins evaluating the patient immediately.

WHY YOU SHOULD CALL 911 FOR A STROKE 1.Dispatchers will offer you verbal instructions. 2.Treatment begins when the paramedic arrives. 3.The ambulance is the most appropriate and safest means of transportation. 4.Inbound radio reports allow the hospital to get ready. 5.You are transported to the closest appropriate hospital.

*I can get to the hospital before an ambulance arrives! *The ambulance is not going to do anything but take me to the hospital! *Ambulance crews are trained to deal with the medical emergency that you are going to the hospital for. *Ambulances provide some of the same life-saving care that patients in emergency rooms will receive. *If you or your loved one go unconscious enroute to the hospital….what’s your plan? MYTHS OF EMS FACTS OF EMS

SUMMARY: If you have signs of a stroke, the ambulance is the best option for you. Treatment starts when you call. Treatment continues all the way to the hospital. This sets up the best potential outcome for you!

THANKS!....MACK HUTCHISON – MEMS QA MANAGER