2. EMERGENT TREATMENT PROTOCOLS FOR STROKE BERT TONEY, M.D. DIRECTOR, EMERGENCY DEPARTMENT FORT SANDERS PARKWEST MEDICAL CENTER WAYNE BAXTER, PARAMEDIC DIRECTOR, FORT SANDERS LOUDON EMERGENCY MEDICAL SERVICE BERT TONEY, M.D. DIRECTOR, EMERGENCY DEPARTMENT FORT SANDERS PARKWEST MEDICAL CENTER WAYNE BAXTER, PARAMEDIC DIRECTOR, FORT SANDERS LOUDON EMERGENCY MEDICAL SERVICE

3. EMERGENT TREATMENT PROTOCOLS FOR STROKE 700,000 PER YEAR ( ONE / MIN. ) 160,000 DEATHS PER YEAR $ 30,000,000,000 PER YEAR IN U.S. ALONE 3RD LEADING CAUSE OF DEATH (AND RISING) TN’S INCIDENCE 10 % > MEAN 700,000 PER YEAR ( ONE / MIN. ) 160,000 DEATHS PER YEAR $ 30,000,000,000 PER YEAR IN U.S. ALONE 3RD LEADING CAUSE OF DEATH (AND RISING) TN’S INCIDENCE 10 % > MEAN

4. EMERGENT TREATMENT PROTOCOLS FOR STROKE TYPES –ISCHEMIC THROMBOTIC EMBOLIC –HEMORRHAGIC SAH ICH TYPES –ISCHEMIC THROMBOTIC EMBOLIC –HEMORRHAGIC SAH ICH

5. EMERGENT TREATMENT PROTOCOLS FOR STROKE CURRENT THERAPY OF ISCHEMIC STROKE –ANALOGOUS TO AMI –THROMBOLYTICS 3 HOUR WINDOW (RISK/BENEFIT RATIO) COMPLICATIONS ONE HOUR STANDARD CURRENT THERAPY OF ISCHEMIC STROKE –ANALOGOUS TO AMI –THROMBOLYTICS 3 HOUR WINDOW (RISK/BENEFIT RATIO) COMPLICATIONS ONE HOUR STANDARD

6. EMERGENT TREATMENT PROTOCOLS FOR STROKE BARRIERS TO SUCCESSFUL EARLY STROKE MANAGEMENT –PATIENT APATHY –EMS/DISPATCH AWARENESS –OBTAINING CT –CONTRAINDICATIONS CHECKLIST –OBTAINING CONSENT –WAITING ON ED M.D. TO SEE PATIENT BARRIERS TO SUCCESSFUL EARLY STROKE MANAGEMENT –PATIENT APATHY –EMS/DISPATCH AWARENESS –OBTAINING CT –CONTRAINDICATIONS CHECKLIST –OBTAINING CONSENT –WAITING ON ED M.D. TO SEE PATIENT

7. EMERGENT TREATMENT PROTOCOLS FOR STROKE ATTACKING THE BARRIERS –PUBLIC EDUCATION –EDUCATION OF EMS/DISPATCH –PRE-HOSPITAL MANAGEMENT/ PRE- NOTIFICATION –NURSE-DRIVEN PROTOCOLS –CRUISE-MISSILE CT –PARALLEL PROCESSING –CONSENTS –CONTRAINDICATIONS ATTACKING THE BARRIERS –PUBLIC EDUCATION –EDUCATION OF EMS/DISPATCH –PRE-HOSPITAL MANAGEMENT/ PRE- NOTIFICATION –NURSE-DRIVEN PROTOCOLS –CRUISE-MISSILE CT –PARALLEL PROCESSING –CONSENTS –CONTRAINDICATIONS

8. OLD EMS-PRE 1996 STROKES NOT AN EMERGENCY! –ACUTE PROBLEMS TREATED EFFICIENTLY –BP ACTIVELY MANAGED –OUTCOMES USUALLY ASSURED AT THE TIME OF INCIDENT. –PROTOCOLS NOT NEEDED. –DISPATCH PROTOCOLS LOW PRIORITY

9. NEW EMS 1996-BEYOND APPARENTLY YOU CAN TEACH AN OLD DOG! DISPATCH : FIRST LINK IN CHAIN –EMERGENCY MEDICAL DISPATCH –PUBLIC EDUCATION E-911 –99% OF TN SERVED BY 911 –STROKE CARE MORE LIKE TRAUMA PROTOCOLS –EARLY NOTIFICATION

10. EMS EDUCATION AAOS EMERGENCY CARE, 6TH EDITION 1995 THE BASIC EMT: CPHC 1997 MOSBY’S EMT BASIC TEXTBOOK 1996

11. EMS EDUCATION AAOS EMERGENCY CARE, 6TH EDITION 1995 THE BASIC EMT: CPHC 1997 MOSBY’S EMT BASIC TEXTBOOK 1996 2 SENTENCES NOT MENTIONED

12. PATIENT EVALUATION-WEEDING OUT THE ZEBRAS MIMICS –SEPSIS, SYNCOPE, SEIZURES, HYPOGLYCEMIA, RADIAL NERVE PALSY, CARDIAC DISEASE! –TODD’S PARALYSIS USE TRAUMA SKILLS FOR ASSESSING THE STROKE PATIENT –GLASGOW COMA SCALE –NIH STROKE SCALE

13. WHAT SHOULD WE TEACH EMS ? ETIOLOGY OF STROKES –BIOCHEMICAL SEQUENCES SIGNS AND SYMPTOMS IMPORTANCE OF TIA EVALUATION KEY VITAL SIGNS –TIME OF SYMPTOM ONSET –HISTORY –PHYSICAL ASSESSMENT

14. WHAT SHOULD WE TEACH EMS ? TIME IS BRAIN!

15. Treating the flock HYPERTENSION NOT NORMALLY TREATED HYPOGLYCEMIA: GLUCOSE < 80 BEFORE TX NOTIFY STROKE CENTERS EARLY!

16. NOTIFICATION OF STROKE CENTERS TPA CHECK-OFF NIHSS ON-SCENE TIME < 10 MINUTES NOTIFY STROKE CENTER W/IN 5 MIN TRANSPORT EMERGENCY TRANSPORT

17. NURSE-DRIVEN PROTOCOLS FOR STROKE

18. EMERGENT TREATMENT PROTOCOLS FOR STROKE MINUTES DOOR TO TPA IN STROKE TARGET CHANGES INSTITUTED MEAN = 93 MINMEAN = 60 MIN PATIENTS

19. EMERGENT TREATMENT PROTOCOLS FOR STROKE WHY ? –PROTOCOLS –SO MUCH EFFORT, SO FEW PATIENTS

20. EMERGENT TREATMENT PROTOCOLS FOR STROKE WHAT THE FUTURE HOLDS –INTERVENTIONAL TX –NEWER THROMBOLYTICS –NEURO-PROTECTIVE AGENTS WHAT THE FUTURE HOLDS –INTERVENTIONAL TX –NEWER THROMBOLYTICS –NEURO-PROTECTIVE AGENTS