1. STROKE: “BRAIN ATTACK”
STROKE: "BRAIN ATTACK" Cheryl Behm, RN CCHS: WR Lakewood Hospital
STROKE: “BRAIN ATTACK”
Tom Beers
EMS Coordinator
Huron Hospital & Trauma Center
2/07-4/07

3. OBJECTIVES
List at least 2 conditions that can present with focal neurological signs or mimic stroke.
Recognize principles of prehospital care.
Identify the 3 components of the Cincinnati Prehospital Stroke Scale.

4. OBJECTIVES
Identify the time frame in which an ischemic stroke patient can be treated with fibrinolytic therapy.
Appreciate the importance of rapid transport and prearrival notification of the ED.
Documents stroke assessment accurately on the run sheet.

5. STATISTICS Stroke Facts:
Each year, about 700,000 Americans suffer a new or recurrent stroke.
- 500,000 are 1st attacks; 200,000 are recurrent attacks.
This means that a stroke occurs every seconds.
Stroke kills over 150,000 people/year.
Stroke accounts for 1 of every 16 deaths.
Stroke is the #3 cause of death behind heart diseases and cancer.

6. STATISTICS Stroke Facts:
About every 3-4 minutes, someone dies of a stroke.
Of every 5 people who die from a stroke, 2 are men and 3 are women.
For every 100,000 people in the US (2004), about 50 people died of a stroke.

7. STATISTICS Stroke Facts:
The stroke death rates/100,000 population for specific groups were:
- 48 for white males.
- 47 for white females.
- 74 for black males.
- 65 for black females.

8. STATISTICS Stroke Facts:
And finally, in 2007, Americans will pay about $63 billion for stroke-related medical costs and disability!

9. STROKE/BRAIN ATTACK Sudden focal neurological deficit.
Occurs when a blood vessel bringing O2 and nutrients to the brain either bursts or becomes clogged (blood clot or other particle).
Brain doesn’t get blood flow.
No O2 – brain cells can’t function and die within minutes.

10. STROKE/BRAIN ATTACK
Part of the body controlled by these brain cells is unable to function.
Devastating effects of the stroke are PERMANENT:
- Dead brain cells not replaced.
- Other brain cells may gradually take on the function of the lost cells.

11. CLASSIFICATIONS Ischemic:
- Blood vessel supplying the brain is occluded – disrupts blood flow to the brain.
- 85% of strokes are ischemic.
- Cerebral thrombosis (blood clots develop in the brain artery itself)
- Cerebral embolism (clots develop elsewhere in the body and migrate to the brain).
- Further classified by vascular supply or anatomic location.

12. CLASSIFICATIONS Ischemic:
- Can use fibrinolytic drugs in ischemic strokes.
* 3 hour window of time from symptom onset to administration of fibrinolytic.
- Must obtain a CT scan of the brain to confirm that there is no hemorrhage and that it is an ischemic stroke.

13. CEREBRAL INFARCTION (Ischemic Stroke)

14. CLASSIFICATIONS Hemorrhagic:
- Due to rupture of an artery with bleeding:
* Onto the surface of the brain (subarachnoid hemorrhage)
* Into the parenchyma of the brain (intracerebral hemorrhage)
- Bleeding disrupts blood supply to brain.
- Most common cause of SAH is an aneurysm.
- Most common cause of intracerebral hemorrhage is hypertension.

15. CLASSIFICATIONS Hemorrhagic:
Fibrinolytic drugs CANNOT be used with hemorrhagic strokes as they may increase the amount of bleeding and worsen the stroke.
Symptoms are more severe and the pt appears to be more ill with hemorrhagic stroke.
Deteriorate rapidly.

16. SUBARACHNOID HEMORRHAGE

17. INTRACEREBRAL HEMORRHAGE

18. TRANSIENT ISCHEMIC ATTACKS (TIAs)
Present like strokes.
Resolve on their own within minutes to hours.
Warning sign of future stroke.
Temporary condition – 10% chance of stroke within 90 days after a TIA.

19. STROKE RISK FACTORS Modifiable: High blood pressure Smoking TIAs
Heart disease (Atrial fib, CHF, CAD)
Diabetes
Increased blood coagulation states
High RBC count and Sickle Cell Anemia
Carotid bruit

20. STROKE RISK FACTORS Unmodifiable: Age (over 55) Gender (male)
Race (African American)
Prior stroke
Heredity

21. SIGNS AND SYMPTOMS
Sudden numbness or weakness of the face, arm, or leg, especially on one side of the body.
Sudden confusion, trouble speaking, or understanding.
Sudden difficulty seeing in one or both eyes.
Sudden difficulty in walking, dizziness, loss of balance or coordination.
Sudden, severe headache with no known cause.

22. CASE STUDY # 1

24. DIFFERENTIAL DIAGNOSIS
6:35 PM
Upon arrival, you find an African-American woman sitting on a bench. She is confused but responsive to verbal stimuli.
Summary clinical signs and symptoms:
- Regular heart rate and adequate perfusion
- No evidence of ischemic chest pain
- Adequate airway and ventilation
- Right-sided paralysis
- Dysarthria
- Hypertension

25. DIFFERENTIAL DIAGNOSIS
1. What additional information do you need?
2. What is your differential diagnosis now?

26. DIFFERENTIAL DIAGNOSIS OF FOCAL NEUROLOGICAL DEFICIT
Hemorrhagic stroke
Ischemic stroke
Craniocerebral/cervical trauma
Meningitis/encephalitis
Hypertensive encephalopathy

27. DIFFERENTIAL DIAGNOSIS OF FOCAL NEUROLOGICAL DEFICIT
Intracranial mass
Seizure
Migraine
Metabolic problems, including hypo/hyperglycemia, drug OD
What other information would be helpful?

28. CASE DEVELOPMENT
The daughter reports that her mother felt fine while shopping, then suddenly said her arm felt funny. She then fell to the ground. She did not hit her head or lose consciousness. With further questioning the daughter reveals that her mother did not complain of a headache and had no signs or history of seizures, diabetes, chest pain, or palpitations.
What additional assessments may be helpful now?

29. CINCINNATI PREHOSPITAL STROKE SCALE
Facial droop (ask patient to show teeth and smile)
Arm drift (ask patient to extend arms, palms up, with eyes closed)
Speech (ask patient to say “You can’t teach an old dog new tricks”)
Look for abnormalities!

32. What is your conclusion from
CASE DEVELOPMENT
6:43 PM
Patient demonstrates a right-sided facial droop, right-arm weakness, and slurred speech.
What is your conclusion from
your examination?

33. CASE DEVELOPMENT 1. What are your priorities of care?
Do you need further information?
Obtain as much information as possible during transport; bring the family member along if possible.

34. SUMMARY OF PRIORITIES OF PREHOSPITAL CARE OF PATIENTS WITH POSSIBLE STROKE
Assessment and support of cardiorespiratory function and serum glucose.
Determination of precise time of onset of signs and symptoms.
Rapid transport to ED.
Prearrival notification of ED.
Assessment of neurological function.
Rapid determination of essential medical information.

35. How can you help clarify the information?
CASE DEVELOPMENT
The daughter states that her mother’s symptoms developed shortly before the call to EMS, but she is not sure of the exact time.
How can you help clarify the information?

36. CASE DEVELOPMENT
The daughter remembers that she and her mother were walking past an electronics store, and her mother stopped to watch the weather on the local news program. The weather report always airs at 6:20 PM.
1. What should you do with this information?
2. What are appropriate assessment and management priorities during transport?

37. CASE DEVELOPMENT
During transport the patient’s vital signs are again obtained:
HR = 92 (normal sinus rhythm)
RR = 22min. and unlabored
BP = 198/120 mm Hg 7:00 PM (40 minutes after onset) Patient arrives in ED.

38. DOCUMENTATION ESSENTIAL TO DOCUMENT:
- Time of onset of symptoms and witness(es) to validate sources.
* Establish the time of onset of stroke signs and symptoms “Time Zero” – TIME IS BRAIN TISSUE
* All assessments and therapies can be related to that time.
* Three (3) hour window of time for administration of thrombolytics for ischemic strokes.

39. CASE STUDY #2

40. CASE STUDY #2
You are dispatched to the home of a 65-year-old Hispanic man who is c/o weakness.
What could be some causes of this weakness?
- Hypoglycemia - GI bleeding
- Stroke - Dehydration
- MI - Infection
- Trauma

41. CASE STUDY #2
You arrive on the scene and find a 65 year old Hispanic man sitting on a chair in the kitchen.
- Eyes closed
- Seems sleepy/drowsy, but responds to your voice.
- Slow to answer questions.
- Slightly disoriented.
No one else is home
Need to continuously monitor his level of consciousness.

42. CASE STUDY #2 What would you do first? a. Assess ABCs b. Check VS
c. Check blood sugar and O2 sat
d. Obtain IV access

43. CASE STUDY #2 ASSESS ABCs. - Ensure patent airway
- Ensure adequate breathing
- Assess circulation
What would you do next?
a. Check VS
b. Check blood sugar and O2 sat
c. Start IV
d. Examine pt

44. CASE STUDY #2 CHECK VS - HR: 104/min - RR: 24/min - BP: 118/60
What is your next step?
a. Check blood sugar and O2 sat
b. Start IV
c. Obtain pt history
d. Examine pt
e. Transport

45. CASE STUDY #2 OBTAIN PT HISTORY - Pt states that he is weak.
- Answers questions appropriately.
- c/o lightheadedness.
- When asked about meds, he points to a list on the table.
- Pt is wearing an ID bracelet for diabetes and end stage renal disease.
- He is taking insulin, an antidepressant, and a multivitamin.
Try to find out when the pt last felt normal.
If this is a possible stroke, try to find out the exact time of symptom onset (In ischemic stroke, 3 hour window of time for fibrinolytics).

46. CASE STUDY #2 What should you do next? a. Transport pt b. Start IV.
c. Check blood sugar and O2 sat.
d. Examine pt.

47. CASE STUDY #2 Examine pt. - Diaphoretic, tachypneic, tachycardic
- Mildly confused; responds slowly.
- Focused neuro exam:
* Slurred speech
* Some weakness in the left arm and leg
* No facial droop

48. CASE STUDY #2 What should you do next? a. Check blood sugar and O2 sat
b. Start IV
c. Call medical control
d. Transport

49. CASE STUDY #2 Check blood sugar and O2 sat - O2 sat – 96%
- Blood sugar: 42 mg/dl.
Represents hypoglycemic reaction
- Give amp of D50
- Mental status improves
- Weakness disappears
Hypoglycemia can present like a stroke!

50. CASE STUDY #2 SUMMARY ABCs Check VS Focused history and physical
Identify and treat other causes
- Check blood sugar and O2 sat
Notify hospital
Rapid transport

51. CASE STUDY #3

52. CASE STUDY #3
You are dispatched to see a 72-year-old African American female. The family describes her as being confused. On arrival you find a 72-year-old female who:
Is Obese.
Can’t provide history.
Has difficulty understanding questions.
Has difficulty speaking
Seems confused.

53. CASE STUDY #3 What would you do first? a. Assess ABCs. b. Check VS.
c. Check blood sugar and O2 sat.
d. Start IV.

54. CASE STUDY #3 Assess ABCs. - Airway is open and patent.
- Breathing is adequate.
- Strong bilateral radial pulses palpated.
What would you do next?
a. Check VS.
b. Check blood sugar and O2 sat.
c. Examine pt.
d. Obtain focused history.

55. CASE STUDY #3 Check VS - HR: 96/min - RR: 18/min - BP: 196/110
What would you do next?
a. Check blood sugar and O2 sat.
b. Start IV. c. Obtain history.
d. Examine pt.

56. CASE STUDY #3 Obtain history - Pt is struggling with questions.
* Difficulty understanding
* Cannot answer questions
* Words not understandable
Son relates that his mother was eating dinner 20 minutes ago when she began to drool and food started to fall out of her mouth.

57. CASE STUDY #3
Find out when the symptoms started or when the pt last seemed normal.
Get a clear description of symptoms.
Ask:
- How was the pt earlier today?
- Has this happened before?
- Has the pt had any recent trauma?
- Has there been any signs of seizure activity before the onset of symptoms?
- History of HTN or diabetes?
- Is the pt taking any medications or does the pt have any allergies?
- Have any other family members had a similar illness?
- Ask about risk factors
* Does the pt have HTN, diabetes, smoke, etc.

58. CASE STUDY #3
The son states that his mother has HTN, diabetes, and smokes 1 pkg cigarettes/day.
What would you do next?
a. Start an IV.
b. Check blood sugar and O2 sat.
c. Focused neuro exam.

59. CASE STUDY #3 Complete a focused neuro exam.
- Abrupt symptom onset with focal deficits.
* Speech abnormality
* Subtle weakness of right arm and leg
* PERL
- Which one of the above is not included in the CPSS?
* Cincinnati Prehospital Stroke Scale (CPSS): Facial droop, arm drift, speech abnormalities.

60. CASE STUDY #3 A normal CPSS does NOT rule out stroke.
Possible causes of this pt’s symptoms:
- Ischemic stroke
- Hemorrhagic stroke
- TIA
- Head/neck trauma
- Hypoglycemia
- Seizure
- Migraine headache
- OD, toxic exposure
TIA or stroke is likely due to multiple risk factors – HTN, diabetes, smoking.

61. CASE STUDY #3 What should you do next?
a. Check blood glucose and O2 sat.
b. Call medical control en route.
c. Transport.
Check blood glucose and O2 sat.
- Blood glucose: 86; O2 sat: 97%.
a. Start IV.
b. Call Medical Control enroute.

62. CASE STUDY #3 Call medical control enroute.
- You report the VS as HR: 96; RR: 18; BP: 196/110; Blood glucose: 86; O2 sat: 97%.
- You relate the CPSS.
- You tell medical control that the symptoms started about 20 minutes prior to your arrival.
- You ask for meds to decrease BP.
Medical control asks you not to give any meds for BP control.
- HTN can develop after an ischemic or hemorrhagic stroke.
- Do NOT attempt to control it in the field.
- BP will decrease as pain, N/V, etc improve.

63. CASE STUDY #3 Medical control tells you to: - Monitor neuro status.
- Start IV of NS at KVO.
- Cardiac monitor.
- O2
After arrival in the ED, the pt has a CT scan done which shows no hemorrhage and is diagnosed as an ischemic stroke.
Fibrinolytics given and by that evening, all symptoms resolved.

64. CASE STUDY #3 SUMMARY ABCs. Check VS. Focused history and physical.
- Verify focal neuro findings with CPSS.
Check BS and O2 sat.
Determine time of symptom onset.
Notify medical control.
Transport rapidly.

65. CASE STUDY #4

66. CASE STUDY #4
You are dispatched to the home of a 52-year-old African American male whose wife called saying that her husband has a severe headache.
On arrival, you find him seated on the couch.
He appears to be uncomfortable.
He is c/o a severe headache that came on suddenly while he was mowing the lawn.

67. CASE STUDY #4 You check the ABCs:
- The pt is sitting on the couch with his hands over his eyes.
- He is slow to answer questions.
- There is no airway obstruction and his RR is 22/min.
- He has strong radial pulses bilaterally.

68. CASE STUDY #4 You then check his VS: - HR: 110 - RR: 22 - BP: 210/120
The focused history and physical show the headache started suddenly while he was mowing his lawn.
- States that he has never had a headache like this before in his life.
- Pt has history of HTN – is on BP meds but hasn’t taken them for 4 days because he ran out.

69. CASE STUDY #4 You next conduct a CPSS which shows:
- Left sided upper extremity weakness.
- Left facial droop.
- Slow speech.
Remember that a normal CPSS does not rule out a stroke!

70. CASE STUDY #4 How do you lower BP in the field? a. SL NTG
b. Morphine Sulfate 5 mg IV
c. Small (250cc) bolus NS
d. None of the above
DO NOT TREAT ELEVATED BP IN THE FIELD!

71. CASE STUDY #4
HTN after an ischemic or hemorrhagic stroke is common and will decrease once the pain, anxiety, agitation, N/V, or increased ICP are alleviated.
Again, do not treat the increased BP in the field!

72. CASE STUDY #4 SUMMARY Assess ABCs. Check VS.
Do not treat HTN in the prehospital setting.
Complete the focused history and physical.
This pt had 3 risk factors for stroke:
- Male - African American
- HTN
Notify hospital and give report.
Transport rapidly.

73. DOCUMENTATION ESSENTIAL TO DOCUMENT:
CINCINNATI PREHOSPITAL STROKE SCALE:
- Facial droop
- Arm drift
- Speech
TIME OF SYMPTOM ONSET
SEQUENTIAL VITAL SIGNS (several sets VS)
ALERT THE ED TO POSSIBLE STROKE PATIENT AS SOON AS YOU HAVE COMPLETED THE PRE-HOSPITAL STROKE CRITERIA.
RAPID TRANSPORT TO THE
NEAREST APPROPRIATE HOSPITAL.

74. QUESTIONS???