1. EMS Assessment and Care for CVA
Presented by Tom Beers
EMS Coordinator
for the

2. Stroke Facts
EMS personnel play a critical role in the emergency care of acute stroke patients.
Here’s why.
Every 45 seconds in the United States someone experiences a stroke.
Each year more than 750,000 people in the U.S. experience a stroke.
Stroke is the third leading cause of death in the United States and leading cause of adult disability.
Stroke is a medical emergency; Stroke is a “Brain Attack.”
Stroke is treatable within 3 hours of symptom onset.
EMS transport shortens time to hospital care significantly.
EMS is the first medical contact for over 50 percent of stroke patients.

3. Introduction
Stroke
advancements give hope for restoration of lost neurological function
key is clot-busting therapy within 3 hours of onset
time lost is brain lost

4. Terms
atherosclerosis - A condition characterized by the deposit of fatty plaques containing cholesterol and lipids on the innermost layer of the walls of large and medium-sized arteries.
embolism - A clot that travels from one part of the body to another until it becomes lodged in one of the small arteries of the brain and blocks blood flow.
hemorrhagic stroke - A type of stroke that occurs when a blood vessel bursts inside the brain.
infarction - A localized area of cell death due to a lack of oxygenated blood.
ischemia - A deficiency of oxygenated blood in a body part as a result of a constriction or blockage of the blood vessel.

5. Terms
stroke (CVA) - A vascular disease that affects the blood vessels supplying blood to the brain. A stroke occurs when a blood vessel bringing oxygen and nutrients to the brain bursts or is clogged by a blood clot or embolus. A stroke can cause neurological deficits.
thrombus - A blood clot that typically forms over fatty plaque deposits that form on the inner wall of arteries. This plaque and subsequent narrowing may progress slowly over years, particularly in those patients who smoke or have high cholesterol or high blood pressure.
transient ischemic attack (TIA) - A disorder of the brain in which brain cells temporarily stop working because of insufficient oxygen causing stroke-like symptoms that resolve completely within 24 hours of onset.

6. Three Regions of the Brain
The central nervous system is responsible for controlling voluntary and involuntary activities of the human body.
Two parts of the central nervous system:
brain
spinal cord
Three regions of the brain are:
Cerebrum
Cerebellum
Brain Stem

7. Three Regions of the Brain, continued
thought
personality
memory
motor skills
tactile (touch)
speech
vision
Cerebrum

8. Three Regions of the Brain, continued
coordination
balance
basic movement
muscle tone
2. Cerebellum
1. Cerebrum

9. Three Regions of the Brain, continued
heart function
respiration
autonomic nervous system
digestion
glandular secretions
2. Cerebellum
1. Cerebrum
3. Brain Stem

10. Types of Stroke 1 There are generally 2 types of stroke:
Ischemic: A blockage caused by a clot. This is the most common type of stroke.

11. Types of Stroke 1 2 There are generally 2 types of stroke:
Ischemic: A blockage caused by a clot. This is the most common type of stroke. 2
Hemorrhagic: A rupture caused by a break in a blood vessel. Less common than ischemic stroke but no less serious.

12. Types of Stroke 1 2 3 Ischemic THROMBUS
clot that develops at the site of the blockage
forms locally near an area of plaque
causes a sudden occlusion of the blood vessel
produces a sudden onset of neurological deficits 1 2 3

13. Types of Stroke Ischemic EMBOLUS
clot floats to site to form a blockage
circulates in bloodstream until it gets stuck in an artery

14. Types of Stroke
Hemorrhagic
ruptured blood vessel on the surface of the brain (subarachnoid)
ruptured blood vessel within the brain (intracerebral)
puts pressure against the brain

15. Types of Stroke BOTH TYPES OF STROKE:
prevent oxygenated blood from reaching the brain tissues

16. Time lost is brain lost; seconds count.
Types of Stroke
BOTH TYPES OF STROKE:
prevent oxygenated blood from reaching the brain tissues
may have only minutes to get patient to definitive treatment
Time lost is brain lost; seconds count.

17. Transient Ischemic Attack (TIA)
Types of Stroke
Transient Ischemic Attack (TIA)
brain cells stop working because of insufficient oxygen
causes stroke-like symptoms that resolve completely within 24 hours

18. Risk Factors
Some of the factors that can contribute to stroke include:
hypertension
smoking
age
gender
heredity
prior stroke
diabetes
carotid artery disease
heart disease
TIAs

19. Signs and Symptoms Some of the signs and symptoms of stroke include:
paralysis or weakness on one side of the body
facial droop on one side
altered level of consciousness
change in personality or mood
headache or dizziness
impaired speech
blurred vision
poor coordination

20. Physical Exam Key clinical indicators respirations pulse mental status
skin signs and color
body position
Relative to stroke:
set of vitals to establish a baseline
Cincinnati Prehospital Stroke Scale
blood glucometry
Look for other explanations of stroke-like symptoms (trauma, medic alert tags, drug use or diabetes).
SICK or NOT SICK

21. Cincinnati Prehospital Stroke Scale
a simplified version of the National Institutes of Health Stroke Scale
accurate in identifying patients with stroke
an abnormal finding in ANY of the three tests strongly suggests a stroke
Test
Normal
Abnormal
facial droop
both sides of the face move equally
one side of the face does not move as well as the other
arm drift
both arms move the same or both arms do not move at all (palms up, eyes closed)
one arm drifts down compared to the other or one arm does not move
speech
patient says correct words with no slurring of words
patient slurs words, says the wrong words, or is unable to speak

22. Cincinnati Prehospital Stroke Scale
How does this patient appear to you?
facial droop

23. Cincinnati Prehospital Stroke Scale
How does this patient appear to you?
facial droop
arm drift

24. Cincinnati Prehospital Stroke Scale
How does this patient appear to you?
facial drift
arm drift
speech

25. Cincinnati Prehospital Stroke Scale
How does this patient appear to you?
facial droop
arm drift
speech

26. Cincinnati Prehospital Stroke Scale
How about now?
facial droop

27. Cincinnati Prehospital Stroke Scale
How does this patient appear to you?
facial droop
arm drift

28. Cincinnati Prehospital Stroke Scale
How does this patient appear to you?
facial droop
arm drift
speech

29. Cincinnati Prehospital Stroke Scale
How does this patient appear to you?
facial droop
arm drift
speech

30. Chief complaint and time of onset are key in the assessment of stroke.
Patient History
Stroke patients often report a loss of motor function and/or a change in speech pattern. Some patients experience an altered level of consciousness.
SAMPLE technique to determine if there is a history of:
hypertension
blood thinners or anticoagulants
arteriovenous malformation (AVM)
cerebral aneurysm
prior stroke
Chief complaint and time of onset are key in the assessment of stroke.

31. Clot-busting drugs must be given within 3 hours of onset of symptoms.
Time of Onset
determine time of onset but keep scene and transport times short
be conscious of the time it takes for the hospital staff to assess and administer thrombolytic therapy
Clot-busting drugs must be given
within 3 hours of onset of symptoms.

32. Care for Stroke Care for a victim of stroke includes:
protecting patient's airway
ensuring adequate respirations
removing secretions that can be aspirated
providing ventilation assistance
proper positioning
administering oxygen if saturation level is below 95% or there are signs of hypoxia

33. Short scene and transport times are important.
Short Scene Times
victims of stroke often deny or rationalize their symptoms
patients eligible for clot-busting drugs must be transported immediately
notify the hospital that a possible stroke patient is en route
avoid delays if the patient waited before calling for help
Short scene and transport times are important.

34. Summary
The three regions of the brain are the cerebrum, cerebellum and brain stem.
The two basic types of stroke are ischemic (blockage) and hemorrhagic (rupture).
An ischemic stroke can be caused by a thrombus which is a clot that forms in a cerebral artery or an embolus which is a clot that travels to the brain.

35. Summary Signs and symptoms of stroke include:
paralysis or weakness on one side of the body
facial droop on one side
altered level of consciousness (from confusion to unconsciousness)
change in personality or mood
headache or dizziness
impaired speech

36. Summary, continued
The three tests of the Cincinnati Prehospital Stroke Scale are facial droop, arm drift and speech.
Determine time of onset of symptoms. This helps determine if a patient meets the three-hour window for clot-busting therapy.
Short scene and transport times are vital.

37. What questions do you have about stroke?

38. Save the Date!!! July 11th! A Shift
Cleveland Clinic EMS Symposium
See Flyers after class!
National Speakers!!!
5 hours of Con Ed!!!