STROKESTROKE

Provena Regional EMS SystemProvena Regional EMS System

January 2010January 2010

““Grandpa had a stroke”Grandpa had a stroke”

Not too long ago this statement meant Not too long ago this statement meant death or disastrous disability for patients death or disastrous disability for patients and families. and families.

In the 21In the 21stst century medical science has century medical science has progressed in the understanding of progressed in the understanding of STROKE, prevention STROKE, prevention

and treatmentand treatment

How big is the problem of How big is the problem of STROKE?STROKE?

Magnitude of the ProblemMagnitude of the Problem

500,000 Americans annually suffer a 500,000 Americans annually suffer a STROKESTROKE

25% die25% die#3 killer of women#3 killer of women25% of women have strokes before age 25% of women have strokes before age

6565#1 cause of long term disability#1 cause of long term disability

Stroke in the USStroke in the US

One case of stroke every 45 secondsOne case of stroke every 45 secondsResults in devastating disabilityResults in devastating disability

16% institutionalized in nursing homes16% institutionalized in nursing homes31% assistance with ADL (bathing, dressing 31% assistance with ADL (bathing, dressing

eating)eating)20% assistance with walking20% assistance with walking30% depressed30% depressedAnnual cost of $43 billionAnnual cost of $43 billion

New AdvancementsNew Advancements

The FDA has approved the same clot The FDA has approved the same clot busting drugs (tPA thrombolytic) used in busting drugs (tPA thrombolytic) used in heart attacks to be used in brain attacks – heart attacks to be used in brain attacks – stroke.stroke.

Only 2% of stroke victims are treated with Only 2% of stroke victims are treated with thrombolytic medicationthrombolytic medication

Aggressive treatment begins with Aggressive treatment begins with assessment and intervention at point of assessment and intervention at point of patient contactpatient contact

Before STROKE can be Before STROKE can be managedmanaged

Learn more about what strokes are and Learn more about what strokes are and how they happen.how they happen.

A very selfish organA very selfish organ

The brain requires The brain requires 20 % of 20 % of the total bloodthe total blood pumped pumped by the heart.by the heart. No fat for storage No fat for storage in the brainin the brain Requires constant Requires constant supply of oxygen and glucose.supply of oxygen and glucose.

Blood Supply to the BrainBlood Supply to the Brain

Carotid arteries – anterior neckCarotid arteries – anterior neckVertebral arteries – through cervical Vertebral arteries – through cervical

vertebraevertebrae

Circle of WillisCircle of Willis

Both blood supplies join on the under Both blood supplies join on the under surface of the brain.surface of the brain.

Fail-safe mechanismFail-safe mechanism

in case of a blockagein case of a blockage

somewhere in somewhere in

circulationcirculation

What can go wrong???What can go wrong???

Disruption of blood flow to the brainDisruption of blood flow to the brainPlaquePlaqueForeign debrisForeign debrisBroken vesselBroken vessel

Ischemic STROKEIschemic STROKE

Progressive ThrombusProgressive Thrombus Plaque deposit – similar to process in heart with Plaque deposit – similar to process in heart with

coronary artery diseasecoronary artery disease

Cerebral Emboli --Clot from somewhere else -- Cerebral Emboli --Clot from somewhere else -- floating debrisfloating debris Blood clotBlood clot Air bubbleAir bubble Bubble of amniotic fluidBubble of amniotic fluid Bone marrow fromBone marrow from

a fracturea fracture

Hemorrhagic Hemorrhagic STROKESTROKE

Aneurysm – weakened area in arteryAneurysm – weakened area in arteryCongenitalCongenitalYounger population younger than 40 yearsYounger population younger than 40 years ““worst headache in my life”worst headache in my life”

Spontaneous Hypertensive BleedSpontaneous Hypertensive BleedBP 200/100BP 200/100

Malformed ArteryMalformed Artery50% younger than 30 years50% younger than 30 years

Transient Ischemic AttackTransient Ischemic Attack

““One Free Spin”One Free Spin”Looks like a stroke but,symptoms improve in Looks like a stroke but,symptoms improve in

1-24 hours1-24 hoursTemporary disruption of blood flow to the Temporary disruption of blood flow to the

brain --Angina of the brainbrain --Angina of the brainWarning signWarning signMimicked by low blood sugarMimicked by low blood sugar30% of patients will have a true stroke in 30 30% of patients will have a true stroke in 30

daysdays

Can STROKES be prevented?Can STROKES be prevented?

Modifiable risk factorsModifiable risk factorsHigh BPHigh BPCigarette smokingCigarette smokingAlcohol intakeAlcohol intakeUncontrolled Heart diseaseUncontrolled Heart diseaseAtrial fibrillationAtrial fibrillationUncontrolled DiabetesUncontrolled DiabetesCarotid congestionCarotid congestion

High blood cholesterolHigh blood cholesterolSedentary lifestyleSedentary lifestyleObesityObesitySeasonsSeasonsStressStress

Risk Factors Unable to ControlRisk Factors Unable to Control

AgeAgeGenderGenderRaceRacePrior strokesPrior strokesHeredityHereditySickle Cell DiseaseSickle Cell Disease

Signs and Symptoms of Signs and Symptoms of STROKESTROKE

HemorrhagicHemorrhagicSudden and dramaticSudden and dramaticViolent explosive headacheViolent explosive headacheVisual disturbanceVisual disturbanceNausea and vomitingNausea and vomitingNeck and back painNeck and back painSensitivity to lightSensitivity to lightWeakness on one sideWeakness on one side

Signs and Symptoms of Signs and Symptoms of STROKESTROKE

Ischemic StrokeIschemic StrokeHarder to detectHarder to detectWeakness in one sideWeakness in one sideFacial droopingFacial droopingNumbness and tinglingNumbness and tinglingLanguage disturbanceLanguage disturbanceVisual disturbanceVisual disturbance

Left Brain DamageLeft Brain Damage

Right side paralysisRight side paralysisSpeech and language disturbanceSpeech and language disturbanceBehavioral changesBehavioral changesSwallowing problemsSwallowing problems

Right Brain DamageRight Brain Damage

Left side paralysisLeft side paralysisSpatial perceptionSpatial perceptionCoordinationCoordinationPerceptionPerception

Primary Stroke CarePrimary Stroke Care

180 minute window of time180 minute window of time Time is tissueTime is tissue The longer the brain is withoutThe longer the brain is without oxygen and glucose the more oxygen and glucose the more brain cells diebrain cells die

Goal is to restore blood flow as Goal is to restore blood flow as soon as possiblesoon as possible

Treatment is a system beginning with EMS and Treatment is a system beginning with EMS and continuing through CCUcontinuing through CCU

Goals of Primary STROKE CareGoals of Primary STROKE Care

Rapid Recognition of STROKE SymptomsRapid Recognition of STROKE SymptomsRapid access in to the systemRapid access in to the systemAssessmentAssessmentTreatmentTreatment

Seven D’s of STROKE CareSeven D’s of STROKE Care

Detection –Detection –of STROKE symptomsof STROKE symptoms

Dispatch–Dispatch– of EMS of EMS

DeliveryDelivery – to a facility prepared to manage STROKE – to a facility prepared to manage STROKE

Door to treatment– Door to treatment– rapid diagnosis and decision rapid diagnosis and decision makingmaking

Data–Data– CT Scan CT Scan

Decision–Decision– Ischemic or Hemorrhagic, does the patient Ischemic or Hemorrhagic, does the patient meet the criteriameet the criteria

Drug –Drug – thrombolytics when appropriate thrombolytics when appropriate

EMS Has a Critical RoleEMS Has a Critical Role

Educate your communityEducate your communityAt first signs of a possible STROKE call At first signs of a possible STROKE call

EMS EMS ““Don’t guess call EMS!!”Don’t guess call EMS!!”

Use a “Use a “FASTFAST” STROKE ” STROKE AssessmentAssessment

Modification of Cincinnati Pre-Hospital Modification of Cincinnati Pre-Hospital Stroke ScreenStroke Screen

FaceFaceArmArmSpeechSpeechTime of onsetTime of onset

FACEFACE

Look for Facial DroopLook for Facial DroopHave the patient smile or show his/her teethHave the patient smile or show his/her teethNORMALNORMAL Both sides of the Both sides of the

face move equally face move equally ABNORMALABNORMAL One side of One side of

the patient’s face droops the patient’s face droops

or does not moveor does not move

ARMSARMS

Motor Weakness: Look for arm drift by asking Motor Weakness: Look for arm drift by asking the patient to close eyes and lift arms, palms upthe patient to close eyes and lift arms, palms up

NORMAL- arms remain NORMAL- arms remain

extended equally or drift extended equally or drift

downward equallydownward equally ABNORMAL – One arm ABNORMAL – One arm

drifts down compared drifts down compared

to the otherto the other

SPEECHSPEECH

Ask the patient to say Ask the patient to say “You can’t teach an “You can’t teach an old dog new tricks”old dog new tricks”

NORMAL –Phrase repeated clearly and NORMAL –Phrase repeated clearly and plainlyplainly

ABNORMAL – Words slurred, abnormal or ABNORMAL – Words slurred, abnormal or unable to speakunable to speak

Abnormal SpeechAbnormal Speech

Slurring of speechSlurring of speechUnable to think of wordsUnable to think of words Inappropriate wordsInappropriate wordsExpressive aphasia – unable to speak Expressive aphasia – unable to speak

words words Receptive aphasia – unable to understand Receptive aphasia – unable to understand

wordswords

TIME OF ONSETTIME OF ONSET

The window of opportunity to effectively The window of opportunity to effectively treat STROKE is 3 hours (180 minutes)treat STROKE is 3 hours (180 minutes)May be extended to 4 ½ hours May be extended to 4 ½ hours

Need to know “ last known well”.Need to know “ last known well”.Difficult whenDifficult when

Patient lives alonePatient lives aloneWoke up with symptomsWoke up with symptoms

Assessing the Stroke PatientAssessing the Stroke Patient

Initial AssessmentInitial AssessmentGeneral ImpressionGeneral ImpressionAirway Airway Airway!!Airway Airway Airway!!High-flow O2High-flow O2CirculationCirculationHIGH PRIORITY! For transportHIGH PRIORITY! For transport

Focused history and physical examFocused history and physical exam Perform thorough neurologic exam.Perform thorough neurologic exam.

Cincinnati Pre-hospital Stroke ScreenCincinnati Pre-hospital Stroke Screen Glasgow Coma ScaleGlasgow Coma Scale History of History of

SeizuresSeizures HeadacheHeadache Nausea/vomitingNausea/vomiting Neck painNeck pain

Get Get DETAILEDDETAILED OPQRST and SAMPLE OPQRST and SAMPLE

Obtain baseline set of vitalsObtain baseline set of vitals Recheck Vital Signs frequentlyRecheck Vital Signs frequently

Pre-hospital priorities of carePre-hospital priorities of care

Conduct general medical assessmentConduct general medical assessment Trauma – recent or within last monthTrauma – recent or within last month

Recent seizureRecent seizure Could be a subdural hematomaCould be a subdural hematoma

Cardiovascular – on heart medicationsCardiovascular – on heart medications Does the patient have atrial fibrillationDoes the patient have atrial fibrillation Does the patient take blood thinnersDoes the patient take blood thinners

Pulse oximetry > 94% Pulse oximetry > 94% Blood sugar treat if ableBlood sugar treat if able

Low blood sugars mimic a strokeLow blood sugars mimic a stroke PupilsPupils

PositionPosition

Protect potentially paralyzed partsProtect potentially paralyzed parts

EMS Packaging Check ListEMS Packaging Check List

Stroke identificationStroke identification Use of FAST ScreenUse of FAST Screen Securing A B CsSecuring A B Cs EKG monitoring if ableEKG monitoring if able Oxygen saturation of > 94%Oxygen saturation of > 94% Management of blood glucoseManagement of blood glucose IV access if ableIV access if able Blood specimens obtained if ableBlood specimens obtained if able Head of Bed elevated 15 degreesHead of Bed elevated 15 degrees Early communication with EDEarly communication with ED Urgent transportUrgent transport

Could this be anything other Could this be anything other than a STROKE?than a STROKE?

Transient Ischemic AttackTransient Ischemic Attack

HypoglycemiaHypoglycemia

Race Against TimeRace Against Time

Goals of STROKE Care 2010Goals of STROKE Care 2010

Standardized assessments, vocabulary, Standardized assessments, vocabulary, protocols and goalsprotocols and goals

Door to treatment goal in ED is 60 minutesDoor to treatment goal in ED is 60 minutesEarly EMS identification of candidates and Early EMS identification of candidates and

packagingpackagingDirect transport from pre-hospital to CT Direct transport from pre-hospital to CT

scan through EDscan through ED

Putting a Patient Through the Putting a Patient Through the ProcessProcess

EMS is dispatchedEMS is dispatched EMS Initial Assessment using FAST ScreenEMS Initial Assessment using FAST Screen ED notified by EMS EARLYED notified by EMS EARLY Paramedic draws labsParamedic draws labs CT scan notified by EDCT scan notified by ED Pharmacy notified by EDPharmacy notified by ED EMS briefly stops at registration to get labels for EMS briefly stops at registration to get labels for

lab tubeslab tubes

EMS stops briefly in ED for physician EMS stops briefly in ED for physician assessmentassessment

EMS and ED nurse take patient directly to EMS and ED nurse take patient directly to CT scan and place the patient on the tableCT scan and place the patient on the table

ED physician talks with family ED physician talks with family ED RN validates assessment and history ED RN validates assessment and history

using NIH Stroke Scaleusing NIH Stroke Scale

ED RN evaluates and treats BP ED RN evaluates and treats BP Radiologist reads CT scan and sends Radiologist reads CT scan and sends

report to EDreport to EDED physician makes decision regarding ED physician makes decision regarding

treatment with thrombolyticstreatment with thrombolyticsED calls pharmacy and requests tPAED calls pharmacy and requests tPAED RN administers tPAED RN administers tPAAdmission to CCUAdmission to CCU

NINDS Recommended GoalsNINDS Recommended Goals

Door to doctorDoor to doctor 10 minutes10 minutes Door to CT completionDoor to CT completion 25 minutes25 minutes Door to CT readDoor to CT read 45 minutes45 minutes Door to treatmentDoor to treatment 60 minutes60 minutes Access to neurological expertise*Access to neurological expertise* 15 minutes15 minutes Access to neuro-surgical expertise*Access to neuro-surgical expertise* 120 minutes120 minutes Admit to monitored bedAdmit to monitored bed 180 minutes180 minutes

* by phone or in person* by phone or in person

Case Study 1: 6:30 pmCase Study 1: 6:30 pm

ALS ambulance is dispatched to a ALS ambulance is dispatched to a shopping mall for a collapsed female.shopping mall for a collapsed female.

What could be the problem?What could be the problem?

What could be the problem?What could be the problem?

SeizureSeizureCodeCodeMyocardial infarctionMyocardial infarctionDiabetic reactionDiabetic reactionOver doseOver doseAnxiety attackAnxiety attackTraumaTraumaSTROKESTROKE

6:35 pm6:35 pm

Upon arrival, you find an African-American Upon arrival, you find an African-American woman sitting on a bench. She is woman sitting on a bench. She is confused, but responds to verbal stimuli. confused, but responds to verbal stimuli.

What assessments do you need?What assessments do you need?

Airway and ventilations are adequateAirway and ventilations are adequateRegular pulse and good perfusionRegular pulse and good perfusionSpeech is garbledSpeech is garbledUnable to move her right arm and legUnable to move her right arm and legDenies chest pain.Denies chest pain.BP 195/105, pulse 90, respirations 18BP 195/105, pulse 90, respirations 18

The patient’s daughter reports that her mother The patient’s daughter reports that her mother felt fine while shopping, when suddenly her arm felt fine while shopping, when suddenly her arm felt funny. She sat down on the bench, and did felt funny. She sat down on the bench, and did not fall or hit her head. She did not lose not fall or hit her head. She did not lose consciousness and did not have a seizure.consciousness and did not have a seizure.

The woman did not complain of a headache, and The woman did not complain of a headache, and has no history of seizures, diabetes, chest pain has no history of seizures, diabetes, chest pain or palpitations.or palpitations.

6:43 pm6:43 pm

This patient, Mrs. Short, is 65 years old. This patient, Mrs. Short, is 65 years old. She has left sided facial drooping and right She has left sided facial drooping and right arm and leg weakness. She can move the arm and leg weakness. She can move the right arm and leg slightly, but with great right arm and leg slightly, but with great difficulty. Her speech is slurred. All of difficulty. Her speech is slurred. All of these signs and symptoms are new in the these signs and symptoms are new in the last half hour.last half hour.

FASTFAST

How does Mrs. Short fare on the FAST How does Mrs. Short fare on the FAST Screen?Screen?FaceFaceArmArmSpeechSpeechTimeTime

Case 1 contCase 1 cont

Face -- left sided facial drooping Face -- left sided facial drooping Arm – right arm and leg weaknessArm – right arm and leg weaknessSpeech – speech is slurredSpeech – speech is slurredTime last known well -- unsureTime last known well -- unsure

HIGH PRIORITYHIGH PRIORITY

Determine precise time of onset of signs Determine precise time of onset of signs and symptoms.and symptoms.

If thrombolytic therapy is to be considered, If thrombolytic therapy is to be considered, its its infusioninfusion must begin within 3 hours of must begin within 3 hours of the onset of symptoms.the onset of symptoms.

Elicit cues to determine exact Elicit cues to determine exact onsetonset

The daughter remembers that she and her The daughter remembers that she and her mother were walking past the electronics mother were walking past the electronics store and stopped to watch the weather on store and stopped to watch the weather on the local news program. The weather is the local news program. The weather is always on at 6:20. The symptoms began always on at 6:20. The symptoms began when they stopped.when they stopped.

The 180 minute clock started at 6:20 pm.The 180 minute clock started at 6:20 pm.

Provide pre-arrival notification to receiving Provide pre-arrival notification to receiving hospital of potential stroke patient.hospital of potential stroke patient.

Rapid transport to an appropriate facility.Rapid transport to an appropriate facility.

6:50 pm6:50 pm

Enroute vital signs are:Enroute vital signs are:BP 198/120BP 198/120Pulse 92Pulse 92Respirations 22Respirations 22

Do you want to treat the blood pressure at this Do you want to treat the blood pressure at this time?time?

Do not treat the high blood pressure. It Do not treat the high blood pressure. It may be the only perfusion for her may be the only perfusion for her distressed brain.distressed brain.

Does Mrs. Short meet the criteria so far to Does Mrs. Short meet the criteria so far to be on the Primary STROKE Care track to be on the Primary STROKE Care track to receive thrombolytics (tPA)?receive thrombolytics (tPA)?

YES, Proceed to a hospital ready to YES, Proceed to a hospital ready to manage an acute STROKEmanage an acute STROKE

Case Study 2: 0635 HoursCase Study 2: 0635 Hours

70 year-old woman, Mrs. Black70 year-old woman, Mrs. Black Awake with slight weakness and tingling Awake with slight weakness and tingling

in her left side. in her left side. Speech is hesitant and slightly slurredSpeech is hesitant and slightly slurredVision seems to be normalVision seems to be normalNo facial droopingNo facial droopingGood eye contactGood eye contact

Case 2 cont.Case 2 cont.

Symptoms began 0530 per husbandSymptoms began 0530 per husbandSpeech was fine before thatSpeech was fine before thatBlood sugar 50 mg/dlBlood sugar 50 mg/dlNo emesis or seizureNo emesis or seizureBP 150/90, Pulse 80, Respirations 16BP 150/90, Pulse 80, Respirations 16O2 sat 92%O2 sat 92%Weighs 140 poundsWeighs 140 poundsNo aspirin intakeNo aspirin intake

FASTFAST

How does Mrs. Black fareHow does Mrs. Black fare

on the FAST Screen?on the FAST Screen?

FaceFace

ArmArm

SpeechSpeech

TimeTime

Case 2 contCase 2 cont

Face -- no droopingFace -- no droopingArm – slight weakness and tinglingArm – slight weakness and tinglingSpeech -- Speech is hesitant and slightly Speech -- Speech is hesitant and slightly

slurredslurredTime known well -- 65 minutes agoTime known well -- 65 minutes ago

Case 2Case 2

Treat the blood sugar and reassess the Treat the blood sugar and reassess the need for additional treatmentneed for additional treatment

High priority transport toHigh priority transport to

a hospital prepared to a hospital prepared to

treat acute STROKEtreat acute STROKE

Case Study 3Case Study 3

1400 hours1400 hours80 year-old man, Mr. Schmidt80 year-old man, Mr. SchmidtDaughter found him 15 minutes agoDaughter found him 15 minutes agoUnknown down timeUnknown down timeAwakeAwakeDrooping left side of faceDrooping left side of faceNo movement of right arm and legNo movement of right arm and legSpeech too slurred to understandSpeech too slurred to understand

Case 3 cont.Case 3 cont.

Seems to see youSeems to see youLooks only to leftLooks only to leftBlood sugar 200 mg/dlBlood sugar 200 mg/dlNo evidence of seizure or emesisNo evidence of seizure or emesisBP 180/100, pulse 72, respirations 15BP 180/100, pulse 72, respirations 15Unsure of aspirinUnsure of aspirin

FASTFAST

How does Mr. Schmidt fareHow does Mr. Schmidt fare

on the FAST Screen?on the FAST Screen?

FaceFace

ArmArm

SpeechSpeech

TimeTime

Case 3 contCase 3 cont

Face --Drooping left side of faceFace --Drooping left side of faceArm – No movement of right arm and legArm – No movement of right arm and legSpeech – Speech too slurred to Speech – Speech too slurred to

understandunderstandTime known well – unknown, daughter Time known well – unknown, daughter

found him 15 minutes ago, but she had found him 15 minutes ago, but she had not had contact with him since yesterdaynot had contact with him since yesterday

Case 3 Cont.Case 3 Cont.

Time of onset = unknownTime of onset = unknownSevere Headache = unknownSevere Headache = unknownEmesis = noEmesis = noASA = unknownASA = unknownSeizures = noSeizures = noConsenting party = yesConsenting party = yesBlood sugar = OKBlood sugar = OK

Case 3Case 3

Time window has closed. Not a candidate Time window has closed. Not a candidate for thrombolytic treatment. Transport to for thrombolytic treatment. Transport to ED for acute care.ED for acute care.

QuizQuiz

What are the 2 general types of stroke?What are the 2 general types of stroke? 1.1. 2.2.

What condition is equivalent to “angina” of the What condition is equivalent to “angina” of the brain?brain? 3.3.

What are 3 risk factors for stroke that can be What are 3 risk factors for stroke that can be modified?modified? 4.4. 5.5. 6.6.

What are 2 risk factors for stroke that cannot be What are 2 risk factors for stroke that cannot be modified?modified? 7.7. 8.8.

What are you measuring in a FAST Stroke What are you measuring in a FAST Stroke Screen?Screen? 9.9. 10.10. 11.11. 12.12.

In the 21In the 21stst century, some patients suffering century, some patients suffering from STROKE can be treated using what from STROKE can be treated using what type of medication?type of medication?13.13.

What is the time deadline that must be What is the time deadline that must be met in order to use the aggressive met in order to use the aggressive medication in the question above?medication in the question above?14.14.

How can EMS make a difference in early How can EMS make a difference in early recognition of STROKE in their recognition of STROKE in their community?community?15.15.

AnswersAnswers

1. Hemorrhagic stroke1. Hemorrhagic stroke 2. Ischemic stroke2. Ischemic stroke 3. TIA (transient ischemic attack)3. TIA (transient ischemic attack) 4. – 6. 4. – 6. High BPHigh BP

Cigarette smoking Cigarette smoking High blood cholesterolHigh blood cholesterol Sedentary lifestyleSedentary lifestyle Carotid CongestionCarotid Congestion ObesityObesity Uncontrolled diabetesUncontrolled diabetes SeasonsSeasons Atrial fibrillationAtrial fibrillation StressStress Uncontrolled heart diseaseUncontrolled heart disease Alcohol intakeAlcohol intake

7-8 7-8 AgeAge prior strokesprior strokes GenderGender heredityheredity RaceRace Sickle cell diseaseSickle cell disease

9. Face9. Face10. Arm10. Arm11. Speech11. Speech12. Last known well12. Last known well

13. Clot busting drugs, thrombolytics, tPA13. Clot busting drugs, thrombolytics, tPA14. 3 hours (180 minutes)14. 3 hours (180 minutes)15. If you have signs or symptoms of a 15. If you have signs or symptoms of a

stroke, don’t guess call EMSstroke, don’t guess call EMS