Drill of the Month Developed by Gloria Bizjak Assessing and Managing Stroke Patients

Drill of the MonthDrill of the MonthDeveloped by Gloria BizjakDeveloped by Gloria Bizjak

Assessing and Managing Assessing and Managing Stroke PatientsStroke Patients

Drill of the MonthDrill of the Month 22


Student Performance Objective:Student Performance Objective:Given information, resources, and opportunity for Given information, resources, and opportunity for discussion and practice, EMTs will be able to:discussion and practice, EMTs will be able to:• List risk factors of stroke, List risk factors of stroke, • List stroke signsList stroke signs• List patient care procedures, List patient care procedures, • Name stroke-care centers Name stroke-care centers • Demonstrate patient care skillsDemonstrate patient care skills

EMTs will follow acceptable Maryland Medical practice EMTs will follow acceptable Maryland Medical practice and Maryland Medical Protocols for Emergency and Maryland Medical Protocols for Emergency Medical Providers.Medical Providers.



OverviewOverview Stroke Risk FactorsStroke Risk Factors Stroke SignsStroke Signs Patient Care ProceduresPatient Care Procedures Stroke-care CentersStroke-care Centers Skills PracticeSkills Practice


Stroke Risk FactorsStroke Risk Factors ImportanceImportance

– To know in order to quickly recognize To know in order to quickly recognize symptoms and determine potential symptoms and determine potential medical problemsmedical problems

– To learn during patient history to To learn during patient history to determine caredetermine care


Stroke Risk FactorsStroke Risk Factors

TypesTypes– Hereditary—not changeableHereditary—not changeable– A function of natural processes; not A function of natural processes; not

changeablechangeable Age and agingAge and aging

– Lifestyle—changeable, treatableLifestyle—changeable, treatable DietDiet Sedentary lifeSedentary life SmokingSmoking


Stroke Risk FactorsStroke Risk Factors UnchangeableUnchangeable

– Age—risk doubles for each decade after Age—risk doubles for each decade after age 55age 55

– Heredity (family history) and raceHeredity (family history) and race Higher risk if family member had a strokeHigher risk if family member had a stroke Higher risk if African American, Hispanic, Higher risk if African American, Hispanic,

Asian/Pacific IslanderAsian/Pacific Islander


Stroke Risk FactorsStroke Risk Factors UnchangeableUnchangeable

– Sex (gender)Sex (gender) More common in men than in womenMore common in men than in women More women than men die of strokeMore women than men die of stroke

– Special risk from use of birth control pillsSpecial risk from use of birth control pills– Special risk from pregnancySpecial risk from pregnancy

– Prior stroke, TIA, heart attackPrior stroke, TIA, heart attack


Stroke Risk FactorsStroke Risk Factors Treatable or controllable risk factorsTreatable or controllable risk factors

– High blood pressureHigh blood pressure Treatment caused a decline in stroke death Treatment caused a decline in stroke death

ratesrates

– SmokingSmoking Damages cardiovascular systemDamages cardiovascular system

– DiabetesDiabetes Treatable, but increases stroke riskTreatable, but increases stroke risk

– Carotid artery disease (CAD)Carotid artery disease (CAD) Carotids supply blood to brainCarotids supply blood to brain Narrowed by plaque reduce/block blood flowNarrowed by plaque reduce/block blood flow



– Peripheral artery diseasePeripheral artery disease Narrowing of vessels (by plaque) carrying Narrowing of vessels (by plaque) carrying

blood to extremitiesblood to extremities Causes higher risk of CADCauses higher risk of CAD

– Atrial fibrillationAtrial fibrillation Quivering causes blood to pool and clotQuivering causes blood to pool and clot Clots break off, lodge in artery to brainClots break off, lodge in artery to brain



– Other heart diseaseOther heart disease CADCAD Heart failureHeart failure Enlarged heartEnlarged heart Heart valve diseaseHeart valve disease Some congenital heart defectsSome congenital heart defects



– Sickle-cell disease/anemiaSickle-cell disease/anemia Affects African-American and Hispanic Affects African-American and Hispanic

childrenchildren Sickled red cells less able to carry oxygenSickled red cells less able to carry oxygen Cells stick to vessel walls, block arteries, Cells stick to vessel walls, block arteries,

reduce flow to brainreduce flow to brain



– High cholesterolHigh cholesterol– Poor dietPoor diet

High in saturated fat, trans fat, cholesterolHigh in saturated fat, trans fat, cholesterol High in sodium increases blood pressureHigh in sodium increases blood pressure High calorie intake contributes to obesityHigh calorie intake contributes to obesity

– Physical inactivity (sedentary living), Physical inactivity (sedentary living), obesityobesity



– Other possible risk factorsOther possible risk factors Geographic locationGeographic location

– Common in southeast US (stroke belt states)Common in southeast US (stroke belt states)

Socioeconomic factorsSocioeconomic factors– Common in low income peopleCommon in low income people

Alcohol abuseAlcohol abuse– Leads to multiple medical complications, including Leads to multiple medical complications, including

strokestroke

Drug abuseDrug abuse– Associated w/societal, health related problems, Associated w/societal, health related problems,

including strokeincluding stroke


Stroke SignsStroke Signs General (important to learn during General (important to learn during

patient history)patient history)– Sudden numbness or weaknessSudden numbness or weakness

Face, arms, legsFace, arms, legs

– Sudden confusionSudden confusion– Trouble speaking or understanding othersTrouble speaking or understanding others– Sudden trouble seeing in one or both eyesSudden trouble seeing in one or both eyes– Sudden trouble walkingSudden trouble walking– Dizziness or loss of balance or coordinationDizziness or loss of balance or coordination


Stroke SignsStroke Signs Cincinnati Prehospital Stroke ScaleCincinnati Prehospital Stroke Scale

– Three simple signs: First 3 letters of Three simple signs: First 3 letters of STRokeSTRoke Per Maryland ProtocolsPer Maryland Protocols Important: Have patient demonstrateImportant: Have patient demonstrate

– S S Can patient Can patient SMILESMILE——facial droopfacial droop one one sideside

– T T Can patient Can patient TALKTALK or say a simple or say a simple coherent sentence—coherent sentence—abnormal speechabnormal speech

– R R Can patient Can patient RAISERAISE both arms straight both arms straight outout in front withoutin front without arm drift arm drift


Stroke SignsStroke Signs Other possibly reliable signOther possibly reliable sign

– Crooked tongueCrooked tongue Ask patient to stick out tongueAsk patient to stick out tongue If it goes to one side or another, it is a If it goes to one side or another, it is a

possible indication of strokepossible indication of stroke– Possible reliable signPossible reliable sign– Difficult to interpret how far to one side or otherDifficult to interpret how far to one side or other


Patient Care ProceduresPatient Care Procedures Based on Maryland ProtocolsBased on Maryland Protocols Initiate general patient careInitiate general patient care

– Arrival and size-upArrival and size-up– Patient approachPatient approach– Initial assessmentInitial assessment

Mental statusMental status A,B,C,D,EA,B,C,D,E Clinical priority (1,2,3,4)Clinical priority (1,2,3,4) Disposition (mode, status)Disposition (mode, status) History and physical exam/assessmentHistory and physical exam/assessment


Patient Care ProceduresPatient Care Procedures TreatmentTreatment

– PresentationPresentation Signs and symptoms (recall stroke signs)Signs and symptoms (recall stroke signs) Seizures or altered mental statusSeizures or altered mental status

– Patient carePatient care Oxygen at 2-6 liters via nasal cannulaOxygen at 2-6 liters via nasal cannula Lay patient flat or slightly elevatedLay patient flat or slightly elevated



– Patient care: Recall Patient care: Recall Fibrolintic Fibrolintic Therapy ChecklistTherapy Checklist All yes/no boxes checked for transport to All yes/no boxes checked for transport to

designated stroke centerdesignated stroke center Inclusion Inclusion (yes)(yes) criteria criteria

– 15 years of age or older15 years of age or older– Signs and symptoms of stroke with neurologic Signs and symptoms of stroke with neurologic

deficit (abnormal deficit (abnormal Cincinnati Prehospital Cincinnati Prehospital Stroke ScaleStroke Scale))

– Patient can be delivered to stroke center w/i 2 Patient can be delivered to stroke center w/i 2 hours of signs/symptoms of onsethours of signs/symptoms of onset



– Patient care: Recall Patient care: Recall Fibrolintic Therapy Fibrolintic Therapy ChecklistChecklist All yes/no boxes checked for transport to designated All yes/no boxes checked for transport to designated

stroke centerstroke center Exclusion Exclusion (no)(no) criteria criteria

– Active internal bleeding (e.g., gastrointestinal bleeding or Active internal bleeding (e.g., gastrointestinal bleeding or urinary bleeding w/i 21 days of onset)urinary bleeding w/i 21 days of onset)

– Known bleeding disorderKnown bleeding disorder– Intracranial surgery, serious head trauma, previous stroke Intracranial surgery, serious head trauma, previous stroke

w/i 3 monthsw/i 3 months– Major surgery or serious trauma w/i 14 daysMajor surgery or serious trauma w/i 14 days– History of intracranial hemorrhageHistory of intracranial hemorrhage– Witnessed seizure at stroke onsetWitnessed seizure at stroke onset– History of cancer of the brainHistory of cancer of the brain



– Patient carePatient care Consult w/nearest designated stroke centerConsult w/nearest designated stroke center Rapid transportRapid transport

– Hospital must have time to prep for patientHospital must have time to prep for patient– Stroke treatments are time sensitiveStroke treatments are time sensitive

Patients benefit from thrombolysis and Patients benefit from thrombolysis and interventional therapiesinterventional therapies

Administration of tissue plasminogen activator (t-Administration of tissue plasminogen activator (t-Pa), or Pa), or fibrolinic therapyfibrolinic therapy, a clot busting drug, , a clot busting drug, can reverse effects of strokecan reverse effects of stroke


Stroke CentersStroke Centers Refer to Maryland ProtocolsRefer to Maryland Protocols

Anne Arundel Medical Primary Stroke CenterAnne Arundel Medical Primary Stroke Center Atlantic General Hospital Primary Stroke CenterAtlantic General Hospital Primary Stroke Center Baltimore Washington Medical Primary Stroke Baltimore Washington Medical Primary Stroke

CenterCenter Calvert Memorial Hospital Primary Stroke CenterCalvert Memorial Hospital Primary Stroke Center Civista Medical Primary Stroke CenterCivista Medical Primary Stroke Center Franklin Square Hospital Primary Stroke CenterFranklin Square Hospital Primary Stroke Center Good Samaritan Hospital Primary stroke Center, Good Samaritan Hospital Primary stroke Center,

MDMD



Greater Baltimore Medical Primary Stroke Greater Baltimore Medical Primary Stroke CenterCenter

Harbor Hospital Primary Stroke CenterHarbor Hospital Primary Stroke Center Harford Memorial Hospital Primary stroke Harford Memorial Hospital Primary stroke

CenterCenter Holy Cross Hospital Primary Stroke CenterHoly Cross Hospital Primary Stroke Center Howard County General Hospital primary Howard County General Hospital primary

Stroke CenterStroke Center Johns Hopkins Bayview Medical Primary Stroke Johns Hopkins Bayview Medical Primary Stroke

CenterCenter Johns Hopkins Hospital Primary Stroke CenterJohns Hopkins Hospital Primary Stroke Center



Maryland General Hospital Primary stroke Maryland General Hospital Primary stroke CenterCenter

Memorial Hospital and Medical Center of Memorial Hospital and Medical Center of Cumberland, Inc. Primary Stroke CenterCumberland, Inc. Primary Stroke Center

The Memorial Hospital at Easton, MD, Inc. The Memorial Hospital at Easton, MD, Inc. Primary Stroke CenterPrimary Stroke Center

Montgomery General Hospital primary Stroke Montgomery General Hospital primary Stroke CenterCenter

Peninsula Regional Medical Center Primary Peninsula Regional Medical Center Primary stroke Centerstroke Center

Saint Agnes hospital Primary Stroke CenterSaint Agnes hospital Primary Stroke Center Saint Joseph Hospital Primary Stroke CenterSaint Joseph Hospital Primary Stroke Center



Saint Mary’s Hospital Primary stroke CenterSaint Mary’s Hospital Primary stroke Center Shady Grove Adventist Hospital Primary stroke Shady Grove Adventist Hospital Primary stroke

CenterCenter Sinai Hospital of Baltimore Primary Stroke Sinai Hospital of Baltimore Primary Stroke

CenterCenter Southern Maryland Hospital Primary Stroke Southern Maryland Hospital Primary Stroke

CenterCenter Suburban Hospital Association Primary Stroke Suburban Hospital Association Primary Stroke

CenterCenter Union Memorial Hospital primary Stroke CenterUnion Memorial Hospital primary Stroke Center University of Maryland Medical System Primary University of Maryland Medical System Primary

Stroke CenterStroke Center



Upper Chesapeake Health System Primary Upper Chesapeake Health System Primary Stroke CenterStroke Center

Washington Adventist Hospital Primary Washington Adventist Hospital Primary Stroke CenterStroke Center

Washington County Health System Primary Washington County Health System Primary Stroke CenterStroke Center


Skills PracticeSkills Practice Patient Care Procedures (per Patient Care Procedures (per

Protocols)Protocols)– Initiate general patient careInitiate general patient care

Arrival and size-upArrival and size-up Patient approachPatient approach Initial assessmentInitial assessment

– Mental statusMental status– A,B,C,D,EA,B,C,D,E

Clinical priority (1,2,3,4)Clinical priority (1,2,3,4) Disposition (mode, status)Disposition (mode, status)


Skills PracticeSkills Practice Patient Care Procedures (per Patient Care Procedures (per

Protocols)Protocols)– TreatmentTreatment

Presentation: Recognize signs; treat Presentation: Recognize signs; treat accordinglyaccordingly

Consult with and notify hospitalConsult with and notify hospital Rapid transportRapid transport



Student Performance Objective:Student Performance Objective:Given information, resources, and opportunity for Given information, resources, and opportunity for discussion and practice, EMTs will be able to:discussion and practice, EMTs will be able to:• List risk factors of stroke, List risk factors of stroke, • List stroke signsList stroke signs• List patient care procedures, List patient care procedures, • Name stroke-care centers Name stroke-care centers • Demonstrate patient care skillsDemonstrate patient care skills

EMTs will follow acceptable Maryland Medical EMTs will follow acceptable Maryland Medical practice and Maryland Medical Protocols for practice and Maryland Medical Protocols for Emergency Medical Providers.Emergency Medical Providers.


Assessing and Managing Stroke Assessing and Managing Stroke PatientsPatients

ReviewReview Stroke Risk FactorsStroke Risk Factors

– List types of risk factorsList types of risk factors– List unchangeable risk factorsList unchangeable risk factors– List treatable or controllable risk factorsList treatable or controllable risk factors– List other possible risk factorsList other possible risk factors

Stroke SignsStroke Signs– List general signsList general signs– List the 3 signs of the Cincinnati Prehospital Stroke ScaleList the 3 signs of the Cincinnati Prehospital Stroke Scale– List other possible reliable signsList other possible reliable signs

Patient Care ProceduresPatient Care Procedures– List general patient care proceduresList general patient care procedures– State patient treatment stepsState patient treatment steps

Stroke-care CentersStroke-care Centers– List stroke centers in your response areaList stroke centers in your response area

Skills PracticeSkills Practice– LList skill steps demonstrated during practice in caring for ist skill steps demonstrated during practice in caring for

stroke patients stroke patients

Documents

Drill of the Month Developed by Gloria Bizjak Assessing and Managing Stroke Patients