STROKE in the 21st Century

Presence Regional EMS System

December 2014

“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 century

medical science has medical science has

progressed in the progressed in the

understanding of STROKE prevention and understanding of STROKE prevention and treatmenttreatment

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

Magnitude of the Problem

795,000 Americans annually suffer a 795,000 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 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 Activities of Daily Living 31% assistance with Activities of Daily Living

(bathing, dressing eating)(bathing, dressing eating)20% assistance with walking20% assistance with walking30% depressed30% depressedAnnual cost of $58 billionAnnual cost of $58 billion

21st Century Management

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 managed

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

A 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 Brain

Two pathways to get blood to brainTwo pathways to get blood to brainCarotid arteries – anterior neckCarotid arteries – anterior neckVertebral arteries – through cervical Vertebral arteries – through cervical

vertebraevertebrae

Good News + Bad News -

Carotid ArteriesCarotid ArteriesLarge +Large +Anterior +Anterior +Frequently occluded with plaque -Frequently occluded with plaque -Easily cleaned out with carotid Easily cleaned out with carotid

endarterectomy +endarterectomy +

Good News + Bad News -

Vertebral ArteriesVertebral ArteriesSmaller -Smaller -Posterior -Posterior - Imbedded in vertebrae of cervical spine +Imbedded in vertebrae of cervical spine +Not accessible for cleaning out –Not accessible for cleaning out –Stents available for occlusions +Stents available for occlusions +

Circle of Willis

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

Shared circulationShared circulationFail-safe mechanismFail-safe mechanism

in case of a blockagein case of a blockage

somewhere in somewhere in

circulationcirculation

Problem with Circle of Willis

Not a smooth circleNot a smooth circleFloating debris can get Floating debris can get

caught in cornerscaught in cornersSite of most cerebral Site of most cerebral

aneurysmsaneurysms

What can go wrong???

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

Ischemic 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 STROKE

Aneurysm – weakened area in arteryAneurysm – weakened area in arteryCongenitalCongenitalYounger population (younger than 40 years)Younger 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 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?

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 lifestyleObesityObesityStressStress

Risk Factors Unable to Control

AgeAgeGender – Gender – more female more female

Race – Race – more African Americanmore African American

Prior strokesPrior strokesHeredityHereditySickle Cell DiseaseSickle Cell DiseaseSeasons --Seasons --more strokes in spring and fallmore strokes in spring and fall

Signs and Symptoms of STROKE

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

Same signs and symptoms as new onset Same signs and symptoms as new onset migraine headachemigraine headache

Signs and Symptoms of STROKE

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 Damage

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

Right Brain Damage

Left side paralysisLeft side paralysisSpatial perception – able to locate items in Spatial perception – able to locate items in

spacespaceCoordinationCoordinationPerception – what is that thing?Perception – what is that thing?

Primary 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 early Treatment is a system beginning with early recognition and continuing through rehabilitationrecognition and continuing through rehabilitation

Goals 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 CareNational Institute of Neurological Diseases and Stroke

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 – thrombolytic when appropriate thrombolytic when appropriate

EMS 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 “FAST” STROKE Assessment

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

FaceFaceArmArmSpeechSpeechTime of onsetTime of onset

FACE

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

ARMS

Motor Weakness: Look for arm drift by asking Motor Weakness: Look for arm drift by asking the patient to close eyes and lift armsthe patient to close eyes and lift arms

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

SPEECH

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 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 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 Patient Initial Assessment

General Impression – level of consciousnessAirway Airway Airway!!High-flow O2CirculationHIGH PRIORITY!

Focused history and physical examPerform thorough neurologic exam.

FAST Stroke ScreenHistory of

Seizures Headache Nausea/vomiting Neck pain

Obtain baseline set of vitalsRecheck Vital Signs frequently

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 hematoma?Could 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

Position

Protect potentially paralyzed partsProtect potentially paralyzed parts

Positioning

When possible keep supineWhen possible keep supineHead elevated 30 degreesHead elevated 30 degrees If put on side, put paralyzed side downIf put on side, put paralyzed side downAble to move and reach with unaffected Able to move and reach with unaffected

armarmKeep affected arm slightly forward so that Keep affected arm slightly forward so that

weight is not on itweight is not on it

STROKE 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 IV access Blood specimens obtained if able Blood specimens obtained if able Head of Bed elevated 30 degreesHead of Bed elevated 30 degrees Early communication with PhysicianEarly communication with Physician Urgent transport to CT ScanUrgent transport to CT Scan

Non Contrast CT of HeadNon Contrast CT of Head

No dyeNo dyeNormalNormalNo bleedsNo bleeds

Acute Hemorrhagic Stroke

Blood shows up whiteBlood shows up white

Sub Arachnoid Bleed

Bleed between dura materBleed between dura mater

and arachnoid materand arachnoid mater

Could this be anything other than a STROKE?

Transient Ischemic AttackTransient Ischemic Attack

HypoglycemiaHypoglycemia

Race Against TimeRace Against Time

Goals of STROKE Care 21st Century

Standardized assessments, vocabulary, Standardized assessments, vocabulary, protocols and goals protocols and goals Everyone calls it the same thingEveryone calls it the same thingEveryone does the same FAST assessmentEveryone does the same FAST assessment

Door of the ED to treatment goal is 60 Door of the ED to treatment goal is 60 minutesminutes

Early identification of candidates who Early identification of candidates who benefit from tPAbenefit from tPA

Direct transport to CT scanDirect transport to CT scan

NINDS Recommended GoalsNational Institute of Neurological Diseases and Stroke

ED Door to doctorED Door to doctor 10 minutes10 minutes ED Door to CT completionED Door to CT completion 25 minutes25 minutes ED Door to CT readED Door to CT read 45 minutes45 minutes ED Door to treatmentED Door 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

SoSo

Get to an Emergency Department that has Get to an Emergency Department that has a plan to deal with stroke.a plan to deal with stroke.

2015 EMS Protocols By-pass a non-designated hospital to

transport patient to a hospital designated by Illinois as capable of managing strokeComprehensive Stroke CenterPrimary Stroke CenterAcute Stroke Ready

If receiving hospital does not have a If receiving hospital does not have a working CT scanner – bypass for one that working CT scanner – bypass for one that doesdoes

Case Study 1: 6:30 pm

You are called by a family member to You are called by a family member to assess a patient in who is not acting right.assess a patient in who is not acting right.

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

What could be the problem?

SeizureSeizureCodeCodeMyocardial infarctionMyocardial infarctionDiabetic reactionDiabetic reactionMedication reactionMedication reactionAnxiety attackAnxiety attackSTROKESTROKE

6:35 pm

Upon arrival, you find a woman sitting in Upon arrival, you find a woman sitting in bed. She is confused, but responds to bed. She is confused, but responds to verbal stimuli. 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 a few minutes ago when suddenly her felt fine a few minutes ago when suddenly her arm felt funny. She did not lose consciousness arm felt funny. She did not lose consciousness and did not have a seizure.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 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 10 minutes.last 10 minutes.

FAST

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

Case 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 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.

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, transport immediately to ED YES, transport immediately to ED designated to treat stroke.designated to treat stroke.

Case 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.

Symptoms began 0615 per patientSymptoms began 0615 per patientSpeech was fine before that (spoke with Speech was fine before that (spoke with

her husband at 066 speech clear)her husband at 066 speech clear)Blood 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%

FAST

How does Mrs. Black fareHow does Mrs. Black fare

on the FAST Screen?on the FAST Screen?

FaceFace

ArmArm

SpeechSpeech

TimeTime

Case 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 -- 20 minutes agoTime known well -- 20 minutes ago

Case 2

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

Watch for choking if oral glucose Watch for choking if oral glucose given!given!

High priority transport toHigh priority transport to

a CT for acute STROKEa CT for acute STROKE

Case Study 3

Called to a home at 1400 hoursCalled to a home at 1400 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.

Blood 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 15

FAST

How does Mr. Schmidt fareHow does Mr. Schmidt fare

on the FAST Screen?on the FAST Screen?

FaceFace

ArmArm

SpeechSpeech

TimeTime

Case 3 contFace --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 not found him 15 minutes ago, but she had not had contact with him since yesterday. had contact with him since yesterday. (She checks on him every day on her way (She checks on him every day on her way to work)to work)

Case 3 Cont..

Time of onset = unknownTime of onset = unknownSevere Headache = unknownSevere Headache = unknownEmesis = noEmesis = noSeizures = noSeizures = noBlood sugar = High OKBlood sugar = High OK

Case 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.

ReviewReview If doing this CE individually, please e-mail

your answers to:

Shelley.Peelman@presencehealth.org Use “December 2014 CE” in subject box. IDPH site code: 06-7100-E-1214 You will receive an e-mail confirmation.

Print this confirmation for your records and document in your PREMSS CE record book.

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 brain?What condition is equivalent to “angina” of the 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 met What is the time deadline that must be met in order to use the aggressive medication in order to use the aggressive medication in the question above?in the question above?14.14.

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. Face

10. Arm10. Arm

11. Speech11. Speech

12. Last known well12. Last known well

13. Clot busting drugs, thrombolytics, tPA13. Clot busting drugs, thrombolytics, tPA

14. 3 hours (180 minutes)14. 3 hours (180 minutes)