Acute Stroke - the role of EMS

Diane Handler, RN, MSN, MeD, ANVP Stroke CoordinatorMercy Medical Center, Cedar Rapids. Iowadhandler@mercycare.org

Stroke is an emergency Stroke is treatable Stroke occurs at all ages! 1.9 million brain cells die/minute

The Facts

1. Understand symptoms of stroke. 2. Know the difference between ischemic

stroke and hemorrhagic stroke and treatment guidelines.

3. Review stroke syndromes to better understand stroke presentations.

4. Know times to treat goals for stroke. 5. Review triage considerations and when to

divert.

Objectives

780,000 strokes/ year Community role- education s/s and call 911 Dispatch role

Stroke high priority (like AMI) Screen for stroke symptoms 60 second turn around

More Facts

9 minutes to scene 15 minute on scene time Cincinnati stroke scale (arm, speech,

droop) Time of onset Check blood glucose Family/witness to ED/ cell phone # OVER TRIAGE -30%

EMS Role

Arm drift slurred speech facial droop

If one is positive = consider stroke

Cincinnati Stroke Scale

History – and why Time of onset Meds- on coumadin? Past medical Hx- HTN, diabetes, past stroke or

TIA A Fib, A Fib, A Fib, A Fib, A Fib…

Your Role

Acute Stroke Treatment

What is tPA? (tissue plasminogen activator) Approved for stroke in 1996 Enzyme that activates the clot busting system

in the body

Treatment

IV tPA Symptom onset 4.5 hrs IV tPA Symptom onset 3 hours

80 years old History of both previous stroke and diabetes

Stroke symptoms within 8 hrs- consider Intra-arterial tPA

Deadlines

Too late to ED On Coumadin and INR >1.7 Symptoms rapidly resolving Recent trauma, MI or stroke

Why no tPA

NINDS tPA Trial 30% more likely to have minimal or no

disability at 3 months. 6% risk of symptomatic bleeding with tPA 17% mortality with tPA and 21% with placebo

group

Outcomes

ED goals for time to treat

From Arrival to ED

Door to Doctor- 10 minutes

Door to neurological expertise – 15 minutes (by phone)

Door to CT taken – 25 minutes *

Door to CT interpretation – 45 minutes

Door to treatment with tPA – 60 minutes

Your Role

History EMS straight to CT

Why CT fast and first

What does a typical stroke look like?

Typical Stroke

Weakness on Left or Right side and may have facial droop

Visual gaze deviation Inability to speak and or confused

Typical Stroke…

Left Hemisphere Stroke

R side weakness R facial droop Speech affected- receptive or expressive

Left hemisphere stroke

L side weakness L facial droop Impaired decision making

Right hemisphere stroke

77 yo w, female Triage 1018 L facial droop, L hemiparesis, Last time seen normal 0828 Did not want to come to hospital Time to treat with tPA 49 minutes

Right hemisphere “Typical Stroke”

Small vessel disease Hypertension High cholesterol Diabetes Smoking Sedentary life style

Why did I have a stroke?Another typical stroke type

Cerebellum Loss of balance

Brain Stem Loss of consciousness

Occipital Lobes Visual changes

“Zebra” Strokes

38 yo female from Micronesia Symptom onset 0445 headache and dizziness,

LOB Posterior circulation Cerebellum stroke

Cause of stroke? Associated problems- heart disease, anemia

Less typical Stroke

43 yo male, unresponsive Hx not feeling well and vomiting Last normal night before Triage at 0814 L vertebral artery and basilar artery occulsion,

prob dissection (locked in)

Atypical Stroke

Nausea and vomiting Gaze palsy Swallow difficulty, slurred speech Hemiparesis or quadriplegia and sensory

loss Decreased level of consciousness

Brainstem Stroke

Cranial Nerves

82 yo male Sensory loss on left Visual field cut Weakness on the left

R Occipital Lobe Stroke

Less typical Stroke

36 yo female- headache migraine

47 yo female- weak R arm + leg, headache, chest pain Conversion reaction syndrome

65 yo female- slurred speech, decreased LOC hypogylcemia

85 yo male- in restaurant, became unresponsive Hypo-perfusion of brain due to low BP

Stroke Mimics

Seizures with todds paresis Tumor

*Call Stroke Alert in any case- over triage by 30% is expected

Other mimics

EMS Acute Stroke Report

March 2010, time ED arrival 2230 ,Patient 62 yo, M

Symptoms R side weakness, R facial droop, slurred speech (dysarthria), symptoms fluctuated. Time of symptom onset2159 Time to CT taken 25 minute

Treated with t-PA?yes Time to needle 61 minutes Disposition of patient- Intensive Care Center for 24 hours then Cardiac Stroke Center for 24 hours. Then home.

Comments- Good in transit time for EMS service. Symptoms fluctuated but tPA was given as symptoms could have stabilized to a major stroke. Patient made a good recovery with no rehab issues.

EMS Acute Stroke Report

Triage time- 1104, Sept 2010, 1104, 79 yo F Symptoms- R arm weakness, R facial droop,

dysarthria, symptom onset “Last normal” 0915 Taken dTo CT directly Treated with t-PA? yes Time to needle 43 minutes

Disposition of patient -To ICC then Cardiac Stroke Center

Comments: Patient has made a good recovery. Patient has a history of A Fib but was not treated with Coumadin as she was a fall risk in previous living situation. On MRI, multiple areas of stroke were noted in left frontal and temporal lobe – likely due to cardio-embolism from the A Fib. Started on Coumadin and will watch in new living area to prevent falls.

EMS Acute Stroke Report

Aug 2010, Triage 1723 66 yo, W, M SymptomsWeakness R side, leg greater

than arm. Time of symptom onset1300 Time to CT scan takenOn arrival Treated with t-PA?No, Arrived > 3 hours so could not give tPA

Disposition of patient To Cardiac Stroke Center, Acute, inpatient rehab and eventually home.

Comments: Had patient arrived within time IV tPA could have been given. For patients < 80 years old and with no prior history of stroke and diabetes, IV tPA can be given up to 4 ½ hours of symptom onset. Patients who are > 80 years old and who have both past stroke and diabetes need to be treated within 3 hours of symptom onset. * Education of patient to call 911 right away.

EMS Acute Stroke Report

Nov. 2010 56 yo, W, F, Symptoms -R Facial droop, R side

weakness. Time of symptom onset- 2130, Time to CT scan immediately, Treated with t-PA? yes Time to needle - 44 minutes

Disposition of patient - Intensive Care Center, then Stroke Center and home soon.

Comments: Good times to treat. Patient did very well post tPA. Had a small left “subcorticol” stroke (under the cerebral hemispheres). Complete work up done to find the cause in 56 yo female with no known risk factors.

Questions

How many brain cells die per minute?

What is the goal for response time?

What is the goal for on scene time?

Why not give tPA past 4.5 hours?