BY: Ramon Medina EMT-LP/RN

• Discuss types of strokes

• Discuss the physical and neurological assessment of stroke patients

• Discuss pertinent historical findings

• Discuss pre-hospital and emergency management of strokes• Discuss pre-hospital and emergency management of strokes

• Discuss fibrinolytic treatment for strokes

• Each year approx. 795,000 Americans have a new or recurrent stroke.

• Every 40 seconds someone in this country will experience a stroke.

• Stroke kills more than 137,000 people a year, on average • Stroke kills more than 137,000 people a year, on average every 4 minutes someone dies of stroke

• 4th leading cause of death in the U.S.

• Leading cause of disability in the U.S.

• Americans will pay about 74 billion in stroke related medical cost and disability

1. Hypertension

2. Age

3. Elevated Cholesterol

4. Smoking

5. Diabetes5. Diabetes

6. Elevated BMI

Left Hemisphere Stroke

• Movement on right side of body

• Speech and language

Right Hemisphere Stroke

• Movement of left side of body

• Analytical and perceptual task• Capabilities and memory task

• Short term memory

Cerebellar Stroke

• Reflexes

• Balance

• Coordination

Brain Stem Stroke

• Involuntary life-support functions

• Coordination

• Types:• Ischemic

• Decrease in cerebral blood flow due to either a thrombus or an embolus.

• Ischemic strokes account for approx. 87% of all strokes

• Hemorrhagic Stroke• Hemorrhagic Stroke

• Account for approx. 10% on all strokes

• Occurs when a blood vessel in the brain ruptures leaking blood into the brain, yet are responsible for more than 30% of stroke deaths

• TIA (transient ischemic attack)

• Present in the same way strokes do, but are only a brief episode of cerebral ischemia.

• TIA’s are often a warning sign that a stroke is imminent.

• Sudden weakness or numbness of the face, arm, or leg especially on one side of the body.

• Sudden confusion

• Trouble speaking or understanding

• Sudden trouble seeing in one or both eyes• Sudden trouble seeing in one or both eyes

• Sudden trouble walking

• Dizziness or loss of balance or coordination

• Sudden severe H/A with no known cause

• Hypertensive Encephalopathy

• H/A, delirium, significant hypertension, cortical blindness, seizure

• Seizure

• Postictal period

• Hypoglycemia• Hypoglycemia

• Hx of DM, low serum glucose, decreased level of consciousness

• Head Trauma

• Drugs & Alcohol

• CNS Tumor

• Medical History

• Comorbid factors (DM, HTN, A-Fib)

• Seizures, Prior Strokes, Past episodes hypoglycemia

• Medications

• With special attention to anticoagulant or antiplatelet drugs• With special attention to anticoagulant or antiplatelet drugs

• Attempt to determine exact onset of symptoms. Ask both:

• When did the symptoms start ?

• This is the “start” for fibrinolytic treatment window

• When was the last time the patient was seen normal ?

• Other important historical elements include any sign of seizure or trauma before onset of symptoms

• Stroke patients are dispatched at the highest level of care available in the shortest time possible

• Time b/w the receipt of the call and dispatch of the response team is <90 sec.

• EMSS response time is <8 minutes (time of call from receipt of call by dispatch to arrival of EMS to patient)dispatch to arrival of EMS to patient)

• Dispatch time <1 min

• Turnout time (from when a call is received to the unit being en route) <1min

• On-Scene time <15 minutes (barring extenuating circumstances)

•TIME IS BRAIN.!!!

• The goal of stroke care is to minimize brain injury and maximize the patient’s recovery.• Stroke Chain of Survival

1. Detection• Patient or bystander recognition of stroke S/S

2. Dispatch• Immediate activation of 911 and priority EMS dispatch

3. Delivery3. Delivery• Prompt triage and transport to most appropriate stroke hospital and pre-hospital notification

4. Door• Immediate ED triage to high-acuity area

5. Data• Prompt ED evaluation, stroke team activation, lab studies, and brain imaging

6. Decision• Diagnosis and determination of most appropriate therapy; discussion with patient and family

7. Drug• Administration of appropriate drugs or other interventions

8. Disposition• Timely admission to stroke unit, ICU, or transfer

• Maintain airway and administer oxygen to maintain Spo2 >94% and <100%

• Initiate IV of NS @ TKO.

� Avoid use IV fluids containing glucose

• Perform glucose check• Perform glucose check

� Hypoglycemia can mimic stroke symptoms

� If hypoglycemic less than 50mg/dl give D50W 25gms. Administer with caution due D50W decreasing the efficacy of tPA.

• Monitor cardiac rhythm.

� If arrhythmia is present, proceed to the appropriate protocol

� Obtain a 12-lead EKG

• If hypertensive, contact receiving stroke center and/or medical control for hypertension management.

• Systolic >220

• Diastolic >120

• Transport with HOB elevated to 30 degrees if patient can tolerate. Monitor V/S closely.

• Perform exam, noting initial neurological exam for baseline documentation.

• Positive Stroke Assessment Results

• Transport to stroke center.!

• Do not delay transport

• Pre-Hospital notification to receiving hospital

• Obtain phone numbers at which family members or witnesses • Obtain phone numbers at which family members or witnesses can by reached

• Consider transporting a family member along with patient.

• Assess ABC’s• Provide Oxygen

• For hypoxemic stroke patients (O2 saturation <94%) or patients with unknown saturation

• Establish IV access & Obtain blood samples• Baseline blood count, coagulation studies, and blood glucose

• Do not let this delay CT scan• Do not let this delay CT scan

• Perform Neurologic Assessment• NIH Stroke Scale (NIHSS) or similar tool

• Activate Stroke Team• Order CT brain w/o contrast

• Have scan read promptly

• Obtain 12-lead EKG• AMI• A-Fib

• Critical Time Goals (NINDS Recommendations)• Initial patient evaluation within 10 min of ED arrival

• Stroke Team notification within 15 minutes of ED arrival

• Initiate a CT scan within 25 minutes of arrival

• CT w/o contrast

• Interpret the CT scan within 45 min of arrival

• Determine type & location of stroke• Determine type & location of stroke

• May identify other structural abnormalities responsible for stroke like symptoms

• Ensure door-to-drug (needle) time of 60 min from ED arrival

• And within 3 hours from onset of symptoms

• Select patients may have slightly more time; up to 4.5 hours• Exclusion Criteria

• Age >80

• Severe Stroke (NIHHS > 25)

• Taking an oral anticoagulant regardless of INR

• Hx. of both diabetes and prior ischemic stroke

• Given within 3 hours of onset of symptoms and up to 4.5 hours in a select population

• Contraindicated in the hemorrhagic stroke patient

• Other exclusion criteria• Head Trauma

• Stroke within last 3 months• Stroke within last 3 months

• Symptoms suggestive of subarachnoid hemorrhage

• Hx. of previous intracranial hemorrhage

• Elevated blood pressure ( systolic >185mm/hg or diastolic > 110mm/hg)

• Current use of anti-coagulants

• Complications• Intracranial hemorrhage

• Bleeding complications

• Blood Pressure Management

• Potential Approach to arterial HTN in patients with acute ischemic stroke who are candidates for reperfusion therapy.

• For blood pressure > 185/110 mm/hg

• Labetalol 10-20 mg IV over 1-2 min, may repeat x1

• Nicardipine IV 5mg/hr, titrate up by 2.5mg per hour every 5-15min. with a max of 15mg/hr

• Other agents may be considered when appropriate (hydralazine, enalaprilat)

• If blood pressure is not maintained at or below 185/110 mmHg, do not adminster rtPA

• The type and degree of disability following stroke depends on the area of the brain effected and extent.

• 5 types of disability

• Paralysis

• Sensory Disturbance• Sensory Disturbance

• Language Problems

• Thinking and Memory

• Emotional Disturbances

• Sinz, E. & Navarro, K. (2011). Advanced Cardiovascular Life Support Provider Manual. Dallas, TX: AHA

• Holleran, R. (2010). ASTNA Patient Transport Principles and Practice. St. Louis, MO: Mosby

• Pollak, A. (2011). Critical Care Transport. Sudbury, MA: Jones • Pollak, A. (2011). Critical Care Transport. Sudbury, MA: Jones and Bartlett Publishing