start show notes 2 the following presentation is taken from

Start Show Notes

2

The following presentation is taken The following presentation is taken from the from the American Heart American Heart

Association’s Advanced Cardiac Life Association’s Advanced Cardiac Life Support : Principles and Practice, Support : Principles and Practice, Chapter 18,Chapter 18, Acute Stroke: Current Acute Stroke: Current

Treatments and ParadigmsTreatments and Paradigms

Please use this publication as a Please use this publication as a reference.reference.

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Special Thanks To:Special Thanks To:

• ASA Operation StrokeASA Operation StrokeEMS Committee EMS Committee

Volunteers including:Volunteers including:• Bruce Barnhart, ChairBruce Barnhart, Chair• Amy Boise, Vice ChairAmy Boise, Vice Chair• Nancy Parks, RNNancy Parks, RN• Charlann Staab, RNCharlann Staab, RN• Linda Meiner, RNLinda Meiner, RN• Mike Baros, RNMike Baros, RN• Terry Mason, RNTerry Mason, RN• Don Baird, RNDon Baird, RN

• Sandy Nygard, CEPSandy Nygard, CEP• AEMS, Inc.AEMS, Inc.

Robert Londeree, M.D.Robert Londeree, M.D.• Phoenix Fire Phoenix Fire

DepartmentDepartmentJohn Gallagher, M.D.John Gallagher, M.D.

• Air-Evac Services, Inc.Air-Evac Services, Inc.• Professional Medical Professional Medical

Transport (PMT)Transport (PMT)• Cigna HealthcareCigna Healthcare• Halle Heart CenterHalle Heart Center• Dave HeathDave Heath

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StrokeStrokeAn Educational Program An Educational Program

for for Pre-Hospital PersonnelPre-Hospital Personnel

Developed by:Developed by:EMS Committee EMS Committee

Operation Stroke – American Stroke AssociationOperation Stroke – American Stroke AssociationPhoenix, ArizonaPhoenix, Arizona

July 2003July 2003

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Stroke OverviewStroke Overview

Introduction, Definition, Types and Introduction, Definition, Types and RisksRisks

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How Serious Is Stroke in the How Serious Is Stroke in the US?US?• About 700,000 strokes occur each About 700,000 strokes occur each year. year. • Over 167,000 deaths each year.Over 167,000 deaths each year.• #3 killer.#3 killer.• A leading cause of serious long-term A leading cause of serious long-term disability in adults.disability in adults.• 4.7 million stroke survivors.4.7 million stroke survivors.

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IntroductionIntroduction

New emerging therapies offer hope, New emerging therapies offer hope, however the following MUST occur:however the following MUST occur:

• Education of at-risk patients.Education of at-risk patients.• Early recognition of stroke signs.Early recognition of stroke signs.• Prompt transport to the hospital.Prompt transport to the hospital.• Rapid hospital triage and Rapid hospital triage and

evaluation.evaluation.

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IntroductionIntroduction

With rapid, aggressive With rapid, aggressive prehospital stroke prehospital stroke care, at-risk patients care, at-risk patients can be appropriately can be appropriately managed and quickly managed and quickly assessed for assessed for fibrinolytic therapy fibrinolytic therapy that may significantly that may significantly improve their improve their outcome.outcome.

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Definition of StrokeDefinition of Stroke

A stroke is a neurological A stroke is a neurological impairment caused by a impairment caused by a disruption in blood supply to a disruption in blood supply to a region of the brain.region of the brain.

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Classification of StrokeClassification of Stroke

Two major categories:Two major categories:

• Ischemic strokes, caused when a blood Ischemic strokes, caused when a blood vessel supplying the brain is occluded by a vessel supplying the brain is occluded by a clot. Responsible for 75% of all strokes.clot. Responsible for 75% of all strokes.

• Hemorrhagic strokes, caused when a Hemorrhagic strokes, caused when a cerebral artery ruptures.cerebral artery ruptures.

Both forms are life threatening.Both forms are life threatening.

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Hemorrhagic StrokeHemorrhagic Stroke

• Hypertension is Hypertension is the most common the most common cause of cause of intracerebral intracerebral hemorrhage.hemorrhage.

• Other causes:Other causes: Aneurysms andAneurysms and Arteriovenous Arteriovenous

malformations.malformations.

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Risk Factors for StrokeRisk Factors for Stroke

Although some strokes occur Although some strokes occur without warning, most stroke without warning, most stroke victims have prior risk factors.victims have prior risk factors.

Major strokes can be prevented in Major strokes can be prevented in many cases, but only if early many cases, but only if early signs and symptoms are heeded.signs and symptoms are heeded.

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Well-DocumentedWell-Documented

Modifiable Risk FactorsModifiable Risk Factors

Well-DocumentedWell-Documented

Modifiable Risk FactorsModifiable Risk Factors

• HypertensionHypertension

• SmokingSmoking

• DiabetesDiabetes

• Asymptomatic Asymptomatic

Carotid StenosisCarotid Stenosis

• Atrial FibrillationAtrial Fibrillation

• HyperlipidemiaHyperlipidemia

• Sickle Cell Sickle Cell

DiseaseDisease

• Other cardiac Other cardiac

diseasesdiseases

Goldstein et al. Goldstein et al. Circulation.Circulation. 2001:103:163 2001:103:163

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Less Well DocumentedLess Well Documented

Potentially Modifiable Risk Potentially Modifiable Risk FactorsFactors

Less Well DocumentedLess Well Documented

Potentially Modifiable Risk Potentially Modifiable Risk FactorsFactors

• ObesityObesity

• Physical InactivityPhysical Inactivity

• Poor Diet/NutritionPoor Diet/Nutrition

• Alcohol AbuseAlcohol Abuse

• Drug AbuseDrug Abuse

• HypercoagulabilityHypercoagulability

• Hormone Hormone

Replacement TherapyReplacement Therapy

• Oral Contraceptive Oral Contraceptive

UseUse

• Inflammatory ProcessInflammatory Process

Goldstein et al. Goldstein et al. Circulation.Circulation. 2001:103:163 2001:103:163

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Non-modifiable Risk FactorsNon-modifiable Risk Factors

• AgeAge• SexSex• Race/EthnicityRace/Ethnicity• Family HistoryFamily History

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Stroke DiagnosisStroke Diagnosis

Signs and Symptoms of StrokeSigns and Symptoms of Stroke

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Signs and Symptoms of Signs and Symptoms of StrokeStroke

Consider in anyoneConsider in anyonewho has:who has:

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

• Sudden confusion, Sudden confusion, trouble speaking or trouble speaking or understandingunderstanding

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

• Sudden trouble Sudden trouble walking, dizziness, walking, dizziness, loss of balance or loss of balance or coordinationcoordination

• Sudden severe Sudden severe headache with no headache with no known causeknown cause

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THIS IS A LIFE THREATENING EMERGENCY!THIS IS A LIFE THREATENING EMERGENCY!

Emergency healthcare providers must:Emergency healthcare providers must:• Recognize the importance of these symptoms.Recognize the importance of these symptoms.• Respond quickly with medical and / or surgical Respond quickly with medical and / or surgical

interventions.interventions.

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Stroke Signs and Symptoms: Stroke Signs and Symptoms: Hemorrhagic StrokeHemorrhagic Stroke

May present similar to May present similar to Ischemic stroke.Ischemic stroke.

Distinguishing Features:Distinguishing Features:• Appear more seriously illAppear more seriously ill• Deteriorate more rapidlyDeteriorate more rapidly• Severe headacheSevere headache• Alteration in consciousnessAlteration in consciousness• Nausea and/or vomitingNausea and/or vomiting• Neck painNeck pain• Intolerance of noise or lightIntolerance of noise or light

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Transient Ischemic AttackTransient Ischemic Attack

““Temporary” or “mini” stroke.Temporary” or “mini” stroke.

• The signs and symptoms of a TIA The signs and symptoms of a TIA are similar to those of a are similar to those of a completed stroke; however, they completed stroke; however, they typically last only a few minutes typically last only a few minutes to several hours before resolving.to several hours before resolving.

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Transient Ischemic AttackTransient Ischemic Attack

• TIA is the most TIA is the most important important forecaster of forecaster of impending impending stroke.stroke.

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Stroke Patient ManagementStroke Patient Management

The Stroke Chain of Survival The Stroke Chain of Survival and Recoveryand Recovery

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Seven Step Stroke Chain of Seven Step Stroke Chain of Survival and RecoverySurvival and Recovery

Pre-arrival: Post-arrival:Pre-arrival: Post-arrival:1.1. DetectionDetection 4. 4. DoorDoor2.2. DispatchDispatch 5. 5. DataData3.3. DeliveryDelivery 6. 6. DecisionDecision

7. 7. DrugDrug

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1. Detection: 1. Detection: Early RecognitionEarly Recognition1. Detection: 1. Detection: Early RecognitionEarly Recognition

• Early treatment of stroke depends Early treatment of stroke depends on the victim, family members, or on the victim, family members, or other bystanders detecting the other bystanders detecting the event.event.

• Mild signs or symptoms may go Mild signs or symptoms may go unnoticed or be denied by the unnoticed or be denied by the patient or bystander.patient or bystander.

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2. Dispatch: 2. Dispatch: Early EMS Activation Early EMS Activation and Dispatch Instructionsand Dispatch Instructions

• Stroke victims and their families Stroke victims and their families must be taught to activate the must be taught to activate the EMS system as soon as they EMS system as soon as they detect stroke signs or symptoms.detect stroke signs or symptoms.

• EMS dispatchers must EMS dispatchers must appropriately prioritize the call to appropriately prioritize the call to ensure a rapid response within ensure a rapid response within the EMS system.the EMS system.

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3. Delivery:3. Delivery: Pre-hospital Transport Pre-hospital Transport and Managementand Management

The goals :The goals :• Rapid identification of the strokeRapid identification of the stroke• Support of vital functions Support of vital functions • Rapid transport of the victim to Rapid transport of the victim to

the receiving facilitythe receiving facility• Pre-arrival notification of the Pre-arrival notification of the

receiving facilityreceiving facility

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The Cincinnati Pre-hospital Stroke ScaleThe Cincinnati Pre-hospital Stroke Scale

1.1. Facial DroopFacial Droop (have patient show teeth or (have patient show teeth or smile):smile):

NormalNormal - Both sides of face move - Both sides of face move equally well.equally well. AbnormalAbnormal - One side of face does not - One side of face does not move as well as the other side.move as well as the other side.

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2. 2. Arm DriftArm Drift (patient closes eyes and holds both (patient closes eyes and holds both arms out):arms out):

NormalNormal - Both arms move the same - Both arms move the same oror both both arms do not move at all (other findings, arms do not move at all (other findings, such as pronator grip, may be helpful).such as pronator grip, may be helpful). AbnormalAbnormal - One arm does not move - One arm does not move or or one one

arm drifts down compared with the other.arm drifts down compared with the other.

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3. 3. SpeechSpeech (have the patient say "you can't (have the patient say "you can't teach an old dog new tricks"):teach an old dog new tricks"):

NormalNormal - Patient uses correct words with - Patient uses correct words with no slurringno slurring.. AbnormalAbnormal - Patient slurs words, uses - Patient slurs words, uses inappropriate words, inappropriate words, oror is unable to is unable to

speak.speak.

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• The presence of acute stroke is an The presence of acute stroke is an indication for "load and go“.indication for "load and go“.

• Establish the time of onset of stroke Establish the time of onset of stroke signs and symptoms!signs and symptoms!

• This timing will have important This timing will have important implications for potential therapy. If the implications for potential therapy. If the time of onset of symptoms is viewed as time of onset of symptoms is viewed as time "zero," all assessments and time "zero," all assessments and therapies can be related to that time.therapies can be related to that time.

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Once stroke is diagnosed, pre-Once stroke is diagnosed, pre-hospital treatment includes hospital treatment includes management of the ABCs of management of the ABCs of critical care (critical care (AAirway, irway, BBreathing, reathing, and and CCirculation) and close irculation) and close monitoring of vital signs.monitoring of vital signs.

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AirwayAirway: :

• Paralysis of the muscles of the Paralysis of the muscles of the throat, tongue, or mouth can lead throat, tongue, or mouth can lead to partial or complete upper-to partial or complete upper-airway obstruction. airway obstruction.

• Saliva pools or vomit may be Saliva pools or vomit may be aspirated.aspirated.

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BreathingBreathing::

• Breathing abnormalities are Breathing abnormalities are uncommon, except in patients with uncommon, except in patients with severe stroke, and rescue breathing is severe stroke, and rescue breathing is seldom needed.seldom needed.

• Abnormal respirations, however, are Abnormal respirations, however, are prominent in comatose patients and prominent in comatose patients and portend serious brain injury.portend serious brain injury.

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CirculationCirculation::

• Monitor both blood Monitor both blood pressure and cardiac pressure and cardiac rhythm as part of the rhythm as part of the early assessment and early assessment and treatment of a stroke treatment of a stroke patient.patient.

• Hypotension or shock Hypotension or shock is rarely due to stroke, is rarely due to stroke, so other causes so other causes should be sought.should be sought.

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CirculationCirculation::

• Hypertension is often present in Hypertension is often present in stroke patients, but it typically stroke patients, but it typically subsides and does not require subsides and does not require treatment.treatment.

• Treatment of hypertension in the Treatment of hypertension in the field is not recommended! field is not recommended!

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Other Supportive Measures:Other Supportive Measures:• Intravenous access.Intravenous access.• Management of seizures, and diagnosis Management of seizures, and diagnosis

and treatment of hypoglycemia, can be and treatment of hypoglycemia, can be initiated en route to the hospital if initiated en route to the hospital if necessary.necessary.

• Isotonic fluids (Normal Saline or Lactated Isotonic fluids (Normal Saline or Lactated Ringer's solution) are used for Ringer's solution) are used for intravenous therapy; hypotonic fluids are intravenous therapy; hypotonic fluids are contraindicatedcontraindicated..

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Early Notification:Early Notification:• Early notification Early notification

enables personnel to enables personnel to prepare for the prepare for the imminent arrival of imminent arrival of any seriously ill or any seriously ill or injured patient.injured patient.

• In many hospitals this In many hospitals this notification shortens notification shortens the time to evaluation the time to evaluation of, and critical of, and critical interventions for, interventions for, stroke patients.stroke patients.

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4. Door:4. Door: Emergency Department Emergency Department TriageTriage

Even if a potential stroke victim Even if a potential stroke victim

arrives in the emergency arrives in the emergency

department in a timely fashion, too department in a timely fashion, too

often hours may elapse before often hours may elapse before

appropriate neurological appropriate neurological

consultation and diagnostic studies consultation and diagnostic studies

are performed.are performed.

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5. Data:5. Data: Emergency Evaluation and Emergency Evaluation and ManagementManagement

ABCs should ABCs should be reassessed be reassessed and and rechecked rechecked frequently.frequently.

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An emergency An emergency neurological stroke neurological stroke assessment should be assessment should be done quickly focusing done quickly focusing on four key issues:on four key issues:

1.1. Level of consciousnessLevel of consciousness2.2. Type of strokeType of stroke

(hemorrhagic versus (hemorrhagic versus nonhemorrhagic)nonhemorrhagic)

3.3. Location of strokeLocation of stroke (carotid versus (carotid versus vertebrobasilar)vertebrobasilar)

4.4. Severity of strokeSeverity of stroke

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• Obtaining the exact time of stroke Obtaining the exact time of stroke or onset of symptoms from family or onset of symptoms from family or people at the scene is criticalor people at the scene is critical..

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Emergency Diagnostic Emergency Diagnostic StudiesStudies

• Currently, CT is the single Currently, CT is the single most most important diagnostic important diagnostic test.test.

• Goal: CT scan obtained and Goal: CT scan obtained and read read within 45 minutes of the within 45 minutes of the stroke stroke victim's arrival at the victim's arrival at the emergency emergency department.department.

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Emergency Diagnostic Emergency Diagnostic StudiesStudies

• Anticoagulants Anticoagulants and fibrinolytic and fibrinolytic agents should agents should be withheld be withheld until CT has until CT has ruled out a ruled out a brain brain hemorrhage.hemorrhage.

Hemorrhagic StrokeHemorrhagic Stroke

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Differential Diagnosis:Differential Diagnosis:

• Unrecognized seizuresUnrecognized seizures• Confusional statesConfusional states• SyncopeSyncope• Toxic or metabolic disordersToxic or metabolic disorders• HypoglycemiaHypoglycemia• Brain tumorsBrain tumors• Subdural hematomaSubdural hematoma

Adams et al. Adams et al. Stroke.Stroke. 2003;34:1056 2003;34:1056

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6. Decision:6. Decision: Specific Stroke Specific Stroke TherapiesTherapies

General care includes, but is not General care includes, but is not limited to:limited to:

• Prevention of aspirationPrevention of aspiration• Management of hypertensionManagement of hypertension• Management of hyper/hypo-Management of hyper/hypo-

glycemiaglycemia• Management of seizuresManagement of seizures• Management of intra-cranial Management of intra-cranial

pressure (ICP)pressure (ICP)

Acute StrokeAcute Stroke, 2003 American Heart Association, 2003 American Heart Association

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7. Drugs:7. Drugs: Fibrinolytic Therapy for Fibrinolytic Therapy for Ischemic StrokeIschemic Stroke

• Intravenous tPA represents the first FDA-Intravenous tPA represents the first FDA-approved therapy for acute ischemic approved therapy for acute ischemic stroke.stroke.

• In the NINDS trial, patients treated with In the NINDS trial, patients treated with tPA within 3 hours of onset of symptoms tPA within 3 hours of onset of symptoms were at least 30% more likely to have were at least 30% more likely to have minimal or no disability at 3 months minimal or no disability at 3 months compared with those treated with compared with those treated with placeboplacebo..

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• However, there were 10-fold increases in However, there were 10-fold increases in the risk of fatal intracranial hemorrhage in the risk of fatal intracranial hemorrhage in the treated group (3% vs 0.3%) and the the treated group (3% vs 0.3%) and the frequency of all symptomatic hemorrhage frequency of all symptomatic hemorrhage (6.4% vs. 0.6%).(6.4% vs. 0.6%).

• This increase in symptomatic hemorrhage This increase in symptomatic hemorrhage did notdid not lead to an overall increase in lead to an overall increase in mortality in the treated group.mortality in the treated group.

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Careful patient selection and strict Careful patient selection and strict adherence to the treatment adherence to the treatment protocol are essentialprotocol are essential!!

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Because of the time criteria and Because of the time criteria and risk associated with fibrinolytic risk associated with fibrinolytic therapy, it is important for therapy, it is important for hospitals to develop specific hospitals to develop specific strategies and protocols that will strategies and protocols that will achieve rapid initiation of achieve rapid initiation of therapy.therapy.

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NINDS-Recommended Stroke Evaluation NINDS-Recommended Stroke Evaluation Targets for Potential Fibrinolytic Targets for Potential Fibrinolytic Candidates*Candidates*

Door to doctorDoor to doctor 10 minutes10 minutes

Door to CTDoor to CT†† completion 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 expertiseAccess to neurological expertise‡‡ 15 minutes15 minutes

Access to neurosurgical expertiseAccess to neurosurgical expertise‡‡ 2 hours2 hours

Admit to monitored bedAdmit to monitored bed 3 hours3 hours

*Target times will not be achieved in all cases, but they represent a reasonable goal.*Target times will not be achieved in all cases, but they represent a reasonable goal.††CT indicates computed tomography.CT indicates computed tomography.‡‡By phone or in person.By phone or in person.

Time TargetTime Target

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Management of Hemorrhagic Management of Hemorrhagic StrokeStroke

Optimal management:Optimal management:• Prevention of continued bleeding.Prevention of continued bleeding.• Appropriate management of ICP.Appropriate management of ICP.• Timely neurosurgical Timely neurosurgical

decompression when warranted.decompression when warranted.

Large intracerebral or cerebellar Large intracerebral or cerebellar hematomas often require surgical hematomas often require surgical intervention.intervention.

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Summary: Summary: Pre-hospital Critical Pre-hospital Critical Actions and ManagementActions and Management

This is what should happen:This is what should happen:

Recognize the signs of stroke and TIARecognize the signs of stroke and TIA Rapid neuro exam (Cincinnati Stroke Scale Rapid neuro exam (Cincinnati Stroke Scale

or similar).or similar). Determine time of symptom onset (if Determine time of symptom onset (if

possible).possible). Provide rapid transport to an ED capable of Provide rapid transport to an ED capable of

caring for acute stroke (pre-notify).caring for acute stroke (pre-notify). Perform finger-stick to assess serum Perform finger-stick to assess serum

glucose levels.glucose levels.

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Summary: Summary: Pre-hospital Pre-hospital UNACCEPTABLE ActionsUNACCEPTABLE Actions

• Failure to recognize signs Failure to recognize signs and symptoms of stroke/TIAand symptoms of stroke/TIA

• Failure to attempt to Failure to attempt to determine symptom onset.determine symptom onset.• Delay in transport.Delay in transport.• Transporting a potential Transporting a potential

stroke patient to an ED not stroke patient to an ED not capable of treating acute capable of treating acute ischemic stroke with ischemic stroke with fibrinolytic therapy.fibrinolytic therapy.

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Summary: Summary: Pre-hospital Pre-hospital UNACCEPTABLE ActionsUNACCEPTABLE Actions

• Attempts to treat hypertension Attempts to treat hypertension in the field.in the field.

• Failure to notify receiving ED.Failure to notify receiving ED.

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Conclusion:Conclusion:

Now, fibrinolytic and other Now, fibrinolytic and other emerging therapies offer emerging therapies offer practitioners the opportunity to practitioners the opportunity to limit neurological insult and limit neurological insult and improve outcome in stroke improve outcome in stroke patients.patients.

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Conclusion:Conclusion:

The challenge with these therapies The challenge with these therapies is that they require administration is that they require administration within hours of stroke onset, within hours of stroke onset, making the following measures making the following measures imperative:imperative:

• Education of at-risk patientsEducation of at-risk patients• Early recognition of stroke signsEarly recognition of stroke signs• Prompt transport to the hospitalPrompt transport to the hospital• Rapid hospital triage and evaluationRapid hospital triage and evaluation

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