Stroke

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The following presentation is taken from the American Heart Association’s Advanced Cardiac Life Support : Principles and Practice, Chapter 18, Acute Stroke: Current Treatments and Paradigms
Please use this publication as a reference.

Special Thanks To:
ASA Operation Stroke
EMS Committee
Volunteers including:
Bruce Barnhart, Chair
Amy Boise, Vice Chair
Nancy Parks, RN
Charlann Staab, RN
Linda Meiner, RN
Mike Baros, RN
Terry Mason, RN
Don Baird, RN
Sandy Nygard, CEP
AEMS, Inc.
Robert Londeree, M.D.
Phoenix Fire Department
John Gallagher, M.D.
Air-Evac Services, Inc.
Professional Medical Transport (PMT)
Cigna Healthcare
Halle Heart Center
Dave Heath

Stroke An Educational Program for Pre-Hospital Personnel Developed by: EMS Committee Operation Stroke – American Stroke Association Phoenix, Arizona July 2003

Stroke Overview Introduction, Definition, Types and Risks

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

Introduction
New emerging therapies offer hope, however the following MUST occur:
Education of at-risk patients.
Early recognition of stroke signs.
Prompt transport to the hospital.
Rapid hospital triage and evaluation.

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

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

Classification of Stroke
Two major categories:
Ischemic strokes, caused when a blood vessel supplying the brain is occluded by a clot. Responsible for 75% of all strokes.
Hemorrhagic strokes, caused when a cerebral artery ruptures.
Both forms are life threatening.

Hemorrhagic Stroke
Hypertension is the most common cause of intracerebral hemorrhage.
Other causes:
Aneurysms and
Arteriovenous malformations.

Risk Factors for Stroke
Although some strokes occur without warning, most stroke victims have prior risk factors.
Major strokes can be prevented in many cases, but only if early signs and symptoms are heeded.

Well-Documented Modifiable Risk Factors
Hypertension
Smoking
Diabetes
Asymptomatic Carotid Stenosis
Atrial Fibrillation
Hyperlipidemia
Sickle Cell Disease
Other cardiac diseases
Goldstein et al. Circulation. 2001:103:163

Less Well Documented Potentially Modifiable Risk Factors
Obesity
Physical Inactivity
Poor Diet/Nutrition
Alcohol Abuse
Drug Abuse
Hypercoagulability
Hormone Replacement Therapy
Oral Contraceptive Use
Inflammatory Process
Goldstein et al. Circulation. 2001:103:163

Non-modifiable Risk Factors
Age
Sex
Race/Ethnicity
Family History

Stroke Diagnosis Signs and Symptoms of Stroke

Signs and Symptoms of Stroke
Consider in anyone
who has:
Sudden numbness or weakness of 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 walking, dizziness, loss of balance or coordination
Sudden severe headache with no known cause

THIS IS A LIFE THREATENING EMERGENCY!
Emergency healthcare providers must:
Recognize the importance of these symptoms.
Respond quickly with medical and / or surgical
interventions.

Stroke Signs and Symptoms: Hemorrhagic Stroke
May present similar to Ischemic stroke.
Distinguishing Features:
Appear more seriously ill
Deteriorate more rapidly
Severe headache
Alteration in consciousness
Nausea and/or vomiting
Neck pain
Intolerance of noise or light

Transient Ischemic Attack
“Temporary” or “mini” stroke.
The signs and symptoms of a TIA are similar to those of a completed stroke; however, they typically last only a few minutes to several hours before resolving.

Transient Ischemic Attack
TIA is the most important forecaster of impending stroke.

Stroke Patient Management The Stroke Chain of Survival and Recovery

Seven Step Stroke Chain of Survival and Recovery
Pre-arrival: Post-arrival:
Detection 4. Door
Dispatch 5. Data
Delivery 6. Decision
7. Drug

1. Detection: Early Recognition
Early treatment of stroke depends on the victim, family members, or other bystanders detecting the event.
Mild signs or symptoms may go unnoticed or be denied by the patient or bystander.

2. Dispatch: Early EMS Activation and Dispatch Instructions
Stroke victims and their families must be taught to activate the EMS system as soon as they detect stroke signs or symptoms.
EMS dispatchers must appropriately prioritize the call to ensure a rapid response within the EMS system.

3. Delivery: Pre-hospital Transport and Management
The goals :
Rapid identification of the stroke
Support of vital functions
Rapid transport of the victim to the receiving facility
Pre-arrival notification of the receiving facility

The Cincinnati Pre-hospital Stroke Scale
Facial Droop (have patient show teeth or smile):
Normal - Both sides of face move
equally well.
Abnormal - One side of face does not
move as well as the other side.

2. Arm Drift (patient closes eyes and holds both arms out):
Normal - Both arms move the same or both
arms do not move at all (other findings,
such as pronator grip, may be helpful).
Abnormal - One arm does not move or one
arm drifts down compared with the other.

3. Speech (have the patient say "you can't teach an old dog new tricks"):
Normal - Patient uses correct words with
no slurring .
Abnormal - Patient slurs words, uses
inappropriate words, or is unable to speak.

The presence of acute stroke is an indication for "load and go“.
Establish the time of onset of stroke signs and symptoms!
This timing will have important implications for potential therapy. If the time of onset of symptoms is viewed as time "zero," all assessments and therapies can be related to that time.

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

Airway :
Paralysis of the muscles of the throat, tongue, or mouth can lead to partial or complete upper-airway obstruction.
Saliva pools or vomit may be aspirated.

Breathing :
Breathing abnormalities are uncommon, except in patients with severe stroke, and rescue breathing is seldom needed.
Abnormal respirations, however, are prominent in comatose patients and portend serious brain injury.

Circulation :
Monitor both blood pressure and cardiac rhythm as part of the early assessment and treatment of a stroke patient.
Hypotension or shock is rarely due to stroke, so other causes should be sought.

Circulation :
Hypertension is often present in stroke patients, but it typically subsides and does not require treatment.
Treatment of hypertension in the field is not recommended!

Other Supportive Measures:
Intravenous access.
Management of seizures, and diagnosis and treatment of hypoglycemia, can be initiated en route to the hospital if necessary.
Isotonic fluids (Normal Saline or Lactated Ringer's solution) are used for intravenous therapy; hypotonic fluids are contraindicated .

Early Notification:
Early notification enables personnel to prepare for the imminent arrival of any seriously ill or injured patient.
In many hospitals this notification shortens the time to evaluation of, and critical interventions for, stroke patients.

4. Door: Emergency Department Triage
Even if a potential stroke victim arrives in the emergency department in a timely fashion, too often hours may elapse before appropriate neurological consultation and diagnostic studies are performed.

5. Data: Emergency Evaluation and Management
ABCs should be reassessed and rechecked frequently.

An emergency neurological stroke assessment should be done quickly focusing on four key issues:
Level of consciousness
Type of stroke (hemorrhagic versus nonhemorrhagic)
Location of stroke (carotid versus vertebrobasilar)
Severity of stroke

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

Emergency Diagnostic Studies
Currently, CT is the single most important diagnostic test.
Goal: CT scan obtained and read within 45 minutes of the stroke victim's arrival at the emergency department.

Emergency Diagnostic Studies
Anticoagulants and fibrinolytic agents should be withheld until CT has ruled out a brain hemorrhage.
Hemorrhagic Stroke

Differential Diagnosis:
Unrecognized seizures
Confusional states
Syncope
Toxic or metabolic disorders
Hypoglycemia
Brain tumors
Subdural hematoma
Adams et al. Stroke. 2003;34:1056

6. Decision: Specific Stroke Therapies
General care includes, but is not limited to:
Prevention of aspiration
Management of hypertension
Management of hyper/hypo-glycemia
Management of seizures
Management of intra-cranial pressure (ICP)
Acute Stroke , 2003 American Heart Association

7. Drugs: Fibrinolytic Therapy for Ischemic Stroke
Intravenous tPA represents the first FDA-approved therapy for acute ischemic stroke.
In the NINDS trial, patients treated with tPA within 3 hours of onset of symptoms were at least 30% more likely to have minimal or no disability at 3 months compared with those treated with placebo .

However, there were 10-fold increases in the risk of fatal intracranial hemorrhage in the treated group (3% vs 0.3%) and the frequency of all symptomatic hemorrhage (6.4% vs. 0.6%).
This increase in symptomatic hemorrhage did not lead to an overall increase in mortality in the treated group.

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

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

NINDS-Recommended Stroke Evaluation Targets for Potential Fibrinolytic Candidates* *Target times will not be achieved in all cases, but they represent a reasonable goal. † CT indicates computed tomography. ‡ By phone or in person. Time Target 3 hours Admit to monitored bed 2 hours Access to neurosurgical expertise ‡ 15 minutes Access to neurological expertise ‡ 60 minutes Door to treatment 45 minutes Door to CT read 25 minutes Door to CT † completion 10 minutes Door to doctor

Management of Hemorrhagic Stroke
Optimal management:
Prevention of continued bleeding.
Appropriate management of ICP.
Timely neurosurgical decompression when warranted.
Large intracerebral or cerebellar hematomas often require surgical intervention.

Summary: Pre-hospital Critical Actions and Management
This is what should happen:
Recognize the signs of stroke and TIA
Rapid neuro exam (Cincinnati Stroke Scale or similar).
Determine time of symptom onset (if possible).
Provide rapid transport to an ED capable of caring for acute stroke (pre-notify).
Perform finger-stick to assess serum glucose levels.

Summary: Pre-hospital UNACCEPTABLE Actions
Failure to recognize signs and symptoms of stroke/TIA
Failure to attempt to determine symptom onset.
Delay in transport.
Transporting a potential stroke patient to an ED not capable of treating acute ischemic stroke with fibrinolytic therapy.

Summary: Pre-hospital UNACCEPTABLE Actions
Attempts to treat hypertension in the field.
Failure to notify receiving ED.

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

Conclusion:
The challenge with these therapies is that they require administration within hours of stroke onset, making the following measures imperative:
Education of at-risk patients
Early recognition of stroke signs
Prompt transport to the hospital
Rapid hospital triage and evaluation

Stroke

by Carlos Rene Espino de la Cueva

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