Innovations in Stroke Care: the Big Picture for EMS


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Not so long ago pre-hospital stroke care consisted of little more than O2, IV and transport to the ED. In-hospital treatment consisted primarily of therapy to help patients manage their disabilities. In 1996 thrombolytics were approved for use, ushering in the era of modern stroke care. In 2011, as hospitals are developing new methods of treatment for stroke victims, what new options are available for EMS? This program will show you new treatments like site-specific thrombolytics, clot corkscrews, neuroprotective magnesium, cranial hypothermia, stem cell implantation and the role of EMS in delivering these cutting edge care techniques. This lecture is a fast paced, fun and pertinent presentation of the emerging developments in neurovascular medicine.

Teaching Formats:
-Question and Answer

Learning Objectives: Students will learn:
-The Impact of Cerebrovascular Care on the US Healthcare System.
-Pathophysiology and differentiation of embolic, thrombotic, hemorrhagic and lacunar strokes and stroke imitators.
-Stroke specific assessment techniques including Pre-hospital and In-Hospital Stroke Scales.
-Emerging cerebrovascular care technologies including interventional neurology telemedi-cine, intra-arterial TPa, microbubble therapy, clot vacuuming, cerebral hypothermia, neu-roprotective magnesium and stem cell implantation.
-The role of the EMS provider in comprehensive stroke care.

For more information, stroke resources and other presentations like this one, go to

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  • Cushing’s Triad
  • Comprehensive Stroke Care Plan
  • Innovations in Stroke Care: the Big Picture for EMS

    1. 1. EMS Stroke CareSaving Patients’ LifesbyRommie L. Duckworth, LP
    2. 2. The Problem of StrokeStroke is the leading cause of disability. 20% Institutionalized within 3 months. Approx. 25% die within 1 yr of 1st stroke.Stroke is 3rd 4th leading cause of death.
    3. 3. Target Stroke: Acute Care & EMS The sooner that rt-PA is given to stroke patients, the greater thebenefit, especially if started within 90 minutes of symptom onset.
    4. 4. The Connecticut Plan Stroke Prevention and Care Goals• Plan Goal: To create a coordinated system of stroke care and prevention in which it is possible for every Connecticut resident to access appropriate and timely care for optimal post stroke outcomes. A coordinated care system involves EMS, hospital stroke teams, specialized stroke units (where applicable), and standardized care protocols.• Emergency Medical Services (EMS): To facilitate timely access to EMS care, enhanced pre-hospital recognition and treatment, and rapid transport to the appropriate health care facility of patients experiencing a stroke event.
    5. 5. Stroke Center Designation
    6. 6. Stroke Center DesignationTrauma JCAHO CT NY VA TXLevel I CSC Level I I CSCLevel II PSC PSC DSC Level II II PSC Level ASRH Level III SSF III ED III Level Level IV IV
    7. 7. Connecticut and Surrounding PSCs
    8. 8. Why Not Better?
    9. 9. GOOD ENOUGH
    11. 11. 4 Steps for EMS
    12. 12. The Stroke ProcessIschemiaInfarctPenumbra
    13. 13. Cerebrovascular System
    14. 14. Types of Stroke
    15. 15. Stroke AssessmentAt the door
    16. 16. Stroke AssessmentAt the Bedside S - Sudden Onset, Hemiparesis, Focal Neuro Def. A – Aw, who cares! M - Coumadin, HTN, antiepileptics P - Stroke, Seizure, aneurysms, HTN, Mimics… L - Last Seen Normal E - Prior similar episodes, MI, Trauma, Surgery… V/S - Elevated B/P, Low Pulse, Low Resp, Glucose
    17. 17. Stroke Assessment Holding HandsCincinnati Pre Hospital Stroke Scale CPSS• SMILE• ARM DRIFT• PHRASE• Any Positive = greater than 70% chance stroke.Other Pre Hospital Stroke Scales• LAPSS• MEND
    18. 18. Stroke Assessment• Common Stroke Mimics Diff. Dx. • Hypoglycemia • Migraine – ABGT / Better w/Glucose – Past Hx. • Tumor – Photosensitivity – Slow & progressive onset • Head Injury • Abscess – Recent Trauma – Slow & progressive onset • Subdural • Seizure – Previous Trauma – Staring, Aura or shaking • Bell’s Palsy • OD / ETOH – Past Hx. – Acute Hx.
    19. 19. Stroke Assessment
    20. 20. Stroke Assessment• Won’t they just catch it in the ED anyway? – If stroke is missed by EMS… • Longer transport time. • Lower priority in the ED. • No EMS pre-notification = No ED Prep. • Longer time to CT scan = Missed Tx Opportunity. • Potentially missed altogether. • One Shoe!
    21. 21. In-Hospital Care • CT Scan in 30 minutes • CT Reader with CVA ExperiencePrimary • • Stroke team to patient in 15 minutes Physician experienced with TPa and NIHSS Stroke • • Door to Needle time <60 minutes Neurosurgeon with stoke experience <2 hours • Neurologists+ on callCenters • • Diagnostics such as MRI, CT Angiography, etc. Interventional capabilities incl IATPa • Neuro Rehab capabilities
    22. 22. ICH Management• Hemorrhage – ABCs – Seizure Prevention – BP Management – BS Management – Surgery
    23. 23. Thrombolytics• TPa – Systemic – 3-4.5 hours – off-label – At 1 hr is 3x as effective as at 3 hrs• IA-TPa – Delivered Directly – 6 hours – off-label – Earlier is better
    24. 24. Surgical Options
    25. 25. Best Practices THE BRAIN ATTACK COALITION
    26. 26. Best Practices: IDENTIFY• Decrease Time To 911 • Assure Correct EMS Notification Resources – Primary Education – Closest First Response• Prioritize EMS Dispatch – Closest Transport – Standardized Protocols – ALS – Sense of Priority • E911 Coverage – Consolidation of PSAPs – NG911 Coverage • Better Standardization • Single-Call 911
    27. 27. Best Practices: TRIAGE-IFY• Triage To Best Destination – Standardized Protocols – Local Implementation • State • Can Vehicles Leave • Regional Response District • Local • Patient Preference • Provider Preference – Education • Emphasis On Dx, Not Just Speed. • ED Interface Staff Feedback
    28. 28. Best Practices: NOTIFY• Correctly Identify Stroke In The Field – Validated Stroke Scores • Aggregate Data To • Sense of Priority Facilitate ED Diagnosis• ED Pre-Notification – Validated Assessments – Standardized “Code – Receipt of Assessments Stroke” – Telemedicine – Receipt of “Code – NEMSIS Stroke” – QA/QI
    29. 29. Best Practices: CARE-IFY• Extend The Time Frame • Reduce The Distance – Standard Supportive – Increase Accreditation Care of Hospitals as CSC, PSC, – Emerging Tx ASRH • EMS • Formal Accreditation – Field Admin of T-PA • “Survey” Stroke Centers – Therapeutic Hypothermia • Telemedicine • Hospital – IAT-PA – Clot Retrieval
    30. 30. Best Practices: Interfacility Transport• Transfer to Primary Stroke Centers• Prior Transport Arrangements• Critical Care Training• VS and NS q 15 minutes post tPA Admin
    31. 31. Questions
    32. 32. 4 Steps for EMS