Canadian Best Practice Recommendations for Stroke Care

1,201 views
965 views

Published on

Published in: Health & Medicine
0 Comments
0 Likes
Statistics
Notes
  • Be the first to comment

  • Be the first to like this

No Downloads
Views
Total views
1,201
On SlideShare
0
From Embeds
0
Number of Embeds
2
Actions
Shares
0
Downloads
42
Comments
0
Likes
0
Embeds 0
No embeds

No notes for slide
  • Facilitator: Introduce self and participants
  • The Canadian Stroke Strategy first published best practice recommendations in 2006. As part of the implementation strategy for the stroke best practices, educational resources have been developed for priority areas. In the 2008 update, recommendations were added on the EMS management of Stroke patients prior to hospital arrival. At the 2008 consensus meeting, EMS management of stroke patients was identified as one of the top 3 priorities for implementation.
    This educational package is part of ongoing efforts to establish standardized consistent care for stroke patients across Canada and across the continuum of care.
  • Just over half of all stroke and TIA patients arrive at hospital using EMS services. This amounts to approximately 30,000 patient transports per year.
    It is imperative that EMS providers across Canada recognize that stroke is a medical emergency that requires targeted assessment and decision-making on scene to ensure patients get rapid access to levels of stroke care, regardless of geographic location.
  • As part of the development of the EMS recommendations for out-of-hospital stroke care, a core set of assessments was developed with the intent that they would form the basis for all local, regional, and provincial EMS stroke pocket reference guides. This core content is based on the 2010 EMS stroke recommendations.
    The purpose of this educational resource is to promote the uptake of the EMS recommendations by providing detailed information and explanations for each element included in the reference guide core content.
    Through delivery of this education module across all jurisdictions, and to incorporate it into the training of new EMS providers, our goal is to increase consistency, efficiency and appropriateness of EMS assessments and transport decisions for suspected stroke patients.
  • There are 4 main learning objectives of this workshop:
    Read them in order
    Ask if anyone has questions about the objectives before moving on.
  • The first section of the workshop will focus on the process for the development of the stroke best practice recommendations, specifically the recommendations related to EMS care.
  • Best practices and standards are one of five strategic platforms for the CSS. The best practices and standards platform has four main goals
    Note to facilitator … read each one from slide
  • The stroke best practice recommendations were first released in 2006. The recommendations are intended to address topics with the highest levels of evidence and topics that are considered key system drivers.
    The recommendations are reviewed and updated every 2 years following a systematic update process.
    The EMS recommendations were added to the 2008 edition, and have been further refined in the 2010 edition.
  • The development of the EMS stroke recommendations was achieved through a systematic process that included extensive consultation with all levels of service providers and administrators in the delivery of emergency health services. This slide outlines the steps involved in the development of the EMS recommendations. It is important to note that many of these recommendations do not have the highest levels of research evidence and therefore are based on observational studies, indirect evidence and consensus of expert opinion.
    The following groups were actively involved in the development process:
    Paramedics Association of Canada
    EMS Chiefs of Canada
    Members of NAEMSP
    Provincial ministry of health EMS standards and education leaders
    active EMS service providers
    Emergency Department physicians (CAEP)
    As part of the EMS best practices development process, an extensive review of existing screening tools was undertaken, as well as a national consultation on core content for any Canadian stroke screening tool for EMS. As a result, a set of core content has been developed for use by Canadian EMS providers. This core content should be incorporated into all stroke screening tools used across Canada. This core content forms the basis of much of this workshop.
  • Historically, stroke was considered untreatable and was therefore a tragedy, not a medical emergency.
    With the advent of tPA (tissue plasminogen activator) as a treatment option for patients with acute ischemic stroke and newer treatments for hemorrhagic stroke, there has been a paradigm shift and stroke is now better understood as preventable and treatable, and therefore must be treated as a MEDICAL EMERGENCY.
    EMS providers on scene will not be able to distinguish between ischemic and hemorrhagic stroke. tPA treatment is only appropriate for select patients with acute ischemic stroke and is time sensitive – it must be started within 4.5 hours of symptom onset to achieve benefit. “Sooner is better” and the greater the delay, the lower the potential benefits of this therapy.
    There is a range of stroke services provided across hospitals. Facilities with organized stroke care, that can provide emergency treatments such as tPA have demonstrated better patient outcomes.
  • Emergency medical services personnel play a critical role in the out-of-hospital phase of assessment and management of suspected acute stroke patients. The evidence to support training and appropriate processes for emergency medical services in the transport of acute stroke patients is limited at this time. However, several of the recommendations within the Canadian Best Practice Recommendations for Stroke Care (2008) are dependant on and emphasize the need for rapid transport of acute stroke patients to appropriate facility.
    The EMS recommendations address the management of potential stroke patients from the time of first contact with the local emergency medical services to transfer to hospital personnel, as well as care of suspected/confirmed stroke patients who are being transported between healthcare facilities by emergency personnel.
    This recommendation is directed to front-line EMS personnel, including first responders such as emergency medical responders and primary care paramedics who have received the appropriate training to screen for stroke and manage potential stroke patients during transfer, as well as those individuals who support Emergency Medical Services including communications officers and dispatchers.
    Interventions such as reperfusion therapies are time-dependant and therefore EMS personnel must be trained in assessment and transport protocols for stroke patients within their catchment area. Evidence shows that the ED requires up to 60 minutes of assessment and decision-making time for interventions such as tPA, therefore the pre-hospital phase should be less than 3.5 hours.
  • Delays in the pre-hospital phase of care represent a significant and preventable obstacle to quality stroke care.
    A significant proportion of the delay in getting to the hospital is the initial activation of the EMS system by witnesses to the suspected stroke event. This relates to the effectiveness of public awareness and responsiveness in activating the system for a potential stroke patient.
    Delays in out-of-hospital assessment, triage, and transport to appropriate facilities by EMS remain an area where there is also potential for quality improvement. Efforts should be targeted at ensuring potential stroke patients are immediately given high priority, which then should be followed by establishing protocols to ensure rapid transfer to a facility that provides the appropriate levels of hyperacute stroke care.
    The use of a standardized stroke diagnostic screening tool by EMS responders has been recommended to increase sensitivity of identifying potential stroke patients. There are published screening tools such as the Cincinnati and the Los Angeles screening tools which are commonly in use.
    As part of the EMS best practices development process, an extensive review of existing screening tools and literature was undertaken, as well as a national consultation on core content for any Canadian stroke screening tool for EMS. As a result, a set of core content has been developed for use by Canadian EMS providers. This core content should be incorporated into all stroke screening tools used across Canada. This core content forms the bases of much of this workshop.
  • In the decision process to transport to the nearest hospital versus bypassing a closer hospital to take a patient directly to a hospital providing more advanced stroke care, consideration should be given to the ED’s capacity to manage stroke patients, total last seen normal, EMS arrival and on-scene time as well as anticipated transport time, in addition to the patient's condition and care needs.
    Prenotification to the receiving acute care ED enables then to initiate a code stroke protocol prior to patient arrival. This process may decrease access time to CT scans and to assessment by a physician with stroke expertise, with the goal of timely decision-making regarding tPA and other management options. In addition, once the EMS team arrive at the hospital with the patient there should not be delays in the transfer of care. Pre-notification has been shown to decrease time to transfer of care to the receiving ED.
    Some patients my begin to recover from initial symptoms such as arm or leg weakness prior to EMS arrival on scene or during transport. These patients should still be considered as medical emergencies and transported to the appropriate ED.
  • The scope of out-of-hospital care is from first patient contact with emergency medical services (e.g., 9-1-1 or local emergency number) to the transfer of care to the receiving facility (e.g., emergency department).
    There are several structures that need to be organized and in place in order for EMS staff to implement best practice recommendations. These are identified as system implications and the responsibility for these may be in the direct control of the EMS providers, managers, or decision-makers and senior administrators.
    Some of the key system implications are listed here.
  • Performance measures have been developed to enable monitoring of the effectiveness of EMS management of suspected stroke patients and aspects of access to and coordination of services for suspected stroke patients.
    These listed performance measures have been identified by the Canadian Stroke Strategy Information and Evaluation Working Group in consultation with the Best Practices Working Group and EMS provider groups.
    * The performance measure for out-of-hospital time is dependent on multiple factors, such as the elapsed time from symptom onset to first contact with EMS, EMS arrival time, on-scene time, and transport time. The identified target for pre-hospital time < 3.5 hours of =>75% of cases should apply to urban settings, as it is recognized that this may be unrealistic and impractical in rural and remote settings, where additional geographic, logistical and weather factors must also be considered. The target for the rural locations would be to achieve pre-hospital times of less than 3.5 hours at least for 50% of cases.
    Please refer to the current Canadian Best Practice Recommendations for Stroke Care document and the CSS Performance Measurement Manual for more details. Found at www.canadianstrokestrategy.ca
  • The Canadian Stroke Strategy has defined three categories of acute stroke services provided by hospitals in Canada. Most major cities in Canada will have at least one comprehensive stroke centre and the location of these facilities should be known to EMS dispatchers and EMS care providers.
    The first category are comprehensive stroke centres. These hospitals are generally large tertiary centres that may have a regional role in coordination of stroke services. They provide the full range of stroke services listed in the bullet points (review these with participants).
    These hospitals may have established agreements with smaller hospitals to accept transfers of suspected stroke patients for assessment and management. Stroke patient may bypass smaller hospitals and be transported directly to these centres in areas where bypass agreements between hospitals and EMS are in place.
  • The second category of hospitals are those that have physicians with stroke expertise on site and organized protocols and staff for managing stroke patients in the ED and inpatient settings. These hospitals also have the capacity to provide neurovascular imaging, tPA – either independently or supported through a telemedicine stroke program, and access to rehabilitation and secondary prevention services.
    These hospitals may have established agreements with smaller hospitals to accept transfers of suspected stroke patients for assessment and management. Part of the transfer agreements may also include bypass agreements for EMS to directly transport appropriate suspected stroke patients to the intermediate stroke centre without first presenting at the smaller hospital.
    Intermediate stroke hospitals may not have a broader leadership role within their region for stroke services, however they will work in partnership with the closest comprehensive stroke centres and with smaller hospitals.
    Hospitals without specialized stroke services should have agreements in place with intermediate and/or comprehensive stroke centres to transfer suspected stroke patients for assessment, diagnosis and management. In these circumstances, the smaller hospitals should also have repatriation agreements in place and be willing to receive these patients back in a timely manner when they are deemed appropriate for transfer.
  • Section One introduced the best practice recommendations for stroke care, their system implications and relevant performance measures.
    This section will review in detail the key core content components of EMS assessment and transport decision-making for a suspected stroke patient.
  • These are the topics that will be addressed in the next several slides.
  • Facilitator: Add in relevant content on the structure of EMS services and stroke care organization for the province/region/local setting as appropriate to the audience attending this workshop.
  • Facilitator: re-emphasize the content on the slide
  • A goal of the best practice recommendations is to increase consistency and standardization of care for stroke patients across geographic regions and across the continuum of stroke care. This goal includes the consistent assessment and out-of-hospital management of suspected stroke patients by EMS providers.
    The core content identified for on-scene assessment focuses on the most critical elements to facilitate rapid assessment and transport decision-making for suspected stroke patients. It is recognized that EMS providers also have other standard protocols and management strategies that must be carried out in each situation they respond to.
  • The next few slides will provide an overview of the core content recommended for all on-scene stroke assessments. Detailed information about each section is then provided in the remaining slides that follow.
    1. The first core elements address basic A – B – C’s that would be applied to every patient and every situation that EMS responds to.
    For suspected stroke cases, it is important to establish the time of stroke symptom onset and to be as accurate as possible. Documentation of this time on the ambulance call record is critical, as well as in verbal reports to EMS dispatch and the receiving hospital. Some interventions such as tPA are time sensitive and the ‘start time’ for determining eligibility is this LSN time.
    Where possible, it should be determined early whether the patient has palliative care status prior to this suspected stroke event, due to a pre-existing condition, as this is important in determining eligibility for tPA, potential for bypass and other transport and management decisions.
    3. Physical assessment: the important aspects of assessment for suspected stroke patients focus on motor deficits of the arm and leg on the effected side; changes to speech, vision and facial droop. Tools such as the Cincinnati (FAST) and Los Angeles scales may be helpful.
  • 4. Once an assessment of possible deficits has been determined, additional important information for suspected stroke patients include presence of seizures at the time of onset of stroke symptoms or since that time, Glasgow Coma Scale score, and blood glucose level (tested on scene).
    5. Section 5 provides a list of some key contra-indications for tPA that should be determined by EMS on scene as this information will have an impact on transport decisions. This is not a complete list of contra-indications, but should be the first criteria that are reviewed as part of EMS assessment.
  • The total time window that has been established as safe and effective for tPA administration is 4.5 hours from stroke symptom onset. The pre-hospital phase should be less than 3.5 hours from symptom onset to arrival at an acute care hospital (ED), allowing the ED one hour for further diagnosis and treatment. The pre-hospital time is dependent on EMS being contacted by the patient or witness in a timely manner, EMS response time, on-scene time, patient condition, and transport time.
    Although the target is less than 3.5 hours, the reality is the prehospital time from symptom onset should be as short as possible to give the patient the best chance of good outcomes.
    Poor recognition and response by the public remains one of the biggest challenges to total pre-hospital time from symptom onset to ED arrival.
  • 6. Once initial assessment is completed, transport decisions should be made as rapidly as possible and that are appropriate to the patient situation.
    These decisions will be considered in more detail in the slides that follow.
  • Patients who do not appear to meet the criteria for tPA eligibility should still be regarded as medical emergencies and transported to the closest appropriate acute care facility. If the closest hospital does not have the required expertise, a decision might be made to then have the patient transported to a higher level of care either by the same EMS responders or a second crew depending on the time elapsed from initial hospital arrival.
  • Family members should accompany the patient to hospital if present on scene, to provide vital medical information, and to be available to provide consent for treatment if the patient is unable to provide it themselves.
    EMS should make every effort to have someone accompany the patient and/or attempt to obtain contact information prior to leaving the scene if possible.
    Hand-over to the ED staff should be efficient and without delay. Pre-notification will facilitate rapid transfer to care. Symptom onset time, initial condition on arrival to scene and changes in stroke symptoms and overall status since contact, as well as any hospital bypass should be noted on ambulance call record and provided to receiving staff.
  • The remaining slides will provide detailed information for each of the 8 sections of the core content for EMS assessment and management of suspected stroke patients.
    Hospital statistics for Canada indicate that 52% of all stroke patients arrive to hospital by ambulance. Ideally this rate should be higher. More recent public awareness campaigns on the signs and symptoms of stroke have placed a greater emphasis on the need to call for EMS to transport potential stroke patients.
    The range of time lapse from symptom onset to hospital arrival is disconcerting. The goal is to have the total pre-hospital time from symptom onset to ED arrival as less that 3.5 hours.
  • The first criteria to assess is the stability of the patient. If the patient is medically unstable or becomes medically unstable en route - i.e. the, airway, breathing, circulation are compromised and the patient is unable to maintain a patent airway, or maintain good oxygen saturation levels, or are experiencing arrhythmias or low blood pressure - the patient does not fulfill the criteria for tPA and should be taken to the closest appropriate hospital. The standard transport protocol for each jurisdiction should be followed.
  • This list identifies basic information that is important to obtain for suspected stroke patients.
  • The Canadian Stroke Network has developed audit tools for monitoring quality of care for stroke patients. Last seen normal time is a key element collected during focused stroke chart audits, as it is considered the start time for measuring many process and treatment indicators. It is now being collected by many hospitals as part of their routine submissions of all inpatient stroke data to their respective ministry of health and to the Canadian Institute of Health Information.
    If EMS cannot establish an exact time of symptom onset from the patient or witnesses, then an estimated time should be recorded. Standard times have been identified and should be used in EMS documentation. For example … “just after breakfast” should be recorded as 0900 am. The chart in this slide provides standardized times to be recorded across a 24 hour day.
  • Assessment scales such as the Cincinnati scale or the Los Angeles scale can be used to assess the presence of possible functional deficits. The initial deficits that should be assessed in suspected stroke patients include arm and leg weakness, changes in speech, and the presence of facial droop or weakness.
  • These are the five warning signs of stroke that are included in public awareness campaigns through the Heart and Stroke Foundation of Canada. The first three warning signs coincide with the three main symptom areas addressed in the previous slide. Headache should be considered a warning sign of it is sudden onset, and very severe. Dizziness should be considered with respect to suddenness of onset, and the presence of any of the above 4 symptoms in combination with dizziness.
    New campaigns also have added the additional element of calling 9-1-1 or local emergency response number.
  • To assess the patient for arm weakness, have the patient hold each arm up in front of them, one at a time and palm side up, for 5 seconds. Watch to see if the patient is able to move the arm into position, and if so, whether they are able to maintain it in the same position without it drifting or falling. This should be done with patient eyes closed.
    To assess leg weakness have the patient hold the leg up at 30 degrees for 5 seconds.
    Any sign of weakness or drift is a positive sign for stroke, and a potential indicator for tPA eligibility.
  • Patients who may be experiencing a stroke may have trouble talking (expressive aphasia) or understanding other people (receptive aphasia).
    To assess for problems with speech and understanding, say the name of 3 familiar objects and ask the patient to repeat them. Next say a simple sentence and ask the patient to repeat it back to you.
    Problems with these tasks may be a sign of stroke. If someone is present who knows the patient ask them if the current level of speech is normal for the patient or has it changed since the onset of symptoms. the family if the speech is normal.
  • Patients who may be experiencing a stroke may have weakness or paralysis on one side of their face.
    Ask the patient to smile and look for symmetry on both sides of their face. Then ask them to show their teeth, then ask them to grimace. Ask the patient to stick out their tongue. Again look for symmetry. Each of these actions tests facial muscles and the ability of patients to follow simple commands.
    If signs of facial weakness are present, this may indicate a potential stroke.
  • There are two main sub-types of stroke – ischemic stroke, which is caused by blockage of an artery and accounts for approximately 80% of all strokes; and hemorrhagic stroke which is caused by bleeding in the brain and accounts for 20% of all strokes.
    Ischemic stroke: The blockage is usually the result of a blood clot, which may be either thrombotic or embolic in nature. However, blockage may also occur because of progressive blood vessel occlusion due to atherosclerosis, such as in the carotid arteries, or because of local high pressure collapsing small blood vessels.
    Approximately 50% of all strokes are due to atheromatous vaso-occlusive disease of large and small vessels either occurring from thrombosis in situ or artery-artery emboli with distal occlusion. Of the 50% of these strokes, 30% are related to large-vessel disease, especially of the carotid, middle cerebral, or basilar arteries, and 20% are related to small vessel disease of the deep penetrating arteries, such as the lenticulostriate, basilar penetrating, and medullary arteries. These are known as lacunar infarcts. The remaining ischemic strokes are embolic and constitute 30% of all strokes.
    Hemorrhagic stroke is caused by arterial blood vessel rupture. A hemorrhagic stroke is responsible for approximately 20% of all strokes. Hemorrhage can damage brain tissue not only in the area of the hemorrhage but also in areas distant from the hemorrhage, as a result of increased intracranial pressure and compression of brain tissue.
    Approximately 10% of strokes are due to intracerebral hemorrhage (ICH), including hypertensive intracerebral hemorrhage and lobar intracerebral hemorrhage, and 10% are due to subarachnoid hemorrhage (SAH) or bleeding from an arteriovenous malformation.
     
  • Clogging of an artery can be due to atherosclerosis or hardening of the arteries or a blood clot may be formed in the heart and float into the brain and clog the artery. These types of strokes are called ischemic or embolic.
    Clogging of an artery prevents blood from circulating to a specific part of the brain. If the lack of circulation persists, that part of the brain may die and cause a stroke.
    tPA is a potent blood thinning medication that dissolves the blood clots that impede circulation to the brain to help restore blood flow to the affected area. Benefits from receiving tPA have been demonstrated up to 4.5 hours of stroke symptom onset. Unlike acute thrombolysis for a heart attack (acute myocardial infarction), recumbant tissue plasminogen activase is the only thrombolytic approved for use in stroke, and must be administered in a hospital where continuous monitoring and critical care facilities are available.
  • Transient ischemic attacks – or ‘TIA’ - are a form of ischemic stroke that are characterized by the shorter duration of symptoms ( less than 24 hours) followed by full recovery of any deficits initially present. Some physicians will refer to TIA as a ‘mini stroke’ and consider them on the mild end of the severity scale for ischemic stroke rather than as a separate condition.
    The concern with this type of stroke is that a significant proportion of people with TIA’s, who do not begin risk factor management, will go on to have a larger, more debilitating stroke within a year. There is a 10% recurrent stroke rate for TIA patients within the first 3 months of a TIA and these are front loaded with the majority occurring within the first 48 hours of the index minor stroke or TIA.
  • The next few slides provide a brief overview of the anatomy of the brain.
    The largest portion of the brain is the cerebral cortex. The cerebral cortex is divided into 4 lobes:
    Frontal
    Parietal
    Temporal
    Occipital
    Each lobe of the brain, corresponds with unique functions
  • Between the frontal lobe and the parietal lobe, is the motor and sensory strip:
    The motor strip is responsible for the ability of our bodies to move
    The sensory strip is responsible for our ability to experience sensations such as touch and pain.
  • The blood supply to the brain is divided into anterior and posterior circulation.
    The internal carotid arteries and its branches supply the anterior portion. The vertebral and basilar arteries supply the posterior portion.
    The common larger vessels are:
    Anterior cerebral artery
    Middle cerebral artery
    Posterior cerebral artery
    Vertebral artery
    Basilar artery
  • This chart provides a general description of the common deficits that may be seen in patients with stroke. A stroke that occurs in the left hemisphere will manifest symptoms on the right side of the body, and a stroke that occurs in the right hemisphere will manifest symptoms on the left side of the body.
    It is not expected that EMS providers will differentiate an ischemic versus a hemorrhagic stroke in the field, or positively identify a left hemisphere versus a right hemisphere stroke.
    When communicating with the receiving facility is is important and helpful to provide information on which side of the body is exhibiting deficits if any are present.
  • Some patients may present with focal neurological deficits, and, at least initially, may resemble stroke, and who eventually are found to have another cause for their symptoms that is not stroke related.
    Family physicians and EMS providers would not be able to determine stroke mimics from true stroke patients. Only proper history and examination, supplemented by imaging, and conducted by a physicians with expertise I stoke can exclude stroke mimics, allowing the correct diagnosis to be made.
    Hand et al, 2006, state that a mimic was more likely if there was a known history of cognitive impairment, the patient lost consciousness or had a seizure at onset, the patient could still walk, there were no lateralizing signs and the examination revealed confusion, signs in other nonvascular systems and no neurological signs.
    The four most common conditions to mimic stroke symptoms are: postictal deficit, systemic infection, tumour, and toxic-metabolic disturbance.
    Postictal deficit: following a motor seizure, affected limbs may remain paretic for several hours. This sudden hemiparesis can be confused with stroke. It is important to question a family member about a history of seizure disorder and to review the patient’s medications.
    Systemic infection: May be differentiated from stroke by a careful history to identify a slower onset of symptoms and fever.
    Tumour: Sudden bleeding into a tumour or elevated intracranial pressure can produce a sudden onset of neurological deficits. Generally, the onset of neurological deficit with space-occupying lesions is gradual.
    Toxic or metabolic disturbance: Hypoglycemia is the most common toxic or metabolic stroke mimic. Capillary glucose should be performed as soon as possible. Drug overdose, especially cocaine, hyperglycemia and hepatic encephalopathy may also be confused with stroke.
    Bell’s palsy: Hemifacial paralysis caused by Bell’s palsy affects all facial muscles, whereas hemifacial paralysis associated with stroke affects the lower part of the face only.
    Peripheral nerve palsies: Radial nerve palsy can mimic stroke. Selective involvement of wrist and finger extensors with preserved flexors, plus reduced sensation in the radial territory, allows this condition to be differentiated from stroke.
    Old stroke: Careful history and physical examination will usually differentiate new stroke symptoms from those associated with an old stroke.
    Confusion: Stroke usually presents with features in addition to confusion, such as dysphasia.
    Head trauma: Subdural or epidural hematoma, as a result of head trauma, may resemble acute stroke.
  • The patient or witness should be asked about the presence of seizures at the time of stroke onset and the patient should be observed for seizure activity by EMS providers. The presence of seizures are a contraindication for tPA eligibility.
    In addition to confirming stroke symptoms and time of onset, the use of the Glasgow Coma Scale may provide further information, and scores less than 9 are a contraindication for tPA.
    Blood glucose should also be assessed on scene or during transport as hypoglycemia may mimic stroke symptoms.
  • Infants and children may also experience a stroke, although the rates are much lower than for adults.
    Children have a higher incidence of ischemic stroke than hemorrhagic stroke and may be caused by a blood clot in an artery or vein. Children who demonstrate signs and symptoms of stroke should be immediately transported to the nearest acute care facility that provides hyperacute stroke management. Ideally these patients should be transported to a specialized paediatric hospital in regions where such facilities are available.
  • The symptoms that paediatric patients with potential stroke may present with could be similar to adults with unilateral weakness, speech and visual disturbances.
    They may also present with symptoms that appear more vague such as distress, drowsiness, seizures
  • The shift in management of stroke from a more passive approach to recognizing it as a medical emergency was in part due to the release of the first clinical trials demonstrating the benefits of tPA, tissue plasminogen activator, for ischemic stroke. tPA was approved for use in Canada in 1998. In 2008 the ECASS III clinical trial results were released that demonstrated that the benefits of tPA can occur up to 4.5 hours after stroke symptom onset which is an extension of the previously established 3 hour safety and effectiveness time window.
    There is no other treatment that is proven to be as effective at the time of stroke onset for treating ischemic stroke. Although the time window has been extended, it is still imperative that stroke patients have access to definitive treatments as soon as possible – Time is Brain!! (every minute that passes after the stroke = 1 million lost brain cells).
    tPA is a potent clot-busting medication that works to dissolve clots in the brain. It can be administered through an intravenous route or directly into the brain via an intra-arterial procedure. The use of tPA requires expert assessment and monitoring and at this time is only administered once the patient has arrived at the hospital.
    Other clot-busting medications that are used for myocardial infarction patients are not approved for use in stroke.
    In some provinces, thrombolytic therapy with tPA is generally provided at designated regional or local stroke centres, and not all small community hospitals and rural hospitals have this capacity.
    Generally, 30% of patients who receive tPA have substantial improvement in their stroke symptoms; tPA does not significantly affect the outcome of patients with stroke 60% of the time and may result in minor improvements; and up to 10% of patients may experience secondary bleeding associated with tPA administration. Fortunately, most of the bleeding associated with the use of tPA is not life threatening.
  • Ischemic strokes are caused by blockage of blood to the brain and can be treated with tPA. tPA dissolves the blood clot and restores the blood flow.
    On the left and right is a cerebral angiogram in the same patient. On the left the arrow points to the blocked artery. On the right, after receiving tPA, the blood flow returns and the brain circulation is restored to the affected area. The time from symptom onset to administration of tPA is a major determinant of the amount of recovery of brain function that may occur. The benefits of tPA are directly correlated to the time from onset to administration therefore the extended time window should not be considered as permission to take longer in accessing medical help by the public, and in transport decisions by EMS.
  • There are several contraindications to the administration of tPA that have been established through the clinical trials. Of these, there are five primary contraindications that should be assessed on scene by EMS when possible. The contraindications listed on this slide all should play a role in determining potential eligibility for tPA and transport decision making.
    The above listed assessments should be included in the stroke reference guide for EMS providers as part of the screening process. They may also be indicative of another serious issues requiring prompt medical attention. The patient exhibiting these symptoms should still be transported without delay to the closest appropriate acute care facility.
  • Patients who demonstrate symptoms that may be caused by stroke and do not have contraindications for tPA administration as listed in this presentation, should be transported without delay to the closest appropriate acute care facility that provides emergency stroke care.
    EMS providers should have protocols in place to manage suspected stroke patients. This stroke protocol should be initiated as soon as initial on-scene assessment confirms a potential stroke patient.
    The initiation of the stroke protocol should be documented on the ambulance call record.
  • The total time window that has been established as safe and effective for tPA administration is 4.5 hours from stroke symptom onset. The pre-hospital phase should be less than 3.5 hours from symptom onset to arrival at an acute care hospital (ED), allowing the ED one hour for further diagnosis and treatment. The pre-hospital time is dependent on EMS being contacted by the patient or witness in a timely manner, EMS response time, on-scene time, patient condition, and transport time.
    Although the target is less than 3.5 hours, the reality is the prehospital time from symptom onset should be as short as possible to give the patient the best chance of good outcomes.
    Poor recognition and response by the public remains one of the biggest challenges to total pre-hospital time from symptom onset to ED arrival.
    The targets for achieving these times is for greater than 75% of cases in urban settings and greater than 50% of cases in rural settings where additional challenges will have direct impact on total pre-hospital times and achievement of these targets.
  • 6. Once initial assessment is completed, transport decisions should be made as rapidly as possible and that are appropriate to the patient situation.
    If the patient is deemed potentially eligible for tPA as determined in section 5, then additional considerations should include: the local ED response time and stroke service availability, time from symptom onset, transport time, and other acute care needs of the patient
    Transport to closest designated stroke centre versus the closest acute care facility should be determined as above. Transporting potentially eligible tPA patients to a facility without acute stroke management capability (i.e., no CT scanner or does not provide tPA) will increase time to treatment, potentially delay to the point where the patient is no longer within the acceptable treatment time window, and decrease the potential for better outcomes. Time IS Brain
    Pre-notification of the receiving hospital should be done en-route so they can in turn initiate their stroke protocol, alert medical imaging, and have the stroke team on stand-by to receive the patient.
  • Patients who do not appear to meet the criteria for tPA eligibility should still be regarded as medical emergencies and transported to the closest appropriate acute care facility. If the closest hospital does not have the required expertise, a decision might be made to then have the patient transported to a higher level of care either by the same EMS responders or a second crew depending on the time elapsed from initial hospital arrival.
    For patients who may be experiencing a TIA or minor stroke, symptoms may begin to resolve either prior to EMS arrival or en route to hospital. These patients still require emergent medical assessment as the risk of a stroke following a TIA is up to 10% in the first three months with the greatest risk in the first 48 hours following the index event.
    Family members should accompany the patient to hospital if present on scene, to provide vital medical information, and to be available to provide consent for treatment if the patient is unable to provide it themselves.
    EMS should make every effort to have someone accompany the patient and/or attempt to obtain contact information prior to leaving the scene if possible.
    Hand-over to the ED staff should be efficient and without delay. Pre-notification will facilitate rapid transfer to care. Symptom onset time, initial condition on arrival to scene and changes in stroke symptoms and overall status since contact, as well as any hospital bypass should be noted on ambulance call record and provided to receiving staff.
  • EMS providers should be aware of the processes in place within their practice jurisdiction for the management of suspected stroke patients.
    Facilitator: as best as possible, have this information available for presentation at the workshop and customize this slide. Have copies of the protocols available if possible.
  • This slide summarizes a quick check list of assessment criteria that is important for suspected stroke patients.
    If the patient meets the criteria, they may be candidates for acute thrombolysis, and should be transported without delay to the closest appropriate acute care hospital that provides emergency stroke services.
  • If all the key criteria on the stroke reference guide are met, then the patient may be eligible for acute thrombolysis.
    Facilitator: read bullet points on slide
  • It is important that information gathered during assessment and transport related to suspected stroke and tPA contraindications be shared with ED staff. Some of this should be initiated during pre-notification so that the ED staff can notify neurovascular imaging and the stroke team in advance of arrival.
    The information outlined throughout this presentation as part of the EMS core content for assessment and management of suspected stroke patients should be included in verbal reports to the ED and documented on the ACR.
    Some key information may include last seen normal time, initial and changing stroke symptoms, and next of kin or family contact should
  • The CSS recognizes and acknowledges that each EMS service provider will have protocols and processes in place for on-scene management of all patients, and perhaps stroke patients specifically.
    The content provided in this resource should be considered as the minimal information to include in and pocket guides or reference material for EMS management of suspected stroke. We strongly encourage that all the information outlined in this resource be included in reference materials.
    EMS providers should consider local variations and other additional information that would be appropriate to include for their jurisdiction to ensure suspected stroke patients are rapidly assessed and transported to the appropriate level of care with minimal delays.
    Most of the existing stroke reference tools that were in existence in Canada during the development of this resource were obtained and reviewed. The list provided under the second bullet point on the slide includes information that appeared on more than one existing stroke reference tool, but were not considered by the EMS expert working group to be essential for initial assessment and management of suspected stroke patients.
  • Four case studies have been developed based on real patient situations. The case studies include the scenario, the stroke assessment information that follows the core EMS stroke content presented in this resource, and an opportunity to discuss your actions and decision-making considerations.
    Please read through each case scenario and assessment information, then as a large group or working in small groups, discuss your interpretation of the information, the steps you would take on scene for further assessment and patient management, and the considerations for transport.
    Would you bypass a closer small hospital and go to a hospital that has the capacity for acute stroke management in the ED?
    Who is able to make bypass decisions in your region? Do you make the decision as an EMS provider on scene, do you contact dispatch or the receiving hospital? Every region is different so it is important to know the process within the region you work.
  • Case Study #1:
    Read through case study
  • Participants to review and discuss assessment findings.
  • EMS Actions: assessment of scene for any signs of trauma or other concerns; administer oxygen to patient; prepare patient for transport; locate contact information and additional medical history from friend of closest family member or relative
    Transport Considerations:
    last seen normal time unknown therefore patient not eligible for tPA
    History from friend suggested possible TIA one week prior to this event
    patient should be transported to closest appropriate hospital as per local/regional protocol for suspected acute stroke patients
    Patient monitoring and management per EMS protocols during transport
    Prenotification to receiving hospital is advised
  • Case Study #2
    Read case study
  • Participants to review and discuss assessment findings.
  • EMS Actions: administer oxygen to patient; prepare patient for rapid transport; obtain basic medical history from daughter – significant medical conditions, current medications; have daughter follow ambulance to hospital; notify dispatch for approval to transport to stroke centre and bypass smaller closer hospital
    Transport Considerations:
    ABC’s are stable;
    last seen normal time 53 minutes plus on scene time (15 minutes)
    patient may potentially be eligible for tPA – no significant contraindications noted
    patient should be transported to closest hospital that provides acute stroke care as per local/regional protocol for hyperacute stroke patients – this may involve bypass of smaller local hospitals;
    need to consider transport time to ensure remains under 3.5 hours from LSN to hospital arrival
    receiving hospital should receive prenotification of a suspected stroke patient with LSN time of less than 3.5 hours
  • Case Study #3
    Read the Case Study
  • Participants to review and discuss assessment findings.
  • EMS Actions: apply oxygen, ECG leads; provide reassurance to husband; prepare patient for transport; brief medical history from husband; have husband follow ambulance to hospital; notify dispatch for approval to transport to closest stroke centre
    Transport considerations:
    Potentially eligible for tPA
    LSN time < 3.5 hours
    Should be transported to closest designated stroke centre with capacity for hyperacute stroke management
    Small amount of spontaneous recovery noted during transport, EMS continue on to stroke centre as planned
  • Case Study #4
    Review details of case study
  • Participants to review and discuss assessment findings.
  • EMS Actions: apply oxygen, ECG leads; contact local hospital ED from scene
    Transport considerations:
    Potentially eligible for tPA
    LSN time < 3.5 hours
    Shpuld be transported to closest designated stroke centre with capacity for hyperacute stroke management
    En route patient level of consciousness decreases and GCS is 10 by time arrive at hospital
  • Read slide
  • Canadian Best Practice Recommendations for Stroke Care

    1. 1. 1 Canadian Best PracticeCanadian Best Practice Recommendations for Stroke CareRecommendations for Stroke Care
    2. 2. 2 Canadian Best Practice RecommendationsCanadian Best Practice Recommendations for Stroke Carefor Stroke Care Educational WorkshopEducational Workshop For Emergency Medical ServicesFor Emergency Medical Services Care of SuspectedCare of Suspected Acute Stroke PatientsAcute Stroke Patients
    3. 3. 301/30/15 3 PRIORITY:PRIORITY: EMS BestEMS Best PracticesPractices ImplementationImplementation and Uptakeand Uptake Time is BrainTime is Brain
    4. 4. 4 PurposePurpose  To facilitate the uptake and implementation of the Canadian Stroke Strategy best practice recommendations for the out-of-hospital care of stroke patients by emergency medical services (EMS).  The goal of this resource is to create greater consistency and standardization of education and on scene assessments and care of suspected stroke patients.
    5. 5. 5 Learning objectives of workshopLearning objectives of workshop  To understand the components of the Canadian Stroke Strategy best practice recommendation for emergency medical system care of suspected acute stroke patients;  To recognize signs and symptoms of suspected acute stroke patients on scene and to differentiate mimics of acute stroke (hypoglycemia, postictal phase, etc)  To understand the components of out-of-hospital management of acute stroke patients  To identify the key information and assessments to be done on scene for suspected acute stroke patients (align with stroke pocket resource);  To integrate stroke history and assessment information into the decision- making process for transportation of suspected stroke patients to acute care facilities with the appropriate level of stroke care.  To understand the key information required as part of EMS documentation and communication with emergency department staff.
    6. 6. 6 Development andDevelopment and update process forupdate process for the Canadian Bestthe Canadian Best PracticePractice RecommendationsRecommendations for Stroke Carefor Stroke Care Section OneSection One
    7. 7. 8 Canadian Best PracticeCanadian Best Practice Recommendations for Stroke CareRecommendations for Stroke Care  Synthesis of best practice recommendations for stroke care across the continuum  Address critical topic areas  Commitment to keep current with two-year update cycle  First edition released in 2006  EMS recommendations added in 2008 edition  2010 edition to be released in the Fall of 2010  Further refined development process  Increased focus on transitions of care, and rural, remote and northern issues in stroke management
    8. 8. 9 Background:Background: EMS Stroke RecommendationsEMS Stroke Recommendations  First included in 2008 update of best practices  Developed using systematic process:  Review of current research and gray literature  Environmental scan of existing EMS practices and protocols for out-of-hospital care of suspected stroke patients  Review of international stroke recommendations for EMS  Extensive consultation with EMS experts across Canada  Development of expert writing group for recommendations  Final review by external consensus panel process
    9. 9. 10 Acute Stroke Care: A Shift in theAcute Stroke Care: A Shift in the Treatment ParadigmTreatment Paradigm  Stroke is treatable  Short window of opportunity  Treatment requires stroke expertise and carries a risk  Organized stroke care improves outcomes Time IsTime Is BrainBrain 4.54.54.54.5 More than half of suspected stroke patients are transported by EMS
    10. 10. 11 BPR 3.1: Emergency Medical ServicesBPR 3.1: Emergency Medical Services Management of Acute Stroke PatientsManagement of Acute Stroke Patients  Patients who show signs and symptoms of hyper-acute stroke must be treated as a time-sensitive emergency and should be transported without delay to the closest institution that provides emergency stroke care.  The recommended total time from symptom onset to reperfusion for eligible patients, is usually defined as 4.5 hours. This is broken into 2 phases: pre-hospital and ED  The pre-hospital phase, which starts with symptom onset, and includes on-scene management and anticipated transport time, should be less than 3.5 hours (Target performance: at least 75% of the time)  The current evidence shows that emergency department phase should be less than 60 minutes (Target performance: at least 75% of the time) * local variations need to be taken into consideration for out- of-hospital time
    11. 11. 12 Best Practice Recommendations cont’dBest Practice Recommendations cont’d i. Immediate contact with emergency medical services (e.g., 9-1-1) by patients or other members of the public is strongly recommended because it reduces time to treatment for acute stroke [Evidence Level C] ii. The Emergency medical services system must be set up to categorize patients exhibiting signs and symptoms of a hyperacute stroke as a high priority Evidence Level C] iii. A standardized acute stroke out-of-hospital diagnostic screening tool should be used by paramedics (See Table One for CSS core content for EMS stroke reference cards) [Evidence Level B] iv. Out-of-hospital patient management should be optimized to meet the needs of suspected acute stroke patients [Evidence Level A] v. Direct transport protocols must be in place to facilitate the transfer of eligible patients to the closest and most appropriate facility providing acute stroke care [Evidence Level C]
    12. 12. 13 Best Practice Recommendations cont’dBest Practice Recommendations cont’d vi. Direct transport protocol criteria must be based on (1) the local ED performance which is recommended as being less than 60 minutes; and (2) the out-of-hospital phase, including symptom duration and anticipated transport duration, being less than 3.5 hours and/or (3) other acute care needs of the patient [Evidence Level B] vii. History of event, including time of onset, signs and symptoms, and previous medical and drug history, must be obtained from the patient if able and/or a reliable informant when available [Evidence Level C] viii. Paramedics must notify the receiving facility of a suspected acute stroke patient in order for the facility to prepare for patient arrival [Evidence Level C] ix. Transfer of care from paramedics to receiving facility personnel must occur without delay [Evidence Level C]. x. Patients who are not considered potentially eligible for time-sensitive reperfusion should be transported to the closest appropriate emergency department
    13. 13. 14 CSS System ImplicationsCSS System Implications Structures required to enable providers to meet best practice recommendations  These recommendations are referring exclusively to patients with hyper- acute stroke who may be eligible for time-sensitive reperfusion interventions within the therapeutic window. Stroke patients not eligible for reperfusion (do not meet criteria for rapid transport based on standardized screening) should still be transported to and among appropriate facilities  Scope of out-of-hospital care is from first patient contact with emergency medical services to the transfer of care to the receiving facility  Dispatcher training programs that address stroke  Paramedic education that includes stroke assessment and management  Direct transport agreements  Coordinated, seamless transport and disposition  Communication systems to support access
    14. 14. 15 CSS Performance MeasuresCSS Performance Measures Key indicators for monitoring levels of performance and quality of care in meeting best practice recommendations..  Percentage of cases where total out-of-hospital time is less than 3.5 hours – from symptom onset to arrival at an ED (performance target is => 75%) *  Percentage of (suspected) stroke patients arriving in the emergency department who were transported by emergency medical services.  Time from initial call received by emergency dispatch centre to emergency medical services arrival on patient scene.  Time from emergency medical services arrival on patient scene to arrival at appropriate emergency department.  Percentage of potential stroke patients transported by emergency medical services who received a final diagnosis of stroke or transient ischemic attack during hospital stay (in the emergency department or as an inpatient).
    15. 15. 16 Categories of Stroke ServicesCategories of Stroke Services within Canadian Hospitals (CSS)within Canadian Hospitals (CSS)  Comprehensive stroke centres  Specialized resources and personnel available at all times (24 hours a day, 365 days a year) to provide assessment and management of stroke patients  Established written stroke protocols for emergency services, in- hospital care and rehabilitation  Ability to offer thrombolytic therapy to suitable ischemic stroke patients; timely neurovascular imaging and expert interpretation; and coordinated processes for patient transition to ongoing rehabilitation, secondary prevention and community reintegration services  Access to rapid neurosurgical consultation and neurosurgical facilities onsite, as well as interventional radiology services  Have a leadership role in establishing partnerships and providing education to other local hospitals for supporting stroke care services.
    16. 16. 17 Categories of Stroke ServicesCategories of Stroke Services within Hospitals (CSS)within Hospitals (CSS)  Hospitals with intermediate stroke services  Centres with clinicians who have stroke expertise;  Written stroke protocols for emergency services, acute care and/or rehabilitation;  Ability to offer thrombolytic therapy to suitable ischemic stroke patients or protocols to transfer appropriate patients to a comprehensive stroke centre;  Timely neurovascular imaging and timely access to expert interpretation (e.g., telemedicine);  Coordinated processes for patient transition to ongoing rehabilitation and secondary prevention services.  Hospitals without specialized stroke resources  Centres that do not have in-hospital resources such as clinicians with stroke expertise or neuroimaging  These centres should have written agreements in place to facilitate timely transfer of stroke patients to higher levels of care as appropriate.
    17. 17. 18 Section TwoSection Two Detailed Review of Stroke Patient Management
    18. 18. 19 EMS Stroke Patient ManagementEMS Stroke Patient Management  Signs and symptoms of suspected acute stroke patients on scene  Acute stroke mimics (hypoglycemia, postictal phase, etc)  Components of out-of-hospital management of acute stroke patients  Key information and assessments to be done on scene for suspected acute stroke patients (align with stroke pocket reference);  Stroke history and assessment information into the decision- making process for transportation of suspected stroke patients to acute care facilities with the appropriate level of stroke care.  Information required as part of EMS documentation and communication with emergency department staff.
    19. 19. 20 Province’s Provincial Stroke StrategyProvince’s Provincial Stroke Strategy (to be customized for each presentation)  Overview of provincial stroke strategy  Organization and coordination of EMS services within province  Relationship between EMS providers and stroke centres, regions and provincial stroke strategy  Existing protocols and Memorandums of Understanding (MOU’s) for stroke bypass within province.
    20. 20. 21 01/30/15 21 Out-of-Hospital Stroke ManagementOut-of-Hospital Stroke Management Why Is This Important?Why Is This Important?  Acute stroke is a medical emergency and optimizing out-of-hospital care improves patient outcomes  EMS plays a critical role in assessment and management  Acute interventions such as reperfusion are time sensitive Redirecting ambulances to stroke centres facilitates earlier assessment, diagnosis and treatment which may result in better outcomes.
    21. 21. 22 Implementation of EMSImplementation of EMS Stroke Best PracticesStroke Best Practices  Standardize pocket reference content for EMS providers  Builds on existing training  Focuses on key elements most critical in rapid assessment for suspected acute stroke  Based on extensive consultation from all key stakeholders involved in out-of-hospital care of acute stroke patients  Also recognizes that EMS have standard protocols for all calls they respond to
    22. 22. 23 EMS – Stroke Pocket Guide_1EMS – Stroke Pocket Guide_1 1. Patient condition on EMS arrival to scene o Airway, Breathing, Circulatory status 2. Initial history and medical information o Symptom onset/Last seen normal (LSN) date and time (i.e., last stroke symptom-free time) o Palliative status 3. Physical assessment specific to stroke o Current stroke signs and symptoms  ARM/LEG unilateral motor weakness or drift  Speech slurring, loss, inappropriate words, mute, or other changes  Facial droop or weakness Strongly Recommended Content for Inclusion on all EMS Stroke Reference Guides
    23. 23. 24 EMS – Stroke Pocket Guide_2EMS – Stroke Pocket Guide_2 4. Additional Assessments o Presence of seizures o Glasgow Coma Scale score o Blood glucose level 5. Assessment for Contraindications to tPA (may impact transport location decisions) o CTAS 1 and/or uncorrected ABC o Blood glucose <= 3.0 mmol/l o Seizure at onset of symptoms or witnessed by Emergency Medical Service providers o Glasgow Coma Scale <9 o Terminally ill or palliative care patient Strongly Recommended Content for Inclusion on all EMS Stroke Reference Guides
    24. 24. 25 EMS – Stroke Pocket Guide_3EMS – Stroke Pocket Guide_3 6. Transport decisions and considerations Time is Brain – need for efficiency and minimizing time from on-scene arrival to transport to a stroke centre  The recommended total time from symptom onset to reperfusion for eligible patients, is usually defined as 4.5 hours. This is broken into 2 phases: pre-hospital and emergency department:  The pre-hospital phase, which starts with symptom onset, and includes on-scene management and anticipated transport time, should be less than 3.5 hours  The current evidence shows that the emergency department phase should be less than 60 minutes Strongly Recommended Content for Inclusion on all EMS Stroke Reference Guides
    25. 25. 26 EMS – Stroke Pocket Guide_4EMS – Stroke Pocket Guide_4 6. Transport decisions and considerations (cont’d)  Direct transport protocol criteria must be based on (1) the local ED performance which is recommended as being less than 60 minutes; and (2) the out-of-hospital phase, including symptom duration and anticipated transport duration, being less than 3.5 hours and/or (3) other acute care needs of the patient  Transport to closest designated stroke centre (comprehensive or intermediate)  Implement normal EMS en-route transport management (for stroke, 18 g needle is preferred for IV access)  Prenotification to the destination emergency department of a suspected acute stroke in transport Strongly Recommended Content for Inclusion on all EMS Stroke Reference Guides
    26. 26. 27 EMS – Stroke Pocket Guide_5EMS – Stroke Pocket Guide_5 7. Additional Transport Information o These recommendations are referring exclusively to patients with hyper- acute stroke who may be eligible for time-sensitive reperfusion interventions within the therapeutic window. Stroke patients not eligible for reperfusion (do not meet criteria for rapid transport based on standardized screening) should still be transported to and among appropriate facilities o Patients with symptoms that resolve prior to paramedic arrival on scene may not require medical redirect to an acute stroke centre, but should be assessed emergently. o Those patients whose symptoms resolve after paramedic assessment or during transport should continue on medical redirect to a stroke centre. Strongly Recommended Content for Inclusion on all EMS Stroke Reference Guides
    27. 27. 28 EMS – Stroke Pocket Guide_6EMS – Stroke Pocket Guide_6 o It is important to request that a family member accompany the ambulance to the hospital so that they could provide vital information. In the absence of a person being present, verify the contact number of an informant and/or decision-maker. Notes: * local variations need to be taken into consideration for pre-hospital time ^ EMS personnel should identify comprehensive and intermediate stroke centres within the relevant EMS catchment areas 8. Handover to destination emergency department personnel: o Communication to receiving staff (triage nurse or attending physician) o EMS documentation completed and a copy left with the receiving ED Strongly Recommended Content for Inclusion on all EMS Stroke Reference Guides
    28. 28. 29 1. EMS Arrival on scene1. EMS Arrival on scene and Initial Assessmentand Initial Assessment 52% of suspected stroke patients arrive to hospital by ambulance (CIHI 2008) Currently, time from last seen normal to emergency department arrival ranges from 1.7 hours to 8.0 hours
    29. 29. 30 “ABCs” Stable? If not, transport without delay to closest, most appropriate hospital 1.1. Patient condition on EMS arrival to scenePatient condition on EMS arrival to scene oAirway, Breathing, Circulatory status
    30. 30. 31 2. Initial history and medical information2. Initial history and medical information  Last seen normal (LSN) date and time (i.e., last stroke symptom-free time, symptom onset time)  Witnessed  Unwitnessed ♦ Stroke on wakening? When did patient go to sleep relative to time of call to EMS?  Palliative status  DOCUMENTATION of these elements is critical!!!critical!!!
    31. 31. 32 Stroke/TIA onset (last seen normal): Date: (dd/mmm/yyyy) Time: (24hr:min) Patient age at stroke onset (last seen normal) (automatic calculation): _______ If patient age < 16 years of age, trigger hidden SAS variable for exclusion: Is the time of stroke onset (last seen normal) :  Exact (e.g. 08:45)  Estimated (e.g. morning)  Not documented in chart (e.g. date but no time) Estimated Times to Use if Exact Time is Not Documented: Symptoms discovered on awakening or unwitnessed stroke onset:  No  Yes  UTD - The middle of the night = 03:00 - Breakfast=08:00 - Early morning = 08:00 - Morning = 09:00 - Late morning = 10:00 - Lunch=12:00 - Midday = 12 Noon = 12:00 - Early afternoon = 14:00 - Afternoon or mid afternoon = 15:00 - Late afternoon = 16:00 - Dinner/Supper=18:00 - Early evening = 19:00 - Evening = 21:00 - Late evening = 22:00 Canadian Stroke Audit:Canadian Stroke Audit: LSN Documentation RequiredLSN Documentation Required RCSN 2009
    32. 32. 33 3. Physical assessment specific to stroke3. Physical assessment specific to stroke  Current stroke signs and symptoms  Patient has new onset of at least one of the following: ♦ ARM/LEG unilateral motor weakness or drift ♦ Speech slurring, loss, inappropriate words, mute, or other changes ♦ Facial droop or weakness
    33. 33. 34 Warning Signs for StrokeWarning Signs for Stroke WeaknessWeakness - Sudden loss of strength or sudden numbness in the face, arm or leg, even if temporary. Trouble speakingTrouble speaking - Sudden difficulty speaking or understanding or sudden confusion, even if temporary. Vision problemsVision problems - Sudden trouble with vision, even if temporary. HeadacheHeadache - Sudden severe and unusual headache. DizzinessDizziness - Sudden loss of balance, especially with any of the above signs. www.heartandstroke.com
    34. 34. 35 Assessment for arm drift:  Have the patient hold both arms out in front for 5 seconds. If one arm drifts or falls before the 5 sec. count, or the pt. is unable to move one arm, they fit the inclusion criteria. Assessment for Leg Weakness:  Have the patient lift leg at 30 degrees and hold for 5 seconds. Repeat with other leg.  Compare the two sides. If one leg drifts or falls before the count, or the pt. is unable to move one leg, they fit the inclusion criteria. Physical Assessment: Arm and LegPhysical Assessment: Arm and Leg
    35. 35. 36 Assessment for Speech Difficulties  Ask the patient to name 3 objects you show them (i.e. pen, watch, ring).  Ask the patient to repeat a simple sentence (“it is sunny today.”)  If the patient is unable to repeat all the objects, or repeat the sentence they fit the inclusion criteria. Physical Assessment: SpeechPhysical Assessment: Speech Wictk
    36. 36. 37  Ask the patient to  Smile  Show his/her teeth  Grimace  Stick out tongue Physical Assessment: Facial DroopPhysical Assessment: Facial Droop
    37. 37. 38 Ischemic (80%) Hemorrhagic (20%) A Guide to Understanding Stroke, Heart and Stroke Foundation of Canada, 1996 The Anatomy and PhysiologyThe Anatomy and Physiology of a Strokeof a Stroke
    38. 38. 39 Acute Cerebral InfarctionAcute Cerebral Infarction Approximately 70 - 80% of strokes are caused by cerebral thrombosis or cerebral embolism Occlusion of cerebral blood vessels leads to brain cell ischemia and infarction
    39. 39. 40 TIA is defined as a focal (or at times global) neurological impairment of sudden onset, and lasting less than 24 hours, and of presumed vascular origin, and with full recovery. (WHO) Transient Ischemic Attack
    40. 40. 41 Cerebral CortexCerebral Cortex  Divided in to 4 lobes  Frontal  Parietal  Temporal  Occipital www.emc.maricopa.edu/faculty/farabee/biobk/cerebrum_1.gif
    41. 41. 42 Motor & Sensory FunctionMotor & Sensory Function  www.stroke.org Motor Sensory Hip Leg Trunk Arm Hand Language Vision Hearing Posture Balance Coordination NeckArm Fingers Emotions Smell Speech Face Hand
    42. 42. 43 Blood Supply to the BrainBlood Supply to the Brain  Brain derives its arterial supply from carotid and vertebral arteries which begin extracranially  Internal carotid arteries and branches supply anterior 2/3 of cerebral hemispheres  Vertebral and basilar arteries supply posterior and medial regions of hemispheres, brainstem, diencephalon, cerebellum and cervical spinal cord  www.stroke.org
    43. 43. 44 Left and Right HemisphereLeft and Right Hemisphere Left HemisphereLeft Hemisphere  Expressive aphasia  Receptive aphasia  Global aphasia  Right sided weakness/sensory loss  Intellectual impairment- reading, writing, math  Slow and cautious behavior  Defects in right visual field- homonymous hemianopsia Right HemisphereRight Hemisphere  Spatial-perceptual deficits  Left sided weakness/sensory loss  Neglect of the affected side  Distractible  Impulsive behavior  Poor judgment  Loss of flow of speech  Defects in left visual field- homonymous hemianopsia
    44. 44. 45 Stroke MimicsStroke Mimics  The following four conditions represent 62% of stroke mimics  Postictal deficit (unrecognized seizure)  Systemic infection  Tumour/abscess  Toxic-metabolic disturbance  Other mimics  Bell’s palsy  Peripheral nerve palsies  Old stroke  Confusion  Head trauma  Hemiplegic migraine
    45. 45. 46 4. Additional Assessments4. Additional Assessments  Presence of seizures  Glasgow Coma Scale Eye Opening (E)Eye Opening (E) Verbal Response (V)Verbal Response (V) Motor Response (M)Motor Response (M) 4 = Spontaneous 3 = To voice 2 = To pain 1 = None 5 = Normal conversation 4 = Disoriented conversation 3 = Words, but not coherent 2 = No words, only sounds 1 = None 6 = Normal 5 = Localized to pain 4 – Withdraws to pain 3 = Decorticate posture 2 = Decerebrate 1 = None  Blood glucose levels: <= 3 mmol/l
    46. 46. 47 Paediatric ConsiderationsPaediatric Considerations  Stroke occurs at ALL ages  Paediatric stroke rate is 4-6 per 100,000. In neonates it may be as high as 1 per 4000  Types of stroke in children:  There are two types of ischemic stroke: ♦ A stroke caused by a blood clot in an artery is called arterial ischemic stroke (AIS); ♦ A stroke or brain swelling caused by a blood clot in a vein is called cerebral sinovenous thrombosis (CSVT).
    47. 47. 48 Paediatric Stroke PresentationPaediatric Stroke Presentation  The most common effect of stroke is weakness of one side of the body (hemiplegia).  However, may also present with:  Unilateral facial droop  speech may be affected.  Visual disturbances  Abnormal balance and/or coordination  Headache with or without vomiting  Dizziness ( room is spinning)  Stroke due to CSVT may:  Show signs of distress.  Seizures (twitching of the face, arms or legs, or starring spells).  extreme trouble staying awake and alert during the day outside of normal sleeping time.  Signs of a stroke may be difficult to recognize in a young child, depending on the child’s age and stage of development
    48. 48. 49 5. Thrombolytic Therapy5. Thrombolytic Therapy  tPA (tissue plasminogen activator)  Dissolves blood clots  In patients with stroke  30% benefit significantly from treatment  60% do not show major changes with treatment  10% may have a complication associated with treatment (usually bleeding)  Time window for receiving tPA has been increased to 4.5 hours from symptom onset (ECASS III)
    49. 49. 50 As with Heart Attacks, “Brain Attacks” can be treated with tPA to dissolve blood clots and restore blood flow. QuickTime™ and a TIFF (Uncompressed) decompressor are needed to see this picture. Acute Stroke ThrombolysisAcute Stroke Thrombolysis
    50. 50. 51 5. Assessments for Contraindications5. Assessments for Contraindications to tPAto tPA  CTAS 1 and/or uncorrected ABC  Blood glucose <= 3.0 mmol/l  Seizure at onset of symptoms or witnessed by Emergency Medical Service providers  Glasgow Coma Scale <9  Terminally ill or palliative care patient
    51. 51. 52 Patients who show signs and symptoms of hyper-acute stroke must be treated as a time-sensitive emergency and should be transported without delay to the closest acute care facility that provides emergency stroke care. Goal of “Stroke Alert Protocols”Goal of “Stroke Alert Protocols” For EMS ProvidersFor EMS Providers
    52. 52. 53 6. Transportation Decisions6. Transportation Decisions  Time is BrainTime is Brain – need for efficiency and minimizing time from on- scene arrival to transport to a stroke centre  The recommended total time from symptom onset to reperfusion for eligible patients, is usually defined as 4.5 hours. This is broken into 2 phases: pre-hospital and ED  The pre-hospital phase, which starts with symptom onset, and includes on-scene management and anticipated transport time, should be less than 3.5 hours  The current evidence shows that emergency department phase should be less than 60 minutes * local variations need to be taken into consideration for pre-hospital time
    53. 53. 54 6. Transportation Decisions (2)6. Transportation Decisions (2)  Direct transport protocol criteria must be based on (1) the local ED performance which is recommended as being less than 60 minutes; and (2) the out-of-hospital phase, including symptom duration and anticipated transport duration, being less than 3.5 hours and/or (3) other acute care needs of the patient  Transport to closest/designated stroke centre (comprehensive or intermediate)  Implement normal EMS en-route transport management (for stroke, 18 g needle is preferred for IV access)  Prenotification to the destination emergency department of a suspected acute stroke in transport
    54. 54. 55 7. Additional Transportation Considerations7. Additional Transportation Considerations  Patients who are not considered potentially eligible for time-sensitive reperfusion should be transported to the closest appropriate emergency department  Patients with symptoms that resolve prior to paramedic arrival on scene may not require medical redirect to an acute stroke centre, but should be assessed emergently.  Those patients whose symptoms resolve after paramedic assessment or during transport should continue on medical redirect to a stroke centre.  It is important to request that a family member accompany the ambulance to the hospital so that they could provide vital information. In the absence of a person being present, verify the contact number of an informant and/or decision-maker.
    55. 55. 56 Transport of Suspected Stroke Patients:Transport of Suspected Stroke Patients: Local InformationLocal Information  Is there a stroke protocol in place for EMS?  Designated stroke centres – where are they? ♦ Ct scan access ♦ Telestroke considerations  Have bypass protocols been established and communicated to EMS dispatchers and responders?  Who makes the decision to bypass a smaller, closer hospital to get to a stroke centre – dispatch or the receiving centre??  What are the local prenotification practices?  Other local issues – do you know what they are??  Ambulance availability and maximum allowable transport times  Cross-boundary issues Local practices
    56. 56. 57  “ABCs” stable?  Time lapse from symptom onset <= 3.5 hours  Patient is conscious? (GCS >9)  Is blood sugar > 3mmol/L?  Stroke symptoms are not rapidly improving/resolved?  Patient did not have a seizure at onset?  Patient is not terminally ill or palliative? ParamedicParamedic StrokeStroke Reference GuideReference Guide ““Yes” to all = meets criteria = transportYes” to all = meets criteria = transport
    57. 57. 58 If “yes” to all listed criteria, patient may be eligible for acute tPA. An acute stroke transport protocol should be initiated.  Transport CTAS level 2 to nearest acute stroke centre  Initiate verbal link to receiving ED department and provide prenotification, including last seen normal time.  Consider blood glucose and IV but do not delay transport to achieve  Provide supplemental O2, monitor SPO2, ECG ParamedicParamedic Transport DecisionsTransport Decisions
    58. 58. 59 8. Handover to the Emergency Department8. Handover to the Emergency Department  Handover to the ED staff should be done without delay  Communication to receiving staff (triage nurse and/or attending physician) ♦ LSN time ♦ Symptoms on arrival to scene ♦ Changes in symptoms on scene or during transport ♦ Informant or family member present or available  Documentation should be completed and a copy of ambulance call record (ACR) left with the ED ♦ Include: LSN time, indicate whether another hospital was bypassed, note whether stroke protocol initiated
    59. 59. 60 9. Provincial/Regional Variations9. Provincial/Regional Variations  Each EMS provider service may have additional components to be included on prompt cards or stroke reference guides  Examples of other “non-essential” information that has been previously included on some existing provincial stroke pocket guides and is considered routine care by emergency medical services  Previous stroke history  Other vital signs (blood pressure, heart rate, respirations, temperature)  Presence of sensory deficits  Other medical history and comorbidities ♦ Medications (especially antithrombotics) ♦ Cardiac conditions ♦ Recent surgery  Add other local variations and additions (not deletions) to core content
    60. 60. 61 Case StudiesCase Studies What would you do when you arrived on scene?
    61. 61. 62 Case Study #1Case Study #1  You respond to a private residence for a reported unconscious male.  On arrival you are met by a male who identifies himself as a co- worker of the patient. He had stopped by to pick up his friend to drive him to work at 0800 hr, but when his friend did not answer the door he became concerned and peered through the window.  He could see the patient lying motionless on the kitchen floor still in his pyjamas and proceeded to call 911 immediately. He then broke a window to enter the home and found his 58 year old friend unconscious.  The friend reports that one week ago the patient had complained of a brief period of right sided weakness that lasted less than an hour while he was at work, and the patient did not seek medical attention at that time.
    62. 62. 63 Case Study #1: Stroke AssessmentCase Study #1: Stroke Assessment  ABC: the patient’s airway is clear, he is breathing, RR 14, radial pulse present at 64 bpm  Neuro – patient responds to loud voice and painful stimulus by moving left arm and leg; no movement observed from right arm or leg; speech consists of low moans to stimuli; pupils equal and reactive; no seizures observed  GCS: 10  Blood Glucose: 4.5 mmol/L
    63. 63. 64 Case Study #1: EMS ActionsCase Study #1: EMS Actions  EMS actions:  Participants to discuss and complete  Transport considerations:  Participants to discuss and complete
    64. 64. 65 Case Study #2Case Study #2  You respond to a private residence for an unknown problem. On arrival, you are met by a woman who identifies herself as the daughter of the patient.  The woman explains that she stopped by on her way home from work to check on her father, who lives alone. When she spoke to him by telephone before she left work he said that he was not feeling well. His speech was clear at that time. She also states he is a very healthy 76 year old with just some high blood pressure.  When she arrived 30 minutes after the call, she found him sitting in his favourite chair, awake but unable to speak clearly, unable to move his left arm, or get out of the chair. You reassure her and proceed to the patient.  Total time lapse from her phone call to her father (when he was able to speak) until your arrival on scene is 53 minutes.
    65. 65. 66 Case Study #2 : Stroke AssessmentCase Study #2 : Stroke Assessment  ABC: airway clear; breathing spontaneously, RR 24; radial pulse present at 96 bpm; BP 184/100  You examine the patient following the criteria on the stroke reference guide you carry with you, and observe the left side of his face is drooping, he is trying to make sounds that are not interpretable, he is able to move his right arm and leg spontaneously, but not able to move his left arm or leg to command or in response to painful stimuli.  Blood Glucose: 5.0 mmol/L  GCS 12
    66. 66. 67 Case Study #2: EMS ActionsCase Study #2: EMS Actions  EMS actions:  Participants to discuss and complete  Transport considerations:  Participants to discuss and complete
    67. 67. 68 Case Study #3Case Study #3  You respond to a call for a 38 year old woman who was previously well then suddenly collapsed and is unable to move her left side. Her husband recognized the signs and symptoms of stroke from a TV ad and called 911.  You arrive in scene and find the woman conscious, lying on the floor, with left sided facial droop, and unable to move her left arm or leg. Her speech is slurred and partially understandable.  Her husband reports that she was on a 20 hour flight from Europe the week before, and earlier in the day she reported feeling “funny” and having what seemed like a momentary loss of concentration with dizziness and disorientation.  In the ambulance she starts to move her left hand and arm, but cannot lift her arm off of the stretcher or make a fist.
    68. 68. 69 Case Study #3: Stroke AssessmentCase Study #3: Stroke Assessment  ABC’s: airway open, breathing spontaneously, RR 24; radial pulse 96  Neuro: on arrival unable to move left arm or leg, right arm and leg moving spontaneously; facial droop noted on left side; able to attempt to follow commands; speech slurred and difficult to understand; pupils equal and reactive; GCS: 13  Blood Glucose: 4.0 mmolL  No seizure activity observed or reported by husband  LSN time to EMS arrival on scene 28 minutes
    69. 69. 70 Case Study #3: Assessment and ActionsCase Study #3: Assessment and Actions  EMS actions:  Participants to discuss and complete  Transport considerations:  Participants to discuss and complete
    70. 70. 71 Case Study #4Case Study #4  You respond to a call from a grocery store manager that an older woman has collapsed in the store.  When you arrive on scene a witness reports that the patient was in the produce section when she suddenly collapsed. The witness went over to help her and the patient complained of a sudden onset very severe headache that was getting worse.  The patient reported that she never gets headaches and this was really bad and very unusual.
    71. 71. 72 Case Study #4: Assessment and ActionsCase Study #4: Assessment and Actions  ABC’s: airway open, breathing spontaneously, RR 16; radial pulse 68  Neuro: on arrival unable to move left arm or leg; right arm and leg moving spontaneously; facial droop noted on left side; able to attempt to follow commands; speech slurred and difficult to understand; patient agitated; pupils equal and reactive; GCS: 13  Blood Glucose: 5.5 mmol/L  LSN time to EMS arrival on scene 38 minutes
    72. 72. 73 Case Study #4: Stroke AssessmentCase Study #4: Stroke Assessment  EMS actions:  Participants to discuss and complete  Transport considerations:  Participants to discuss and complete
    73. 73. 74 AcknowledgementsAcknowledgements  We acknowledge the Canadian Stroke Strategy Emergency Medical Services task group for their contributions to this workshop and the standardized content of the EMS stroke core reference content.  Parts of this presentation were originally developed by the Central South Regional Stroke Program (Ontario)  Contributions to the content and case studies were received from the Emergency Health Services Branch Education and Patient Care Standards Section of the Ontario Ministry of Health and Long Term Care, and from Karen Stevens RN working with the British Columbia Stroke Strategy
    74. 74. 75
    75. 75. 76 Contact UsContact Us www.canadianstrokestrategy.ca www.canadianstrokenetwork.ca www.heartandstroke.ca

    ×