Stroke TBI Emergency

1. NEUROLOGICAL
EMERGENCIES:
STROKE

2. WHAT IS A STROKE?
“Neurological deficit of cerebrovascular cause that persists beyond 24
hours or is interrupted by death within 24 hours.” - WHO
Death or injury of brain tissue from oxygen deprivation.

3. STROKE FACTS
• A stroke is a medical emergency!
• Approximately 795,000 each year in the US, 5th leading cause of death
(133,000)
• 2nd most frequent cause of death world-wide (>6M)
• 5th leading cause of death in the US
• A leading cause of adult disability
• On average, someone in the US has a stroke every 40 seconds
• Over 4 million stroke survivors in the US
• Crosses all ethnic, racial, and socioeconomic groups
• Direct and indirect cost of stroke annually in US: $38.6 Billion (2009)

4. TYPES OF STROKE
• Ischemic (87%)
• Thrombosis
• Embolism
• Systemic hypoperfusion (shock)
• Cerebral Venous Sinus Thrombosis (CVST)
• Hemorrhagic (13%)
• Intracerebral
• Subarachnoid

5. CVA VS TIA
• TIAs are strokes where symptoms last less than two hours. “mini-
stroke”
• Caused by small clots
• Complete resolution typically occurs without further treatment within 24 hours
• About 15% of all strokes (CVAs) occur after a TIA
• TIA is a medical emergency – even if symptoms have resolved
• CVAs are strokes where symptoms are typically persistent until
treated by medical professionals.
• ASA recommends terminology changes - “Brain Attack”

6. RISK FACTORS
Controllable
• Hypertension (35-50% of stroke risk)
(decrease 10 mmHg Systolic or
5mmHg Diastolic reduces risk ~
40%)
• Hyperlipidemia (high cholesterol)
• Diabetes (2 to 4x multiple)
• Tobacco Use (2 to 4x multiple)
• Alcohol Use
• Physical Inactivity (decrease risk
30m/5d/wk)
• Obesity
• Heart Disease
• Atrial Fibrillation
• Pregnancy
Non-controllable
• Age
• Increases exponentially from 30
• 95% > 45 YO
• 67% > 65 YO
• Gender
• Women are at higher risk
• 60% of stroke deaths are women
• Race
• South Asian (40%)
• African American
• Family History and Genetics
• Previous Stroke or TIA

7. SIGNS / SYMPTOMS
• Hemiparesis – one-sided weakness (very common)
• Aphasia – difficulty speaking or inability to speak
• Headache – caused by hemorrhage (less common, but very
important)
• Confusion or Altered Mental Status
• Dizziness
• Numbness, weakness, or paralysis – usually on one side of the body
• Loss of bladder and/or bowel control

8. SIGNS / SYMPTOMS
• Impaired vision or loss of vision in one eye
• Hypertension
• Dyspnea – difficulty breathing or snoring respirations
• Nausea or vomiting
• Seizures
• Unequal pupils
• Unconsciousness (uncommon)

9. COMMON STROKE SYMPTOMS
LEFT HEMISPHERE STROKE
• Speech problems – what is
being said or inability to get
words out
• Problems with comprehension
• Left gaze preference
• Weakness or numbness of right
face, arm, or leg
RIGHT HEMISPHERE STROKE
• Dysarthria – slurred speech
• Left sided neglect
• Right gaze preference
• Weakness or numbness of left
face, arm, or leg

10. COMMON STROKE SYMPTOMS
BRAINSTEM STROKE
SYMPTOMS
• Nausea, vomiting, or vertigo
• Speech problems
• Dysphasia - swallowing
problems
• Abnormal eye movements
• Decreased consciousness
• Crossed findings
SILENT STROKES
• Asymptomatic
• Statistically significant
• Only detected by MRI

11. COMMON STROKE SYMPTOMS
INTRACEREBRAL
HEMORRHAGE
• Nausea and Vomiting
• Headache
• One sided weakness
• Decreased consciousness
SUBARACHNOID
HEMORRHAGE
• Worst headache of life
• Intolerance to light
• Neck stiffness or pain

12. COMMON STROKE MIMICS
• Alcohol intoxication
• Cerebral infections
• Drug overdose / toxicity
• Epidural hematoma
• Hypoglycemia
• Metabolic disorders
• Migraines
• Neuropathies (Bell’s Palsy)
• Seizure and post seizure, Todd’s
Paralysis
• Brain tumors
• Hypertensive encephalopathy

13. EARLY RECOGNITION OF STROKES
BE-FAST!
• Balance – Loss of balance, headache, or dizziness
• Eyes – Blurred vision or loss of visual fields
• Face – One side of the face drooping
• Arms – Arm or leg weakness
• Speech – Difficulty speaking or forming words
• Time – Time is brain – seek treatment immediately!

14. PATIENT ASSESSMENT
(2019 MARYLAND MEDICAL PROTOCOLS)
Initiate General Patient Care
• Scene Size-Up
• Primary Assessment
• Secondary Assessment
• Perform glucometer check as part of vital sign assessment.
• Perform Stroke Assessments
- The Cincinnati Prehospital Stroke Scale
- Posterior Cerebellar Assessment
- If the Cincinnati Prehospital Stroke Scale OR the Posterior Cerebellar Assessment is
POSITIVE perform the Los Angeles Motor Scale (LAMS).

15. PATIENT ASSESSMENT
(2019 MARYLAND MEDICAL PROTOCOLS)
Cincinnati Prehospital Stroke Scale
• Facial Droop (have patient show teeth or smile)
Normal – both sides of face move equally
Abnormal – one side of face does not move as well as the other side
• Arm Drift (patient closes eyes and holds both arms straight out for 10 seconds)
Normal – both arms move the same or do not move at all
Abnormal – one arm does not move or one arm drifts down compared to the other
• Abnormal Speech (have the patient say “you can’t teach an old dog new tricks”)
Normal – patient uses correct words with no slurring
Abnormal – patient slurs words, uses the wrong words, or is unable to speak

16. PATIENT ASSESSMENT
(2019 MARYLAND MEDICAL PROTOCOLS)
Posterior Cerebellar Assessment (NEW 2019)
Balance and Eyes
- Sudden onset of loss of balance or dizziness
- Sudden vision loss (including intermittent loss or blurred vision)
Other symptoms may include:
- Contralateral sensory deficits (occasionally accompanied with motor deficits)
- Alexia without agraphia (able to write but not read)

17. PATIENT ASSESSMENT
(2019 MARYLAND MEDICAL PROTOCOLS)
Los Angeles Motor Scale (LAMS)
• Facial droop
Absent – 0
Present – 1
• Arm drift
Absent – 0
Drifts down – 1
Falls rapidly – 2
• Grip Strength
Normal – 0
Weak grip – 1
No grip – 2

18. PATIENT ASSESSMENT
(2019 MARYLAND MEDICAL PROTOCOLS)
Strokes during pregnancy or shortly after giving birth are rare – but a
significant increase recently.
Fibrinolytic checklist is NO longer used for stroke patients (2017)

19. PATIENT TREATMENT
(2019 MARYLAND MEDICAL PROTOCOLS)
• Do not administer aspirin
• Position patient with head elevated at 30 degrees
• If patient has a positive Posterior Cerebellar Assessment OR Cincinnati
Prehospital Stroke Scale AND can be delivered to the hospital within 20
hours of last known well time:
• Patient is Priority 1 – notify receiving facility with “Stroke Alert with a last known well
time of XX:XX” ASAP!
• Transport patient to closest Acute Stroke Ready, Primary, or Comprehensive Stroke
Center
• If no stroke center with 30 minutes, go to the nearest hospital
• Consider aeromedical transport
• Obtain and document a contact telephone number for one or more individuals who
have details about the patient’s medical history – this must be provided to the

20. PATIENT TREATMENT
(2019 MARYLAND MEDICAL PROTOCOLS)
• Administer oxygen at 2-6 lpm via NC unless hypoxic or in respiratory
distress
• Use glucometer and treat accordingly if glucose is less than 70 mg/dl
• ALS Interventions include:
• Establish IV access with Lactated Ringers
• Consult if patient is hypotensive
• Consider obtaining blood sample using closed system
• Do not treat hypertension in the field

21. PEDIATRIC PATIENTS (UNDER 18)
(2019 MARYLAND MEDICAL PROTOCOLS)
• Stroke is uncommon but does occur. Most often caused by:
• Congenital Heart Defects
• Infections (including Chicken Pox, Meningitis, or Encephalitis)
• Brain Injury
• Blood Disorders (such as Sickle Cell Disease)
• Most often seen in infants, but can occur at any age
• Consult with Pediatric Base Station, arrange transport to a Pediatric
Trauma Center.
• Johns Hopkins Children’s Center, Baltimore
• Children’s National Medical Center, DC

22. ACUTE ISCHEMIC STROKE
HOSPITAL TREATMENT OPTIONS
• IV-tPA – Tissue Plasminogen Activator “clot-buster” (alteplase)
• Patient must be within the time window of 3.5 hours (4.5 hours for some
patients)
• Intra-arterial Thrombolysis
• Doctor uses a catheter to administer tPA directly into the clot
• Treatment can be administered up to 6 hours from symptom onset
• Patients must meet strict criteria
• Mechanical Thrombectomy
• Uses a device to retrieve the clot
• Treatment can be administered up to 8 hours from symptom onset
• If IV-tPA fails or patient is ineligible, they may be eligible for mechanical

23. STROKE CENTERS
Acute Stroke Ready
• Acute Stroke Team available 24/7, at bedside within 15 minutes
• No designated beds for acute care of stroke patients
• Neurosurgical Services available within 3 hours
• Telemedicine available within 20 minutes of it being necessary
• IV thrombolytics and transfer of patients who have received IV thrombolytics for
medical management of stroke to PSC OR CSC

24. STROKE CENTERS
Primary Stroke Center
• Acute Stroke Team available 24/7, at bedside within 15 minutes
• Stroke unit or designated beds for acute care of stroke patients
• Neurosurgical Services available within 2 hours or available 24/7 if provided on
site
• Telemedicine available if necessary
• IV thrombolytics and medical management of stroke

25. STROKE CENTERS
Comprehensive Stroke Center
• Acute Stroke Team available 24/7, at bedside within 15 minutes
• Dedicated neuro intensive care beds for complex stroke patients with on-site
neurointensivist 24/7
• 24/7 availability of Neurointerventionist, Neuroradiologist, Neurologist,
Neurosurgeon
• Telemedicine available if necessary
• IV thrombolytics, full range of neurological procedures, and medical
management of stroke

26. MIEMSS DESIGNATED STROKE CENTERS
• Acute Stroke Ready (1)
• Garrett County Memorial Hospital, Oakland
• Primary Stroke Centers (35)
• Western Maryland Health System, Cumberland
• Meritus Medical Center, Hagerstown
• Frederick Memorial Hospital, Frederick
• Comprehensive Stroke Centers (3)
• Johns Hopkins Bayview Medical Center, Baltimore
• The Johns Hopkins Hospital, Baltimore
• University of Maryland Medical Center, Baltimore

27. NATIONALLY RECOGNIZED STROKE
CENTERS
About 1600 recognized stroke facilities, including:
• Acute Stroke Ready Hospital – approximately 70
• Primary Stroke Centers – approximately 1,000
• Comprehensive Stroke Centers – approximately 175
• WVU, Morgantown WV
• UPMC, Pittsburgh PA
• UPMC Shadyside, Pittsburgh PA
• AHN, Pittsburgh PA
• UVA, Charlottesville VA

28. RECOVERY
• Rehab can be inpatient, outpatient, or a combination
• Various rehab programs depending on need, including:
• Physical Therapy
• Occupational Therapy
• Speech-Language Therapy
• Patient / Family Education
• Support Groups

29. REDUCING RISK OF ADDITIONAL STROKES
• Maintain a healthy blood pressure – ideally below 120/80
• Maintain healthy blood sugar and cholesterol levels
• Address other health issues, especially atrial fibrillation and sleep
apnea
• Adopt healthy lifestyle habits, including diet and physical and mental
exercise
• Limit or eliminate alcohol, tobacco, and vaping
• Maintenance medications may be required, such as aspirin,
depending on stroke type

30. QUESTIONS ?

31. SOURCES
• American Stroke Association (www.strokeassociation.org)
• MIEMSS 2019 Maryland Medical Protocols (www.miemss.org)
• Western Maryland Health System Stroke Center (www.wmhs.com)
• The Joint Commission [formerly JCAHO] (www.jointcommission.org)
• Wikipedia (www.wikipedia.org)