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  1. 1. Start Show Notes
  2. 2. <ul><li>The following presentation is taken from the American Heart Association’s Advanced Cardiac Life Support : Principles and Practice, Chapter 18, Acute Stroke: Current Treatments and Paradigms </li></ul><ul><li>Please use this publication as a reference. </li></ul>
  3. 3. Special Thanks To: <ul><li>ASA Operation Stroke </li></ul><ul><li>EMS Committee </li></ul><ul><li>Volunteers including: </li></ul><ul><li>Bruce Barnhart, Chair </li></ul><ul><li>Amy Boise, Vice Chair </li></ul><ul><li>Nancy Parks, RN </li></ul><ul><li>Charlann Staab, RN </li></ul><ul><li>Linda Meiner, RN </li></ul><ul><li>Mike Baros, RN </li></ul><ul><li>Terry Mason, RN </li></ul><ul><li>Don Baird, RN </li></ul><ul><li>Sandy Nygard, CEP </li></ul><ul><li>AEMS, Inc. </li></ul><ul><li>Robert Londeree, M.D. </li></ul><ul><li>Phoenix Fire Department </li></ul><ul><li>John Gallagher, M.D. </li></ul><ul><li>Air-Evac Services, Inc. </li></ul><ul><li>Professional Medical Transport (PMT) </li></ul><ul><li>Cigna Healthcare </li></ul><ul><li>Halle Heart Center </li></ul><ul><li>Dave Heath </li></ul>
  4. 4. Stroke An Educational Program for Pre-Hospital Personnel Developed by: EMS Committee Operation Stroke – American Stroke Association Phoenix, Arizona July 2003
  5. 5. Stroke Overview Introduction, Definition, Types and Risks
  6. 6. How Serious Is Stroke in the US? <ul><li>About 700,000 strokes occur each </li></ul><ul><li>year. </li></ul><ul><li>Over 167,000 deaths each year. </li></ul><ul><li>#3 killer. </li></ul><ul><li>A leading cause of serious long-term </li></ul><ul><li>disability in adults. </li></ul><ul><li>4.7 million stroke survivors. </li></ul>
  7. 7. Introduction <ul><li>New emerging therapies offer hope, however the following MUST occur: </li></ul><ul><li>Education of at-risk patients. </li></ul><ul><li>Early recognition of stroke signs. </li></ul><ul><li>Prompt transport to the hospital. </li></ul><ul><li>Rapid hospital triage and evaluation. </li></ul>
  8. 8. Introduction <ul><li>With rapid, aggressive prehospital stroke care, at-risk patients can be appropriately managed and quickly assessed for fibrinolytic therapy that may significantly improve their outcome. </li></ul>
  9. 9. Definition of Stroke <ul><li>A stroke is a neurological impairment caused by a disruption in blood supply to a region of the brain. </li></ul>
  10. 10. Classification of Stroke <ul><li>Two major categories: </li></ul><ul><li>Ischemic strokes, caused when a blood vessel supplying the brain is occluded by a clot. Responsible for 75% of all strokes. </li></ul><ul><li>Hemorrhagic strokes, caused when a cerebral artery ruptures. </li></ul><ul><li>Both forms are life threatening. </li></ul>
  11. 12. Hemorrhagic Stroke <ul><li>Hypertension is the most common cause of intracerebral hemorrhage. </li></ul><ul><li>Other causes: </li></ul><ul><li>Aneurysms and </li></ul><ul><li>Arteriovenous malformations. </li></ul>
  12. 13. Risk Factors for Stroke <ul><li>Although some strokes occur without warning, most stroke victims have prior risk factors. </li></ul><ul><li>Major strokes can be prevented in many cases, but only if early signs and symptoms are heeded. </li></ul>
  13. 14. Well-Documented Modifiable Risk Factors <ul><li>Hypertension </li></ul><ul><li>Smoking </li></ul><ul><li>Diabetes </li></ul><ul><li>Asymptomatic Carotid Stenosis </li></ul><ul><li>Atrial Fibrillation </li></ul><ul><li>Hyperlipidemia </li></ul><ul><li>Sickle Cell Disease </li></ul><ul><li>Other cardiac diseases </li></ul>Goldstein et al. Circulation. 2001:103:163
  14. 15. Less Well Documented Potentially Modifiable Risk Factors <ul><li>Obesity </li></ul><ul><li>Physical Inactivity </li></ul><ul><li>Poor Diet/Nutrition </li></ul><ul><li>Alcohol Abuse </li></ul><ul><li>Drug Abuse </li></ul><ul><li>Hypercoagulability </li></ul><ul><li>Hormone Replacement Therapy </li></ul><ul><li>Oral Contraceptive Use </li></ul><ul><li>Inflammatory Process </li></ul>Goldstein et al. Circulation. 2001:103:163
  15. 16. Non-modifiable Risk Factors <ul><li>Age </li></ul><ul><li>Sex </li></ul><ul><li>Race/Ethnicity </li></ul><ul><li>Family History </li></ul>
  16. 17. Stroke Diagnosis Signs and Symptoms of Stroke
  17. 18. Signs and Symptoms of Stroke <ul><li>Consider in anyone </li></ul><ul><li>who has: </li></ul><ul><li>Sudden numbness or weakness of face, arm, or leg, especially on one side of the body </li></ul><ul><li>Sudden confusion, trouble speaking or understanding </li></ul>
  18. 19. Signs and Symptoms of Stroke <ul><li>Sudden trouble seeing in one or both eyes </li></ul><ul><li>Sudden trouble walking, dizziness, loss of balance or coordination </li></ul><ul><li>Sudden severe headache with no known cause </li></ul>
  19. 20. Signs and Symptoms of Stroke <ul><li>THIS IS A LIFE THREATENING EMERGENCY! </li></ul><ul><li>Emergency healthcare providers must: </li></ul><ul><li>Recognize the importance of these symptoms. </li></ul><ul><li>Respond quickly with medical and / or surgical </li></ul><ul><li>interventions. </li></ul>
  20. 21. Stroke Signs and Symptoms: Hemorrhagic Stroke <ul><li>May present similar to Ischemic stroke. </li></ul><ul><li>Distinguishing Features: </li></ul><ul><li>Appear more seriously ill </li></ul><ul><li>Deteriorate more rapidly </li></ul><ul><li>Severe headache </li></ul><ul><li>Alteration in consciousness </li></ul><ul><li>Nausea and/or vomiting </li></ul><ul><li>Neck pain </li></ul><ul><li>Intolerance of noise or light </li></ul>
  21. 22. Transient Ischemic Attack <ul><li>“Temporary” or “mini” stroke. </li></ul><ul><li>The signs and symptoms of a TIA are similar to those of a completed stroke; however, they typically last only a few minutes to several hours before resolving. </li></ul>
  22. 24. Transient Ischemic Attack <ul><li>TIA is the most important forecaster of impending stroke. </li></ul>
  23. 25. Stroke Patient Management The Stroke Chain of Survival and Recovery
  24. 26. Seven Step Stroke Chain of Survival and Recovery <ul><li>Pre-arrival: Post-arrival: </li></ul><ul><li>Detection 4. Door </li></ul><ul><li>Dispatch 5. Data </li></ul><ul><li>Delivery 6. Decision </li></ul><ul><li>7. Drug </li></ul>
  25. 28. 1. Detection: Early Recognition <ul><li>Early treatment of stroke depends on the victim, family members, or other bystanders detecting the event. </li></ul><ul><li>Mild signs or symptoms may go unnoticed or be denied by the patient or bystander. </li></ul>
  26. 29. 2. Dispatch: Early EMS Activation and Dispatch Instructions <ul><li>Stroke victims and their families must be taught to activate the EMS system as soon as they detect stroke signs or symptoms. </li></ul><ul><li>EMS dispatchers must appropriately prioritize the call to ensure a rapid response within the EMS system. </li></ul>
  27. 31. 3. Delivery: Pre-hospital Transport and Management <ul><li>The goals : </li></ul><ul><li>Rapid identification of the stroke </li></ul><ul><li>Support of vital functions </li></ul><ul><li>Rapid transport of the victim to the receiving facility </li></ul><ul><li>Pre-arrival notification of the receiving facility </li></ul>
  28. 32. 3. Delivery: Pre-hospital Transport and Management <ul><li>The Cincinnati Pre-hospital Stroke Scale </li></ul><ul><li>Facial Droop (have patient show teeth or smile): </li></ul><ul><li>Normal - Both sides of face move </li></ul><ul><li>equally well. </li></ul><ul><li>Abnormal - One side of face does not </li></ul><ul><li>move as well as the other side. </li></ul>
  29. 33. 3. Delivery: Pre-hospital Transport and Management <ul><li>The Cincinnati Pre-hospital Stroke Scale </li></ul><ul><li>2. Arm Drift (patient closes eyes and holds both arms out): </li></ul><ul><li>Normal - Both arms move the same or both </li></ul><ul><li>arms do not move at all (other findings, </li></ul><ul><li>such as pronator grip, may be helpful). </li></ul><ul><li>Abnormal - One arm does not move or one </li></ul><ul><li>arm drifts down compared with the other. </li></ul>
  30. 34. 3. Delivery: Pre-hospital Transport and Management <ul><li>The Cincinnati Pre-hospital Stroke Scale </li></ul><ul><li>3. Speech (have the patient say &quot;you can't teach an old dog new tricks&quot;): </li></ul><ul><li>Normal - Patient uses correct words with </li></ul><ul><li>no slurring . </li></ul><ul><li>Abnormal - Patient slurs words, uses </li></ul><ul><li>inappropriate words, or is unable to speak. </li></ul>
  31. 35. 3. Delivery: Pre-hospital Transport and Management <ul><li>The presence of acute stroke is an indication for &quot;load and go“. </li></ul><ul><li>Establish the time of onset of stroke signs and symptoms! </li></ul><ul><li>This timing will have important implications for potential therapy. If the time of onset of symptoms is viewed as time &quot;zero,&quot; all assessments and therapies can be related to that time. </li></ul>
  32. 36. 3. Delivery: Pre-hospital Transport and Management <ul><li>Once stroke is diagnosed, pre-hospital treatment includes management of the ABCs of critical care ( A irway, B reathing, and C irculation) and close monitoring of vital signs. </li></ul>
  33. 37. 3. Delivery: Pre-hospital Transport and Management <ul><li>Airway : </li></ul><ul><li>Paralysis of the muscles of the throat, tongue, or mouth can lead to partial or complete upper-airway obstruction. </li></ul><ul><li>Saliva pools or vomit may be aspirated. </li></ul>
  34. 38. 3. Delivery: Pre-hospital Transport and Management <ul><li>Breathing : </li></ul><ul><li>Breathing abnormalities are uncommon, except in patients with severe stroke, and rescue breathing is seldom needed. </li></ul><ul><li>Abnormal respirations, however, are prominent in comatose patients and portend serious brain injury. </li></ul>
  35. 39. 3. Delivery: Pre-hospital Transport and Management <ul><li>Circulation : </li></ul><ul><li>Monitor both blood pressure and cardiac rhythm as part of the early assessment and treatment of a stroke patient. </li></ul><ul><li>Hypotension or shock is rarely due to stroke, so other causes should be sought. </li></ul>
  36. 40. 3. Delivery: Pre-hospital Transport and Management <ul><li>Circulation : </li></ul><ul><li>Hypertension is often present in stroke patients, but it typically subsides and does not require treatment. </li></ul><ul><li>Treatment of hypertension in the field is not recommended! </li></ul>
  37. 41. 3. Delivery: Pre-hospital Transport and Management <ul><li>Other Supportive Measures: </li></ul><ul><li>Intravenous access. </li></ul><ul><li>Management of seizures, and diagnosis and treatment of hypoglycemia, can be initiated en route to the hospital if necessary. </li></ul><ul><li>Isotonic fluids (Normal Saline or Lactated Ringer's solution) are used for intravenous therapy; hypotonic fluids are contraindicated . </li></ul>
  38. 42. 3. Delivery: Pre-hospital Transport and Management <ul><li>Early Notification: </li></ul><ul><li>Early notification enables personnel to prepare for the imminent arrival of any seriously ill or injured patient. </li></ul><ul><li>In many hospitals this notification shortens the time to evaluation of, and critical interventions for, stroke patients. </li></ul>
  39. 44. 4. Door: Emergency Department Triage <ul><li>Even if a potential stroke victim arrives in the emergency department in a timely fashion, too often hours may elapse before appropriate neurological consultation and diagnostic studies are performed. </li></ul>
  40. 45. 5. Data: Emergency Evaluation and Management <ul><li>ABCs should be reassessed and rechecked frequently. </li></ul>
  41. 46. 5. Data: Emergency Evaluation and Management <ul><li>An emergency neurological stroke assessment should be done quickly focusing on four key issues: </li></ul><ul><li>Level of consciousness </li></ul><ul><li>Type of stroke (hemorrhagic versus nonhemorrhagic) </li></ul><ul><li>Location of stroke (carotid versus vertebrobasilar) </li></ul><ul><li>Severity of stroke </li></ul>
  42. 47. 5. Data: Emergency Evaluation and Management <ul><li>Obtaining the exact time of stroke or onset of symptoms from family or people at the scene is critical . </li></ul>
  43. 48. Emergency Diagnostic Studies <ul><li>Currently, CT is the single most important diagnostic test. </li></ul><ul><li>Goal: CT scan obtained and read within 45 minutes of the stroke victim's arrival at the emergency department. </li></ul>
  44. 49. Emergency Diagnostic Studies <ul><li>Anticoagulants and fibrinolytic agents should be withheld until CT has ruled out a brain hemorrhage. </li></ul>Hemorrhagic Stroke
  45. 50. Differential Diagnosis: <ul><li>Unrecognized seizures </li></ul><ul><li>Confusional states </li></ul><ul><li>Syncope </li></ul><ul><li>Toxic or metabolic disorders </li></ul><ul><li>Hypoglycemia </li></ul><ul><li>Brain tumors </li></ul><ul><li>Subdural hematoma </li></ul>Adams et al. Stroke. 2003;34:1056
  46. 51. 6. Decision: Specific Stroke Therapies <ul><li>General care includes, but is not limited to: </li></ul><ul><li>Prevention of aspiration </li></ul><ul><li>Management of hypertension </li></ul><ul><li>Management of hyper/hypo-glycemia </li></ul><ul><li>Management of seizures </li></ul><ul><li>Management of intra-cranial pressure (ICP) </li></ul>Acute Stroke , 2003 American Heart Association
  47. 52. 7. Drugs: Fibrinolytic Therapy for Ischemic Stroke <ul><li>Intravenous tPA represents the first FDA-approved therapy for acute ischemic stroke. </li></ul><ul><li>In the NINDS trial, patients treated with tPA within 3 hours of onset of symptoms were at least 30% more likely to have minimal or no disability at 3 months compared with those treated with placebo . </li></ul>
  48. 53. 7. Drugs: Fibrinolytic Therapy for Ischemic Stroke <ul><li>However, there were 10-fold increases in the risk of fatal intracranial hemorrhage in the treated group (3% vs 0.3%) and the frequency of all symptomatic hemorrhage (6.4% vs. 0.6%). </li></ul><ul><li>This increase in symptomatic hemorrhage did not lead to an overall increase in mortality in the treated group. </li></ul>
  49. 54. 7. Drugs: Fibrinolytic Therapy for Ischemic Stroke <ul><li>Careful patient selection and strict adherence to the treatment protocol are essential ! </li></ul>
  50. 55. 7. Drugs: Fibrinolytic Therapy for Ischemic Stroke <ul><li>Because of the time criteria and risk associated with fibrinolytic therapy, it is important for hospitals to develop specific strategies and protocols that will achieve rapid initiation of therapy. </li></ul>
  51. 56. NINDS-Recommended Stroke Evaluation Targets for Potential Fibrinolytic Candidates* *Target times will not be achieved in all cases, but they represent a reasonable goal. † CT indicates computed tomography. ‡ By phone or in person. Time Target 3 hours Admit to monitored bed 2 hours Access to neurosurgical expertise ‡ 15 minutes Access to neurological expertise ‡ 60 minutes Door to treatment 45 minutes Door to CT read 25 minutes Door to CT † completion 10 minutes Door to doctor
  52. 57. Management of Hemorrhagic Stroke <ul><li>Optimal management: </li></ul><ul><li>Prevention of continued bleeding. </li></ul><ul><li>Appropriate management of ICP. </li></ul><ul><li>Timely neurosurgical decompression when warranted. </li></ul><ul><li>Large intracerebral or cerebellar hematomas often require surgical intervention. </li></ul>
  53. 58. Summary: Pre-hospital Critical Actions and Management <ul><li>This is what should happen: </li></ul><ul><li>Recognize the signs of stroke and TIA </li></ul><ul><li>Rapid neuro exam (Cincinnati Stroke Scale or similar). </li></ul><ul><li>Determine time of symptom onset (if possible). </li></ul><ul><li>Provide rapid transport to an ED capable of caring for acute stroke (pre-notify). </li></ul><ul><li>Perform finger-stick to assess serum glucose levels. </li></ul>
  54. 59. Summary: Pre-hospital UNACCEPTABLE Actions <ul><li>Failure to recognize signs and symptoms of stroke/TIA </li></ul><ul><li>Failure to attempt to determine symptom onset. </li></ul><ul><ul><li>Delay in transport. </li></ul></ul><ul><ul><li>Transporting a potential stroke patient to an ED not capable of treating acute ischemic stroke with fibrinolytic therapy. </li></ul></ul>
  55. 60. Summary: Pre-hospital UNACCEPTABLE Actions <ul><li>Attempts to treat hypertension in the field. </li></ul><ul><li>Failure to notify receiving ED. </li></ul>
  56. 61. Conclusion: <ul><li>Now, fibrinolytic and other emerging therapies offer practitioners the opportunity to limit neurological insult and improve outcome in stroke patients. </li></ul>
  57. 62. Conclusion: <ul><li>The challenge with these therapies is that they require administration within hours of stroke onset, making the following measures imperative: </li></ul><ul><li>Education of at-risk patients </li></ul><ul><li>Early recognition of stroke signs </li></ul><ul><li>Prompt transport to the hospital </li></ul><ul><li>Rapid hospital triage and evaluation </li></ul>