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![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)](https://image.slidesharecdn.com/dm1912-230412090319-bba1c4c7/85/DM_1912-ppt-31-320.jpg)
DM_1912.ppt
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- 2. WHAT IS ASTROKE? “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 • Astroke 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 LEFTHEMISPHERE 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 BRAINSTEMSTROKE 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 OFSTROKES 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 MARYLANDMEDICAL 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 MARYLANDMEDICAL 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 MARYLANDMEDICAL 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 MARYLANDMEDICAL 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 MARYLANDMEDICAL 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 MARYLANDMEDICAL 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 MARYLANDMEDICAL 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 (UNDER18) (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 HOSPITALTREATMENT 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 StrokeReady • 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 StrokeCenter • 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 StrokeCenter • 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 STROKECENTERS • 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 About1600 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 canbe 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 OFADDITIONAL 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
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- 31. SOURCES • American StrokeAssociation (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)