Start ShowStart Show NotesNotes
2
The following presentation isThe following presentation is
taken from thetaken from the American HeartAmerican Heart
Ass...
3
Special Thanks To:Special Thanks To:
• ASA Operation StrokeASA Operation Stroke
EMS CommitteeEMS Committee
Volunteers in...
4
StrokeStroke
An Educational ProgramAn Educational Program
forfor
Pre-Hospital PersonnelPre-Hospital Personnel
Developed ...
5
Stroke OverviewStroke Overview
Introduction, Definition, Types and RisksIntroduction, Definition, Types and Risks
6
How Serious Is Stroke inHow Serious Is Stroke in
the US?the US?
• About 700,000 strokes occur eachAbout 700,000 strokes ...
7
IntroductionIntroduction
New emerging therapies offer hope,New emerging therapies offer hope,
however the following MUST...
8
IntroductionIntroduction
With rapid, aggressiveWith rapid, aggressive
prehospital strokeprehospital stroke
care, at-risk...
9
Definition of StrokeDefinition of Stroke
A stroke is a neurological impairmentA stroke is a neurological impairment
caus...
10
Classification of StrokeClassification of Stroke
Two major categories:Two major categories:
• Ischemic strokes, caused ...
11
12
Hemorrhagic StrokeHemorrhagic Stroke
• Hypertension is theHypertension is the
most commonmost common
cause ofcause of
i...
13
Risk Factors for StrokeRisk Factors for Stroke
Although some strokes occur withoutAlthough some strokes occur without
w...
14
Well-DocumentedWell-Documented
Modifiable Risk FactorsModifiable Risk Factors
• HypertensionHypertension
• SmokingSmoki...
15
Less Well DocumentedLess Well Documented
Potentially Modifiable RiskPotentially Modifiable Risk
FactorsFactors
• Obesit...
16
Non-modifiable RiskNon-modifiable Risk
FactorsFactors
• AgeAge
• SexSex
• Race/EthnicityRace/Ethnicity
• Family History...
17
Stroke DiagnosisStroke Diagnosis
Signs and Symptoms of StrokeSigns and Symptoms of Stroke
18
Signs and Symptoms ofSigns and Symptoms of
StrokeStroke
Consider in anyoneConsider in anyone
who has:who has:
• Sudden ...
19
Signs and Symptoms ofSigns and Symptoms of
StrokeStroke
• Sudden trouble seeingSudden trouble seeing
in one or both eye...
20
Signs and Symptoms ofSigns and Symptoms of
StrokeStroke
THIS IS A LIFE THREATENING EMERGENCY!THIS IS A LIFE THREATENING...
21
Stroke Signs andStroke Signs and
Symptoms:Symptoms: Hemorrhagic StrokeHemorrhagic Stroke
May present similar toMay pres...
22
Transient Ischemic AttackTransient Ischemic Attack
““Temporary” or “mini” stroke.Temporary” or “mini” stroke.
• The sig...
23
24
Transient Ischemic AttackTransient Ischemic Attack
• TIA is the mostTIA is the most
importantimportant
forecaster offor...
25
Stroke Patient ManagementStroke Patient Management
The Stroke Chain of Survival andThe Stroke Chain of Survival and
Rec...
26
Seven Step Stroke Chain ofSeven Step Stroke Chain of
Survival and RecoverySurvival and Recovery
Pre-arrival: Post-arriv...
27
28
1. Detection:1. Detection: Early RecognitionEarly Recognition
• Early treatment of stroke depends onEarly treatment of ...
29
2. Dispatch:2. Dispatch: Early EMSEarly EMS
Activation and DispatchActivation and Dispatch
InstructionsInstructions
• S...
30
31
3. Delivery:3. Delivery: Pre-hospitalPre-hospital
Transport and ManagementTransport and Management
The goals :The goals...
32
3. Delivery:3. Delivery: Pre-hospitalPre-hospital
Transport and ManagementTransport and Management
The Cincinnati Pre-h...
33
3. Delivery:3. Delivery: Pre-hospitalPre-hospital
Transport and ManagementTransport and Management
The Cincinnati Pre-h...
34
3. Delivery:3. Delivery: Pre-hospitalPre-hospital
Transport and ManagementTransport and Management
The Cincinnati Pre-h...
35
3. Delivery:3. Delivery: Pre-hospitalPre-hospital
Transport and ManagementTransport and Management
• The presence of ac...
36
3. Delivery:3. Delivery: Pre-hospitalPre-hospital
Transport and ManagementTransport and Management
Once stroke is diagn...
37
3. Delivery:3. Delivery: Pre-hospitalPre-hospital
Transport and ManagementTransport and Management
AirwayAirway::
• Par...
38
3. Delivery:3. Delivery: Pre-hospitalPre-hospital
Transport and ManagementTransport and Management
BreathingBreathing::...
39
3. Delivery:3. Delivery: Pre-hospitalPre-hospital
Transport and ManagementTransport and Management
CirculationCirculati...
40
3. Delivery:3. Delivery: Pre-hospitalPre-hospital
Transport and ManagementTransport and Management
CirculationCirculati...
41
3. Delivery:3. Delivery: Pre-hospitalPre-hospital
Transport and ManagementTransport and Management
Other Supportive Mea...
42
3. Delivery:3. Delivery: Pre-hospitalPre-hospital
Transport and ManagementTransport and Management
Early Notification:E...
43
44
4. Door:4. Door: Emergency DepartmentEmergency Department
TriageTriage
Even if a potential stroke victimEven if a poten...
45
5. Data:5. Data: Emergency EvaluationEmergency Evaluation
and Managementand Management
ABCs shouldABCs should
be reasse...
46
5. Data:5. Data: Emergency EvaluationEmergency Evaluation
and Managementand Management
An emergencyAn emergency
neurolo...
47
5. Data:5. Data: Emergency EvaluationEmergency Evaluation
and Managementand Management
• Obtaining the exact time of st...
48
Emergency DiagnosticEmergency Diagnostic
StudiesStudies
• Currently, CT is the single mostCurrently, CT is the single m...
49
Emergency DiagnosticEmergency Diagnostic
StudiesStudies
• AnticoagulantsAnticoagulants
and fibrinolyticand fibrinolytic...
50
Differential Diagnosis:Differential Diagnosis:
• Unrecognized seizuresUnrecognized seizures
• Confusional statesConfusi...
51
6. Decision:6. Decision: Specific StrokeSpecific Stroke
TherapiesTherapies
General care includes, but is notGeneral car...
52
7. Drugs:7. Drugs: Fibrinolytic TherapyFibrinolytic Therapy
for Ischemic Strokefor Ischemic Stroke
• Intravenous tPA re...
53
7. Drugs:7. Drugs: Fibrinolytic TherapyFibrinolytic Therapy
for Ischemic Strokefor Ischemic Stroke
• However, there wer...
54
7. Drugs:7. Drugs: Fibrinolytic TherapyFibrinolytic Therapy
for Ischemic Strokefor Ischemic Stroke
Careful patient sele...
55
7. Drugs:7. Drugs: Fibrinolytic TherapyFibrinolytic Therapy
for Ischemic Strokefor Ischemic Stroke
Because of the time ...
56
NINDS-Recommended Stroke EvaluationNINDS-Recommended Stroke Evaluation
Targets for Potential FibrinolyticTargets for Po...
57
Management ofManagement of
Hemorrhagic StrokeHemorrhagic Stroke
Optimal management:Optimal management:
• Prevention of ...
58
Summary:Summary: Pre-hospital CriticalPre-hospital Critical
Actions and ManagementActions and Management
This is what s...
59
Summary:Summary: Pre-hospitalPre-hospital
UNACCEPTABLE ActionsUNACCEPTABLE Actions
• Failure to recognize signs andFail...
60
Summary:Summary: Pre-hospitalPre-hospital
UNACCEPTABLE ActionsUNACCEPTABLE Actions
• Attempts to treat hypertension inA...
61
Conclusion:Conclusion:
Now, fibrinolytic and other emergingNow, fibrinolytic and other emerging
therapies offer practit...
62
Conclusion:Conclusion:
The challenge with these therapies isThe challenge with these therapies is
that they require adm...
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  • 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.
    Please use this publication as a reference.
  • Until recently care of the stroke patient was largely supportive, with therapy focusing on treating respiratory and cardiovascular complications of the stroke. Because little therapy was directed toward altering the course of the stroke itself, little emphasis was placed on rapid transport or intervention.
  • Now, however, fibrinolytic and other emerging therapies (such as neuroprotective agents, which are not available at this time but show promise in early studies) offer practitioners the opportunity to limit neurological insult and improve outcome in stroke patients. The challenge with these therapies is that they require administration within 3 hours of stroke onset, making the following measures imperative:
    Education of at-risk patients
    Early recognition of stroke signs
    Prompt transport to the hospital
    Rapid hospital triage and evaluation
  • Definition of Stroke:
    A stroke is a neurological impairment caused by a disruption in blood supply to a region of the brain.
  • Classification of Stroke:
    Strokes can be classified into two major categories:
    Ischemic strokes - Occur because a blood vessel supplying the brain is occluded.
    Hemorrhagic strokes - Occur because a cerebral artery ruptures.
    Although both forms can be life threatening, ischemic stroke rarely leads to death within the first hour, whereas hemorrhagic stroke can be fatal at onset. Even among those who survive the first few hours after a stroke, brain injury progresses quickly and can lead to permanent disability. The classification of stroke as ischemic or hemorrhagic is important because management of the two differs markedly.
  • Hemorrhagic Stroke:
    The most common cause of a subarachnoid hemorrhage is an aneurysm. Arteriovenous malformations account for approximately 5% of all subarachnoid hemorrhages. Hypertension is the most common cause of intracerebral hemorrhage.
  • Although some strokes occur without warning, most stroke victims have prior risk factors.The best way to prevent a stroke is to identify at-risk patients and, once they are identified, control as many risk factors as possible. Some risk factors can be eliminated (eg, smoking), controlled (eg, high blood pressure, diabetes mellitus), or treated (eg, by antiplatelet therapy or carotid endarterectomy) to reduce the risk of stroke. Some rather low-level risk factors become significant when combined with other risk factors. For example, oral contraceptives and cigarette smoking together increase the risk of stroke considerably in young women.
    At-risk patients should receive aggressive education to increase their knowledge about stroke, its risk factors, and its signs and symptoms.
  • Well-documented modifiable risk factors and less-well documented modifiable risk factors recently published by Goldstein et al. Circulation. 2001:103:163
    __________________________________
    Hypertension - Major risk factor for both cerebral infarction and intracerebral hemorrhage. The incidence of stroke increases in proportion to both systolic and diastolic blood pressure.
    Smoking - Active (current) smoking has been long recognized as a major risk factor for stroke.
    Diabetes - Insulin-dependent diabetics have both an increased susceptibility to atherosclerosis and an increase prevalence of atherogenic risk factors, notably hypertension, obesity, and abnormal blood lipids.
    Carotid Stenosis - Frequently, patients with severe (>75%) carotid artery stenosis, progressing carotid artery stenosis, or heart disease have increased chance of stroke.
    Atrial Fibrillation –Aggressive treatment of atrial fibrillation is an important way to help prevent stroke.
    Hyperlipidemia - Management of patients with elevated cholesterol decreases risk of stroke.
    Sickle Cell Disease and other cardiac diseases - Modifiable risk factors using appropriate preventative treatment.
  • Non-modifiable Risk Factors:
    Age - Age is the single most important risk factor for stroke worldwide. In persons past the age of 55 years, the incidence of stroke increases for both men and women. However, it is important to note that stroke is not just a disease of the elderly; a quarter of all stroke victims are younger than 65.
    Sex - Men are at greater risk for stroke than women. However, since more women than men live beyond the age of 65 years, more women than men older than 65 actually die of stroke each year.
    Race/Ethnicity - African Americans have more than twice the risk of death and disability from stroke than whites. Much of this risk can be explained by the greater number of risk factors present in African Americans (eg, smoking, high blood pressure, sickle cell anemia, high cholesterol, and diabetes).
    Family History - Risk of stroke is greater for people who have a family history of stroke, but this risk is probably complicated by the presence of multiple common risk factors in families (eg, smoking, high blood pressure). The risk of stroke for someone who has already had a stroke is many times that of someone who has not. Recurrent stroke risk is highest within the first 30 days after a stroke, and long-term risk of recurrence averages 4% to 14% per year.
  • The warning signs of an ischemic stroke or transient ischemic attack (TIA) may be subtle or transient, but they foretell a potentially life-threatening neurological illness. Typical signs and symptoms of anterior and posterior-circulation strokes are presented in this presentation. Emergency healthcare providers should recognize the importance of these symptoms and respond quickly with medical or surgical measures of proven efficacy in stroke prevention.
  • Reference: Heartsaver CPR: A Comprehensive Course for the Lay Responder: 2000 American Heart Association
  • THIS IS A LIFE THREATENING EMERGENCY!
    Emergency healthcare providers should recognize the importance of these symptoms and respond quickly with medical or surgical measures of proven efficacy in stroke prevention.
  • Hemorrhagic strokes may present similar to ischemic strokes.
  • Transient Ischemic Attack:
    A TIA is a reversible episode of focal dysfunction of the brain or vision that is secondary to transient occlusion of an artery. 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. The patient who experiences a TIA usually presents to medical personnel with a normal neurological exam, so that the diagnosis is often based on history alone.
  • TIA is the most important forecaster of brain infarction.
    Approximately 5% of patients with TIAs will develop a cerebral infarction within the first month. The risk increases to 12% at 1 year and an additional 5% for every year after that. Evaluation to determine the likely cause of TIA and institution of appropriate treatment can significantly reduce the risk of stroke. Carotid endarterectomy is of proven benefit among patients with recent TIA who have a severe (>70%) narrowing of the origin of the internal carotid artery. Oral anticoagulants are usually prescribed to prevent embolism to the brain in patients with cardiac causes of stroke, particularly those with atrial fibrillation.
  • Optimal care of the stroke victim of acute stroke must minimize delay in recognition of stroke symptoms, activation of the EMS system, rapid transport to and pre-arrival notification of a hospital capable of acute stroke care, appropriate evaluation and selection of eligible candidates (if applicable) for fibrinolytic therapy, and administration of fibrinolytics. Delays at any of these major points can increase the the negative outcome of the stroke patient – to include making them ineligible for fibrinolytic therapy.
    Major Actions
    Detection
    Early recognition – onset of stroke signs and symptoms
    Dispatch
    Activation of the EMS system and prompt EMS response
    Delivery
    Transportation, with prearrival notification, to receiving hospital
    Provision of appropriate prehospital assessment and care
    Door
    Immediate general and neurologic assessment in the ED
    Aim or predefined evaluation targets
    Date
    CT scan
    Serial neurologic exams
    Review for tPA exclusions
    Review patient data
    Decision
    Patient remains candidate for tPA therapy? If “yes,” then:
    - Review risks and benefits with patient and family
    - Obtain informed consent for tPA therapy
    Drug
    Begin tPA treatment within 3-hour time limit
  • 1. Detection
    Surveys completed within major metropolitan areas found that less than 20% of those asked could name numbness or weakness of one side of the body as a stroke warning sign. All other warning signs were even less known.
    Public education is an essential part of any strategy to ensure timely access to care for stroke victims. It has been successful in reducing the time to arrival in the emergency department.
  • 2. Dispatch
    Stroke victims and their families must be taught to activate the EMS
    system as soon as they detect stroke signs or symptoms. Currently only
    half of stroke victims use the EMS system despite the fact that this
    system provides the safest and most efficient method for transporting the
    patient to the hospital.
    Although highly skilled dispatchers can be effective in triaging
    emergencies over the telephone, additional education about stroke is
    required. In a recent study, just over half of the EMS dispatchers correctly
    diagnosed stroke from the initial EMS call.
    Contact with the EMS system not only enables the dispatch of trained
    providers but also puts the victim or family members in contact with
    someone who can provide emergency information. EMS dispatchers can
    instruct bystanders in lifesaving skills, such as airway management,
    positioning of the patient, and rescue breathing, while EMS personnel are
    en route.
  • 3. Delivery
    Rapid identification of the stroke
    Support of vital functions
    Rapid transport of the victim to the receiving facility
    Pre-arrival notification of the receiving facility
    EMS providers must be effectively trained in the recognition and treatment of stroke. EMS system protocols must assign a high priority to stroke patients. In most EMS systems, stroke patients are treated under a generic "altered mental status" protocol. Stroke must be suspected quickly by EMTs and paramedics in the field. In one study EMTs and paramedics correctly identified stroke and TIA in 72% of the patients with either condition.
    Training must incorporate protocols that cover early recognition, early stabilization, early transportation, and early notification of the receiving facility.
    Extensive medical histories and neurological exams by pre-hospital personnel are impractical, especially because gathering this data may delay transport to the ED.
  • The Cincinnati Pre-hospital Stroke Scale, named for the location it was developed, identifies a high percentage of acute stroke patients by assessing only 3 physical findings:
    Facial Droop
    Arm Drift
    Speech
  • This evaluation can be done in less than one minute. Patients with one of the three findings – as a new event – have a 72% probability of a stroke; if all 3 findings are present, the probability of an acute stroke is more than 85%. Immediately contact medical control providers and the destination ED and provide prearrival notification. These patients require rapid transport to the hospital.
  • Once the diagnosis of stroke is suspected, time in the field must be minimized. The presence of acute stroke is an indication for "load and go" because there is limited time to institute therapy, and newer therapies can be provided only in the emergency department of the receiving hospital. A more extensive examination or institution of supportive therapies can be accomplished en route to the hospital and in the emergency department.
    If possible, prehospital providers should establish the time of onset of stroke signs and symptoms. This timing will have important implications for potential therapy. If the time of onset of symptoms is viewed as time "zero," all assessments and therapies can be related to that time.
    Early notification of emergency department personnel has always played a critical role in emergency cardiac care and trauma systems. Early notification enables personnel to prepare for the imminent arrival of any seriously ill or injured patient. In many hospitals this notification shortens the time to evaluation of, and critical interventions for, stroke patients.
  • Airway:
    Paralysis of the muscles of the throat, tongue, or mouth can lead to partial or complete upper-airway obstruction. Saliva pools in the throat and may be aspirated. Vomiting occurs, particularly with hemorrhagic stroke, and aspiration of vomitus is a concern. Frequent suctioning of the oropharynx or nasopharynx is required. Supplemental oxygen can be administered according to the needs of the patient.
    Tracheal or bronchial obstruction can occur in stroke patients. Paramedics may need to provide endotracheal intubation in the field when basic airway management is ineffective. Comatose patients are at particular risk for upper-airway obstruction and often require endotracheal intubation.
    Exercise caution in moving the neck if there is a possibility of cervical trauma. Most patients with stroke will be able to relate a history of recent injuries, but this information may be unavailable for a comatose patient. Infrequently a patient will have a stroke in conjunction with a head or neck injury, or the patient will fall with the onset of stroke and have a secondary cervical injury. In such cases the neck should not be hyperextended or the patient turned until a firm cervical collar is in place.
  • Breathing:
    Breathing abnormalities are uncommon, except in patients with severe stroke, and rescue breathing is seldom needed. Abnormal respirations, however, are prominent in comatose patients and portend serious brain injury. Irregular respiratory rates include prolonged pauses, Cheyne-Stokes respirations, or neurogenic hyperventilation. Shallow respirations or inadequate air exchange resulting from paralysis can also occur. Rescue breathing, assisted ventilation, and supplemental oxygen may be helpful.
  • Circulation:
    Cardiac arrest is an uncommon complication of stroke and usually follows respiratory arrest. Very few stroke patients will require chest compressions. Cardiovascular disturbances, on the other hand, are frequent, and monitoring of both blood pressure and cardiac rhythm is part of the early assessment and treatment of a stroke patient. Hypotension or shock is rarely due to stroke, so other causes should be sought.
  • Hypertension is often present in stroke patients, but it typically subsides and does not require treatment. Treatment of hypertension in the field is not recommended. Decisions about this therapy should be made in the emergency department, where blood pressure can be monitored continuously. Cardiac arrhythmias may point to an underlying cardiac cause of stroke or may be a consequence of the stroke. Bradycardia may indicate hypoxia or elevation of ICP.
  • Isotonic fluids (Normal Saline or Lactated Ringer's solution) are used for intravenous therapy; hypotonic fluids are contraindicated. Glucose-containing solutions should be avoided unless hypoglycemia is documented by rapid glucose test or is strongly suspected from history. Bolus administration of fluids is not indicated unless hypovolemia is present.
    Pulse, respirations, and blood pressure should be checked frequently so that changes or abnormalities can be detected. Disturbances in these signs are frequent.
  • 4. Door
    Hospitals should notify community EMS services whether they have the equipment and personnel to manage patients with acute stroke.
    Some hospitals use "Code Stroke" or assemble a specific "stroke team" or prepare a designated "stroke unit" to organize personnel and equipment and evaluate and care for the stroke patient as efficiently as possible. This efficiency is maximized through the use of checklists, standing orders, and protocols.
  • Level of Consciousness: Determining the stroke patient's level of consciousness is crucial. Depressed consciousness within hours of onset of stroke implies a severe brain insult with increased ICP, usually from an intracerebral or subarachnoid hemorrhage. Early stupor or coma is uncommon with nonhemorrhagic strokes although it may occur with massive hemispheric or brain stem infarction.
    Type of Stroke: (Hemorrhagic versus nonhemorrhagic) Histories and physical findings of hemorrhagic and ischemic stroke overlap, and emergency personnel should not depend solely on the clinical presentation for diagnosis. In most cases, a noncontrast CT scan is the definitive test for differentiating ischemic from hemorrhagic stroke.
    Location of Stroke: In alert patients with brain infarction, higher cortical, language, visual, cranial nerve, motor, and sensory functions should be assessed. The neurological signs help distinguish carotid infarction from infarction of the vertebrobasilar distribution.
    Severity of Stroke: The National Institutes of Health Stroke Scale (NIHSS) measures neurological function that correlates with stroke severity and long-term outcome in patients with ischemic stroke. It was designed to provide a reliable, valid, and easy-to-perform alternative to the standard neurological examination for patients with ischemic stroke.
  • Diagnostic studies ordered in the emergency department are aimed at establishing stroke as the cause of the patient's symptoms, differentiating brain infarction from brain hemorrhage and determining the most likely cause of the stroke.
  • Noncontrast CT scan is the most important diagnostic test for an acute stroke.
    On CT images blood from a hemorrhagic stroke has a density that is only about 3% greater than the density of brain tissue. On modern CT scanners this 3% difference in density can be manipulated so that the hemorrhage and free blood will appear distinctly white in comparison with surrounding tissue.
    During the first few hours of a thrombotic or embolic stroke, the noncontrast CT scan will generally appear normal. Brain structures without normal blood flow appear initially the same as structures with good blood flow on the CT scan. For this reason the CT scan will continue to appear “normal” for a few hours after blood flow is blocked or reduced to an area of the brain. A well-defined area of hypodensity, purported to be caused by a lack of blood flow past an occlusion, will rarely develop within the first 3 hours of a stroke.
  • Several conditions mimic stroke. Frequent alternative diagnoses include unrecognized seizures, confusional states, syncope, toxic or metabolic disorders, including hypoglycemia, brain tumors, and subdural hematoma. These mimics are commonly, but not always, associated with global findings rather than focal neurological symptoms and are usually readily detected with standard laboratory tests.
  • 7. Drugs
    All patients presenting within 3 hours of the onset of signs and symptoms consistent with an acute ischemic stroke should be considered for intravenous fibrinolytic therapy.
    These are the current AHA recommendations for management of acute stroke:
    Give t-PA intravenously (0.9 mg/kg, maximum 90 mg), with 10% of the dose given as a bolus followed by an infusion lasting 60 minutes.
    Treatment must be initiated within 3 hours of the onset of ischemic symptoms, tPA cannot be recommended for a person who has had a stroke more than 3 hours earlier, except in an investigational setting. Intravenous tPA is not recommended when the time of stroke onset cannot be ascertained reliably, including strokes recognized on awakening.
  • The use of fibrinolytic agents carries the real risk of major bleeding. Whenever possible, the risks and potential benefits of tPA should be discussed with the patient and the patient's family before treatment is initiated. Use caution when treating people with severe stroke or early CT changes of a recent major cerebral infarction (eg, sulcal effacement, mass effect, or edema) because these findings are associated with an increased risk of hemorrhage following tPA administration.
    The AHA recommendations for treatment of bleeding complications include the following:
    Fibrinolytic therapy should not be used unless facilities that can handle bleeding complications are readily available.
    Bleeding is considered the likely cause of neurological worsening after use of a fibrinolytic drug.
    CT should be obtained on an emergency basis. The following steps should be taken when any life-threatening hemorrhagic complication (including intracranial bleeding) occurs:
    Discontinue the infusion of fibrinolytic drug
    Obtain blood for coagulation tests
    Obtain neurosurgical consultation as necessary
    Consider transfusion, cryoprecipitate, and platelets
  • Three hours was chosen as the upper limit for treating acute stroke patients with IV tPA because that was the time window in the NINDS trial and the FDA used the NINDS protocol to define the upper limit of 3 hours. The NINDS investigators chose 3 hours because prior studies had raised concerns about the safety of giving tPA beyond 3 hours.
    The fibrinolytic protocol should address the following issues:
    Identification of patients with stroke in the prehospital setting
    Assurance of prearrival hospital notification
    Development and maintenance of rapid triage and medical evaluation in the emergency department
    Development of a mechanism for rapidly obtaining a noncontrast head CT
    Identification of who will read the CT
    Determination of contraindications to fibrinolytic therapy
    Location of fibrinolytic drugs and determination of how they will be mixed
    Designation of who will administer drug
    Consultation for atypical cases or hemorrhagic complications
    Determination of where the patient will be admitted
  • The National Institute of Neurological Disorders and Stroke (NINDS) study group has recommended timed goals for the evaluation of stroke patients who are candidates for fibrinolytic therapy. The purpose of these targets or goals is to suggest a timeline that provides a specific evaluation level for 80% of patients with acute stroke.
  • Hemorrhage into the brain can be a devastating condition, causing collapse or sudden development of a focal neurological deficit. Death may occur because of compression or distortion of vital, deep brain structures or increased ICP.
    Optimal management relies on the prevention of continued bleeding, appropriate management of ICP, and timely neurosurgical decompression when warranted. Large intracerebral or cerebellar hematomas often require surgical intervention.
  • Start Show Notes 2 The following presentation is taken from ...

    1. 1. Start ShowStart Show NotesNotes
    2. 2. 2 The following presentation isThe following presentation is taken from thetaken from the American HeartAmerican Heart Association’s Advanced CardiacAssociation’s Advanced Cardiac Life Support : Principles andLife Support : Principles and Practice,Practice, Chapter 18,Chapter 18, AcuteAcute Stroke: Current Treatments andStroke: Current Treatments and ParadigmsParadigms Please use this publication asPlease use this publication as a reference.a reference.
    3. 3. 3 Special Thanks To:Special Thanks To: • ASA Operation StrokeASA Operation Stroke EMS CommitteeEMS Committee Volunteers including:Volunteers including: • Bruce Barnhart, ChairBruce Barnhart, Chair • Amy Boise, Vice ChairAmy Boise, Vice Chair • Nancy Parks, RNNancy Parks, RN • Charlann Staab, RNCharlann Staab, RN • Linda Meiner, RNLinda Meiner, RN • Mike Baros, RNMike Baros, RN • Terry Mason, RNTerry Mason, RN • Don Baird, RNDon Baird, RN • Sandy Nygard, CEPSandy Nygard, CEP • AEMS, Inc.AEMS, Inc. Robert Londeree, M.D.Robert Londeree, M.D. • Phoenix Fire DepartmentPhoenix Fire Department John Gallagher, M.D.John Gallagher, M.D. • Air-Evac Services, Inc.Air-Evac Services, Inc. • Professional MedicalProfessional Medical Transport (PMT)Transport (PMT) • Cigna HealthcareCigna Healthcare • Halle Heart CenterHalle Heart Center • Dave HeathDave Heath
    4. 4. 4 StrokeStroke An Educational ProgramAn Educational Program forfor Pre-Hospital PersonnelPre-Hospital Personnel Developed by:Developed by: EMS CommitteeEMS Committee Operation Stroke – American Stroke AssociationOperation Stroke – American Stroke Association Phoenix, ArizonaPhoenix, Arizona July 2003July 2003
    5. 5. 5 Stroke OverviewStroke Overview Introduction, Definition, Types and RisksIntroduction, Definition, Types and Risks
    6. 6. 6 How Serious Is Stroke inHow Serious Is Stroke in the US?the US? • About 700,000 strokes occur eachAbout 700,000 strokes occur each year.year. • Over 167,000 deaths each year.Over 167,000 deaths each year. • #3 killer.#3 killer. • A leading cause of serious long-A leading cause of serious long- termterm disability in adults.disability in adults. • 4.7 million stroke survivors.4.7 million stroke survivors.
    7. 7. 7 IntroductionIntroduction New emerging therapies offer hope,New emerging therapies offer hope, however the following MUST occur:however the following MUST occur: • Education of at-risk patients.Education of at-risk patients. • Early recognition of stroke signs.Early recognition of stroke signs. • Prompt transport to the hospital.Prompt transport to the hospital. • Rapid hospital triage andRapid hospital triage and evaluation.evaluation.
    8. 8. 8 IntroductionIntroduction With rapid, aggressiveWith rapid, aggressive prehospital strokeprehospital stroke care, at-risk patientscare, at-risk patients can be appropriatelycan be appropriately managed and quicklymanaged and quickly assessed forassessed for fibrinolytic therapyfibrinolytic therapy that may significantlythat may significantly improve theirimprove their outcome.outcome.
    9. 9. 9 Definition of StrokeDefinition of Stroke A stroke is a neurological impairmentA stroke is a neurological impairment caused by a disruption in bloodcaused by a disruption in blood supply to a region of the brain.supply to a region of the brain.
    10. 10. 10 Classification of StrokeClassification of Stroke Two major categories:Two major categories: • Ischemic strokes, caused when a bloodIschemic strokes, caused when a blood vessel supplying the brain is occluded by avessel supplying the brain is occluded by a clot. Responsible for 75% of all strokes.clot. Responsible for 75% of all strokes. • Hemorrhagic strokes, caused when aHemorrhagic strokes, caused when a cerebral artery ruptures.cerebral artery ruptures. Both forms are life threatening.Both forms are life threatening.
    11. 11. 11
    12. 12. 12 Hemorrhagic StrokeHemorrhagic Stroke • Hypertension is theHypertension is the most commonmost common cause ofcause of intracerebralintracerebral hemorrhage.hemorrhage. • Other causes:Other causes: Aneurysms andAneurysms and ArteriovenousArteriovenous malformations.malformations.
    13. 13. 13 Risk Factors for StrokeRisk Factors for Stroke Although some strokes occur withoutAlthough some strokes occur without warning, most stroke victims havewarning, most stroke victims have prior risk factors.prior risk factors. Major strokes can be prevented inMajor strokes can be prevented in many cases, but only if early signsmany cases, but only if early signs and symptoms are heeded.and symptoms are heeded.
    14. 14. 14 Well-DocumentedWell-Documented Modifiable Risk FactorsModifiable Risk Factors • HypertensionHypertension • SmokingSmoking • DiabetesDiabetes • AsymptomaticAsymptomatic Carotid StenosisCarotid Stenosis • Atrial FibrillationAtrial Fibrillation • HyperlipidemiaHyperlipidemia • Sickle Cell DiseaseSickle Cell Disease • Other cardiacOther cardiac diseasesdiseases Goldstein et al.Goldstein et al. Circulation.Circulation. 2001:103:1632001:103:163
    15. 15. 15 Less Well DocumentedLess Well Documented Potentially Modifiable RiskPotentially Modifiable Risk FactorsFactors • ObesityObesity • Physical InactivityPhysical Inactivity • Poor Diet/NutritionPoor Diet/Nutrition • Alcohol AbuseAlcohol Abuse • Drug AbuseDrug Abuse • HypercoagulabilityHypercoagulability • Hormone ReplacementHormone Replacement TherapyTherapy • Oral Contraceptive UseOral Contraceptive Use • Inflammatory ProcessInflammatory Process Goldstein et al.Goldstein et al. Circulation.Circulation. 2001:103:1632001:103:163
    16. 16. 16 Non-modifiable RiskNon-modifiable Risk FactorsFactors • AgeAge • SexSex • Race/EthnicityRace/Ethnicity • Family HistoryFamily History
    17. 17. 17 Stroke DiagnosisStroke Diagnosis Signs and Symptoms of StrokeSigns and Symptoms of Stroke
    18. 18. 18 Signs and Symptoms ofSigns and Symptoms of StrokeStroke Consider in anyoneConsider in anyone who has:who has: • Sudden numbness orSudden numbness or weakness of face, arm,weakness of face, arm, or leg, especially onor leg, especially on one side of the bodyone side of the body • Sudden confusion,Sudden confusion, trouble speaking ortrouble speaking or understandingunderstanding
    19. 19. 19 Signs and Symptoms ofSigns and Symptoms of StrokeStroke • Sudden trouble seeingSudden trouble seeing in one or both eyesin one or both eyes • Sudden troubleSudden trouble walking, dizziness,walking, dizziness, loss of balance orloss of balance or coordinationcoordination • Sudden severeSudden severe headache with noheadache with no known causeknown cause
    20. 20. 20 Signs and Symptoms ofSigns and Symptoms of StrokeStroke THIS IS A LIFE THREATENING EMERGENCY!THIS IS A LIFE THREATENING EMERGENCY! Emergency healthcare providers must:Emergency healthcare providers must: • Recognize the importance of these symptoms.Recognize the importance of these symptoms. • Respond quickly with medical and / or surgicalRespond quickly with medical and / or surgical interventions.interventions.
    21. 21. 21 Stroke Signs andStroke Signs and Symptoms:Symptoms: Hemorrhagic StrokeHemorrhagic Stroke May present similar toMay present similar to Ischemic stroke.Ischemic stroke. Distinguishing Features:Distinguishing Features: • Appear more seriously illAppear more seriously ill • Deteriorate more rapidlyDeteriorate more rapidly • Severe headacheSevere headache • Alteration in consciousnessAlteration in consciousness • Nausea and/or vomitingNausea and/or vomiting • Neck painNeck pain • Intolerance of noise or lightIntolerance of noise or light
    22. 22. 22 Transient Ischemic AttackTransient Ischemic Attack ““Temporary” or “mini” stroke.Temporary” or “mini” stroke. • The signs and symptoms of a TIA areThe signs and symptoms of a TIA are similar to those of a completedsimilar to those of a completed stroke; however, they typically laststroke; however, they typically last only a few minutes to several hoursonly a few minutes to several hours before resolving.before resolving.
    23. 23. 23
    24. 24. 24 Transient Ischemic AttackTransient Ischemic Attack • TIA is the mostTIA is the most importantimportant forecaster offorecaster of impending stroke.impending stroke.
    25. 25. 25 Stroke Patient ManagementStroke Patient Management The Stroke Chain of Survival andThe Stroke Chain of Survival and RecoveryRecovery
    26. 26. 26 Seven Step Stroke Chain ofSeven Step Stroke Chain of Survival and RecoverySurvival and Recovery Pre-arrival: Post-arrival:Pre-arrival: Post-arrival: 1.1. DetectionDetection 4.4. DoorDoor 2.2. DispatchDispatch 5.5. DataData 3.3. DeliveryDelivery 6.6. DecisionDecision 7.7. DrugDrug
    27. 27. 27
    28. 28. 28 1. Detection:1. Detection: Early RecognitionEarly Recognition • Early treatment of stroke depends onEarly treatment of stroke depends on the victim, family members, or otherthe victim, family members, or other bystanders detecting the event.bystanders detecting the event. • Mild signs or symptoms may goMild signs or symptoms may go unnoticed or be denied by the patientunnoticed or be denied by the patient or bystander.or bystander.
    29. 29. 29 2. Dispatch:2. Dispatch: Early EMSEarly EMS Activation and DispatchActivation and Dispatch InstructionsInstructions • Stroke victims and their familiesStroke victims and their families must be taught to activate the EMSmust be taught to activate the EMS system as soon as they detect strokesystem as soon as they detect stroke signs or symptoms.signs or symptoms. • EMS dispatchers must appropriatelyEMS dispatchers must appropriately prioritize the call to ensure a rapidprioritize the call to ensure a rapid response within the EMS system.response within the EMS system.
    30. 30. 30
    31. 31. 31 3. Delivery:3. Delivery: Pre-hospitalPre-hospital Transport and ManagementTransport and Management The goals :The goals : • Rapid identification of the strokeRapid identification of the stroke • Support of vital functionsSupport of vital functions • Rapid transport of the victim to theRapid transport of the victim to the receiving facilityreceiving facility • Pre-arrival notification of thePre-arrival notification of the receiving facilityreceiving facility
    32. 32. 32 3. Delivery:3. Delivery: Pre-hospitalPre-hospital Transport and ManagementTransport and Management The Cincinnati Pre-hospital Stroke ScaleThe Cincinnati Pre-hospital Stroke Scale 1.1. Facial DroopFacial Droop (have patient show teeth or(have patient show teeth or smile):smile): NormalNormal - Both sides of face move- Both sides of face move equally well.equally well. AbnormalAbnormal - One side of face does not- One side of face does not move as well as the other side.move as well as the other side.
    33. 33. 33 3. Delivery:3. Delivery: Pre-hospitalPre-hospital Transport and ManagementTransport and Management The Cincinnati Pre-hospital Stroke ScaleThe Cincinnati Pre-hospital Stroke Scale 2.2. Arm DriftArm Drift (patient closes eyes and holds(patient closes eyes and holds both arms out):both arms out): NormalNormal - Both arms move the same- Both arms move the same oror bothboth arms do not move at all (other findings,arms do not move at all (other findings, such as pronator grip, may be helpful).such as pronator grip, may be helpful). AbnormalAbnormal - One arm does not move- One arm does not move oror oneone arm drifts down compared with the other.arm drifts down compared with the other.
    34. 34. 34 3. Delivery:3. Delivery: Pre-hospitalPre-hospital Transport and ManagementTransport and Management The Cincinnati Pre-hospital Stroke ScaleThe Cincinnati Pre-hospital Stroke Scale 3.3. SpeechSpeech (have the patient say "you can't(have the patient say "you can't teach an old dog new tricks"):teach an old dog new tricks"): NormalNormal - Patient uses correct words- Patient uses correct words withwith no slurringno slurring.. AbnormalAbnormal - Patient slurs words, uses- Patient slurs words, uses inappropriate words,inappropriate words, oror is unable tois unable to speak.speak.
    35. 35. 35 3. Delivery:3. Delivery: Pre-hospitalPre-hospital Transport and ManagementTransport and Management • The presence of acute stroke is anThe presence of acute stroke is an indication for "load and go“.indication for "load and go“. • Establish the time of onset of stroke signsEstablish the time of onset of stroke signs and symptoms!and symptoms! • This timing will have important implicationsThis timing will have important implications for potential therapy. If the time of onset offor potential therapy. If the time of onset of symptoms is viewed as time "zero," allsymptoms is viewed as time "zero," all assessments and therapies can be relatedassessments and therapies can be related to that time.to that time.
    36. 36. 36 3. Delivery:3. Delivery: Pre-hospitalPre-hospital Transport and ManagementTransport and Management Once stroke is diagnosed, pre-Once stroke is diagnosed, pre- hospital treatment includeshospital treatment includes management of the ABCs of criticalmanagement of the ABCs of critical care (care (AAirway,irway, BBreathing, andreathing, and CCirculation) and close monitoring ofirculation) and close monitoring of vital signs.vital signs.
    37. 37. 37 3. Delivery:3. Delivery: Pre-hospitalPre-hospital Transport and ManagementTransport and Management AirwayAirway:: • Paralysis of the muscles of theParalysis of the muscles of the throat, tongue, or mouth can lead tothroat, tongue, or mouth can lead to partial or complete upper-airwaypartial or complete upper-airway obstruction.obstruction. • Saliva pools or vomit may beSaliva pools or vomit may be aspirated.aspirated.
    38. 38. 38 3. Delivery:3. Delivery: Pre-hospitalPre-hospital Transport and ManagementTransport and Management BreathingBreathing:: • Breathing abnormalities areBreathing abnormalities are uncommon, except in patients withuncommon, except in patients with severe stroke, and rescue breathingsevere stroke, and rescue breathing is seldom needed.is seldom needed. • Abnormal respirations, however, areAbnormal respirations, however, are prominent in comatose patients andprominent in comatose patients and portend serious brain injury.portend serious brain injury.
    39. 39. 39 3. Delivery:3. Delivery: Pre-hospitalPre-hospital Transport and ManagementTransport and Management CirculationCirculation:: • Monitor both bloodMonitor both blood pressure and cardiacpressure and cardiac rhythm as part of therhythm as part of the early assessment andearly assessment and treatment of a stroketreatment of a stroke patient.patient. • Hypotension or shock isHypotension or shock is rarely due to stroke, sorarely due to stroke, so other causes should beother causes should be sought.sought.
    40. 40. 40 3. Delivery:3. Delivery: Pre-hospitalPre-hospital Transport and ManagementTransport and Management CirculationCirculation:: • Hypertension is often present inHypertension is often present in stroke patients, but it typicallystroke patients, but it typically subsides and does not requiresubsides and does not require treatment.treatment. • Treatment of hypertension in theTreatment of hypertension in the field is not recommended!field is not recommended!
    41. 41. 41 3. Delivery:3. Delivery: Pre-hospitalPre-hospital Transport and ManagementTransport and Management Other Supportive Measures:Other Supportive Measures: • Intravenous access.Intravenous access. • Management of seizures, and diagnosisManagement of seizures, and diagnosis and treatment of hypoglycemia, can beand treatment of hypoglycemia, can be initiated en route to the hospital ifinitiated en route to the hospital if necessary.necessary. • Isotonic fluids (Normal Saline or LactatedIsotonic fluids (Normal Saline or Lactated Ringer's solution) are used for intravenousRinger's solution) are used for intravenous therapy; hypotonic fluids aretherapy; hypotonic fluids are contraindicatedcontraindicated..
    42. 42. 42 3. Delivery:3. Delivery: Pre-hospitalPre-hospital Transport and ManagementTransport and Management Early Notification:Early Notification: • Early notificationEarly notification enables personnel toenables personnel to prepare for theprepare for the imminent arrival of anyimminent arrival of any seriously ill or injuredseriously ill or injured patient.patient. • In many hospitals thisIn many hospitals this notification shortensnotification shortens the time to evaluationthe time to evaluation of, and criticalof, and critical interventions for, strokeinterventions for, stroke patients.patients.
    43. 43. 43
    44. 44. 44 4. Door:4. Door: Emergency DepartmentEmergency Department TriageTriage Even if a potential stroke victimEven if a potential stroke victim arrives in the emergency departmentarrives in the emergency department in a timely fashion, too often hoursin a timely fashion, too often hours may elapse before appropriatemay elapse before appropriate neurological consultation andneurological consultation and diagnostic studies are performed.diagnostic studies are performed.
    45. 45. 45 5. Data:5. Data: Emergency EvaluationEmergency Evaluation and Managementand Management ABCs shouldABCs should be reassessedbe reassessed and recheckedand rechecked frequently.frequently.
    46. 46. 46 5. Data:5. Data: Emergency EvaluationEmergency Evaluation and Managementand Management An emergencyAn emergency neurological strokeneurological stroke assessment should beassessment should be done quickly focusing ondone quickly focusing on four key issues:four key issues: 1.1. Level of consciousnessLevel of consciousness 2.2. Type of strokeType of stroke (hemorrhagic versus(hemorrhagic versus nonhemorrhagic)nonhemorrhagic) 3.3. Location of strokeLocation of stroke (carotid versus(carotid versus vertebrobasilar)vertebrobasilar) 4.4. Severity of strokeSeverity of stroke
    47. 47. 47 5. Data:5. Data: Emergency EvaluationEmergency Evaluation and Managementand Management • Obtaining the exact time of stroke orObtaining the exact time of stroke or onset of symptoms from family oronset of symptoms from family or people at the scene is criticalpeople at the scene is critical ..
    48. 48. 48 Emergency DiagnosticEmergency Diagnostic StudiesStudies • Currently, CT is the single mostCurrently, CT is the single most important diagnostic test.important diagnostic test. • Goal: CT scan obtained and readGoal: CT scan obtained and read within 45 minutes of the strokewithin 45 minutes of the stroke victim's arrival at the emergencyvictim's arrival at the emergency department.department.
    49. 49. 49 Emergency DiagnosticEmergency Diagnostic StudiesStudies • AnticoagulantsAnticoagulants and fibrinolyticand fibrinolytic agents shouldagents should be withheld untilbe withheld until CT has ruled outCT has ruled out a braina brain hemorrhage.hemorrhage. Hemorrhagic StrokeHemorrhagic Stroke
    50. 50. 50 Differential Diagnosis:Differential Diagnosis: • Unrecognized seizuresUnrecognized seizures • Confusional statesConfusional states • SyncopeSyncope • Toxic or metabolic disordersToxic or metabolic disorders • HypoglycemiaHypoglycemia • Brain tumorsBrain tumors • Subdural hematomaSubdural hematoma Adams et al.Adams et al. Stroke.Stroke. 2003;34:10562003;34:1056
    51. 51. 51 6. Decision:6. Decision: Specific StrokeSpecific Stroke TherapiesTherapies General care includes, but is notGeneral care includes, but is not limited to:limited to: • Prevention of aspirationPrevention of aspiration • Management of hypertensionManagement of hypertension • Management of hyper/hypo-glycemiaManagement of hyper/hypo-glycemia • Management of seizuresManagement of seizures • Management of intra-cranialManagement of intra-cranial pressure (ICP)pressure (ICP) Acute StrokeAcute Stroke, 2003 American Heart Association, 2003 American Heart Association
    52. 52. 52 7. Drugs:7. Drugs: Fibrinolytic TherapyFibrinolytic Therapy for Ischemic Strokefor Ischemic Stroke • Intravenous tPA represents the first FDA-Intravenous tPA represents the first FDA- approved therapy for acute ischemic stroke.approved therapy for acute ischemic stroke. • In the NINDS trial, patients treated with tPAIn the NINDS trial, patients treated with tPA within 3 hours of onset of symptoms were atwithin 3 hours of onset of symptoms were at least 30% more likely to have minimal or noleast 30% more likely to have minimal or no disability at 3 months compared with thosedisability at 3 months compared with those treated with placebotreated with placebo..
    53. 53. 53 7. Drugs:7. Drugs: Fibrinolytic TherapyFibrinolytic Therapy for Ischemic Strokefor Ischemic Stroke • However, there were 10-fold increases in theHowever, there were 10-fold increases in the risk of fatal intracranial hemorrhage in therisk of fatal intracranial hemorrhage in the treated group (3% vs 0.3%) and the frequencytreated group (3% vs 0.3%) and the frequency of all symptomatic hemorrhage (6.4% vs.of all symptomatic hemorrhage (6.4% vs. 0.6%).0.6%). • This increase in symptomatic hemorrhageThis increase in symptomatic hemorrhage diddid notnot lead to an overall increase in mortality inlead to an overall increase in mortality in the treated group.the treated group.
    54. 54. 54 7. Drugs:7. Drugs: Fibrinolytic TherapyFibrinolytic Therapy for Ischemic Strokefor Ischemic Stroke Careful patient selection and strictCareful patient selection and strict adherence to the treatment protocoladherence to the treatment protocol are essentialare essential!!
    55. 55. 55 7. Drugs:7. Drugs: Fibrinolytic TherapyFibrinolytic Therapy for Ischemic Strokefor Ischemic Stroke Because of the time criteria and riskBecause of the time criteria and risk associated with fibrinolytic therapy, itassociated with fibrinolytic therapy, it is important for hospitals to developis important for hospitals to develop specific strategies and protocols thatspecific strategies and protocols that will achieve rapid initiation ofwill achieve rapid initiation of therapy.therapy.
    56. 56. 56 NINDS-Recommended Stroke EvaluationNINDS-Recommended Stroke Evaluation Targets for Potential FibrinolyticTargets for Potential Fibrinolytic Candidates*Candidates* Door to doctorDoor to doctor 10 minutes10 minutes Door to CTDoor to CT†† completioncompletion 25 minutes25 minutes Door to CT readDoor to CT read 45 minutes45 minutes Door to treatmentDoor to treatment 60 minutes60 minutes Access to neurological expertiseAccess to neurological expertise‡‡ 15 minutes15 minutes Access to neurosurgical expertiseAccess to neurosurgical expertise‡‡ 2 hours2 hours Admit to monitored bedAdmit to monitored bed 3 hours3 hours *Target times will not be achieved in all cases, but they represent a reasonable goal.*Target times will not be achieved in all cases, but they represent a reasonable goal. †† CT indicates computed tomography.CT indicates computed tomography. ‡‡ By phone or in person.By phone or in person. Time TargetTime Target
    57. 57. 57 Management ofManagement of Hemorrhagic StrokeHemorrhagic Stroke Optimal management:Optimal management: • Prevention of continued bleeding.Prevention of continued bleeding. • Appropriate management of ICP.Appropriate management of ICP. • Timely neurosurgical decompressionTimely neurosurgical decompression when warranted.when warranted. Large intracerebral or cerebellarLarge intracerebral or cerebellar hematomas often require surgicalhematomas often require surgical intervention.intervention.
    58. 58. 58 Summary:Summary: Pre-hospital CriticalPre-hospital Critical Actions and ManagementActions and Management This is what should happen:This is what should happen:  Recognize the signs of stroke and TIARecognize the signs of stroke and TIA  Rapid neuro exam (Cincinnati StrokeRapid neuro exam (Cincinnati Stroke Scale or similar).Scale or similar).  Determine time of symptom onset (ifDetermine time of symptom onset (if possible).possible).  Provide rapid transport to an ED capableProvide rapid transport to an ED capable of caring for acute stroke (pre-notify).of caring for acute stroke (pre-notify).  Perform finger-stick to assess serumPerform finger-stick to assess serum glucose levels.glucose levels.
    59. 59. 59 Summary:Summary: Pre-hospitalPre-hospital UNACCEPTABLE ActionsUNACCEPTABLE Actions • Failure to recognize signs andFailure to recognize signs and symptoms of stroke/TIAsymptoms of stroke/TIA • Failure to attempt to determineFailure to attempt to determine symptom onset.symptom onset. • Delay in transport.Delay in transport. • Transporting a potential strokeTransporting a potential stroke patient to an ED not capable ofpatient to an ED not capable of treating acute ischemic stroketreating acute ischemic stroke with fibrinolytic therapy.with fibrinolytic therapy.
    60. 60. 60 Summary:Summary: Pre-hospitalPre-hospital UNACCEPTABLE ActionsUNACCEPTABLE Actions • Attempts to treat hypertension inAttempts to treat hypertension in the field.the field. • Failure to notify receiving ED.Failure to notify receiving ED.
    61. 61. 61 Conclusion:Conclusion: Now, fibrinolytic and other emergingNow, fibrinolytic and other emerging therapies offer practitioners thetherapies offer practitioners the opportunity to limit neurologicalopportunity to limit neurological insult and improve outcome in strokeinsult and improve outcome in stroke patients.patients.
    62. 62. 62 Conclusion:Conclusion: The challenge with these therapies isThe challenge with these therapies is that they require administrationthat they require administration within hours of stroke onset, makingwithin hours of stroke onset, making the following measures imperative:the following measures imperative: • Education of at-risk patientsEducation of at-risk patients • Early recognition of stroke signsEarly recognition of stroke signs • Prompt transport to the hospitalPrompt transport to the hospital • Rapid hospital triage and evaluationRapid hospital triage and evaluation

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