2010 Jan Stroke

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STROKESTROKE

Provena Regional EMS SystemProvena Regional EMS SystemJanuary 2010January 2010

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³Grandpa had a stroke´³Grandpa had a stroke´

Not too long ago this statement meantNot too long ago this statement meantdeath or disastrous disability for patientsdeath or disastrous disability for patients

and families.and families. In the 21In the 21stst century medical science hascentury medical science has

progressed in the understanding of progressed in the understanding of STROKE, preventionSTROKE, prevention

and treatmentand treatment

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How big is the problem of How big is the problem of STROKE?STROKE?

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Magnitude of the ProblemMagnitude of the Problem

500,000 Americans annually suffer a500,000 Americans annually suffer aSTROKESTROKE

25% die25% die #3 killer of women#3 killer of women

25% of women have strokes before age25% of women have strokes before age

6565 #1 cause of long term disability#1 cause of long term disability

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Stroke in the USStroke in the US

One case of stroke every 45 secondsOne case of stroke every 45 seconds

Results in devastating disabilityResults in devastating disability

16% institutionalized in nursing homes16% institutionalized in nursing homes 31% assistance with ADL (bathing, dressing31% assistance with ADL (bathing, dressing

eating)eating)

20% assistance with walking20% assistance with walking

30% depressed30% depressed

Annual cost of $43 billion Annual cost of $43 billion

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New AdvancementsNew Advancements

The FDA has approved the same clotThe FDA has approved the same clotbusting drugs (tPA thrombolytic) used inbusting drugs (tPA thrombolytic) used inheart attacks to be used in brain attacksheart attacks to be used in brain attacks ± ±

stroke.stroke. Only 2% of stroke victims are treated withOnly 2% of stroke victims are treated with

thrombolytic medicationthrombolytic medication

Aggressive treatment begins with Aggressive treatment begins withassessment and intervention at point of assessment and intervention at point of patient contactpatient contact

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Before STROKE can beBefore STROKE can be

managedmanaged Learn more about what strokes are andLearn more about what strokes are and

how they happen.how they happen.

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A very selfish organ A very selfish organ

The brain requiresThe brain requires

20 % of 20 % of

the total bloodthe total blood

pumpedpumped

by the heart.by the heart.

No fat for storageNo fat for storage

in the brainin the brain Requires constantRequires constant

supply of oxygen and glucose.supply of oxygen and glucose.

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Blood Supply to the BrainBlood Supply to the Brain

Carotid arteriesCarotid arteries ± ± anterior neckanterior neck

Vertebral arteriesVertebral arteries ± ± through cervicalthrough cervical

vertebraevertebrae

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Circle of WillisCircle of Willis

Both blood supplies join on the under Both blood supplies join on the under surface of the brain.surface of the brain.

FailFail--safe mechanismsafe mechanismin case of a blockagein case of a blockage

somewhere insomewhere in

circulationcirculation

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What can go wrong???What can go wrong???

Disruption of blood flow to the brainDisruption of blood flow to the brain

PlaquePlaque

Foreign debrisForeign debris Broken vesselBroken vessel

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Ischemic STROKEIschemic STROKE

Progressive ThrombusProgressive Thrombus

Plaque depositPlaque deposit ± ± similar to process in heart withsimilar to process in heart withcoronary artery diseasecoronary artery disease

Cerebral EmboliCerebral Emboli ----Clot from somewhere elseClot from somewhere else ----floating debrisfloating debris

Blood clotBlood clot

Air bubble Air bubble

Bubble of amniotic fluidBubble of amniotic fluid

Bone marrow fromBone marrow from

a fracturea fracture

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HemorrhagicHemorrhagic STROKESTROKE

Aneurysm Aneurysm ± ± weakened area in arteryweakened area in artery

CongenitalCongenital

Younger population younger than 40 yearsYounger population younger than 40 years ³worst headache in my life´³worst headache in my life´

Spontaneous Hypertensive BleedSpontaneous Hypertensive Bleed

BP 200/100BP 200/100

Malformed ArteryMalformed Artery

50% younger than 30 years50% younger than 30 years

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Transient Ischemic AttackTransient Ischemic Attack

³One Free Spin´³One Free Spin´

Looks like a stroke but,symptoms improve inLooks like a stroke but,symptoms improve in11--24 hours24 hours

Temporary disruption of blood flow to theTemporary disruption of blood flow to thebrainbrain ----Angina of the brain Angina of the brain

Warning signWarning sign

Mimicked by low blood sugar Mimicked by low blood sugar 30% of patients will have a true stroke in 3030% of patients will have a true stroke in 30

daysdays

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Can STROKES be prevented?Can STROKES be prevented?

Modifiable risk factorsModifiable risk factors

High BPHigh BP

Cigarette smokingCigarette smoking Alcohol intake Alcohol intake

Uncontrolled Heart diseaseUncontrolled Heart disease

Atrial fibrillation Atrial fibrillation

Uncontrolled DiabetesUncontrolled Diabetes

Carotid congestionCarotid congestion

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High blood cholesterolHigh blood cholesterol

Sedentary lifestyleSedentary lifestyle

ObesityObesity SeasonsSeasons

StressStress

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Risk Factors Unable to ControlRisk Factors Unable to Control

Age Age

Gender Gender

RaceRace Prior strokesPrior strokes

HeredityHeredity

Sickle Cell DiseaseSickle Cell Disease

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Signs and Symptoms of Signs and Symptoms of

STROKESTROKE HemorrhagicHemorrhagic

Sudden and dramaticSudden and dramatic

Violent explosive headacheViolent explosive headache Visual disturbanceVisual disturbance

Nausea and vomitingNausea and vomiting

Neck and back painNeck and back pain

Sensitivity to lightSensitivity to light

Weakness on one sideWeakness on one side

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Signs and Symptoms of Signs and Symptoms of

STROKESTROKE Ischemic StrokeIschemic Stroke

Harder to detectHarder to detect

Weakness in one sideWeakness in one side Facial droopingFacial drooping

Numbness and tinglingNumbness and tingling

Language disturbanceLanguage disturbance

Visual disturbanceVisual disturbance

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Left Brain DamageLeft Brain Damage

Right side paralysisRight side paralysis

Speech and language disturbanceSpeech and language disturbance

Behavioral changesBehavioral changes Swallowing problemsSwallowing problems

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Right Brain DamageRight Brain Damage

Left side paralysisLeft side paralysis

Spatial perceptionSpatial perception

CoordinationCoordination PerceptionPerception

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Primary Stroke CarePrimary Stroke Care

180 minute window of time180 minute window of time Time is tissueTime is tissue

The longer the brain is withoutThe longer the brain is without

oxygen and glucose the moreoxygen and glucose the morebrain cells diebrain cells die

Goal is to restore blood flow asGoal is to restore blood flow as

soon as possiblesoon as possible

Treatment is a system beginning with EMS andTreatment is a system beginning with EMS andcontinuing through CCUcontinuing through CCU

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Goals of Primary STROKE CareGoals of Primary STROKE Care

Rapid Recognition of STROKE SymptomsRapid Recognition of STROKE Symptoms

Rapid access in to the systemRapid access in to the system

Assessment Assessment TreatmentTreatment

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Seven D¶s of STROKE CareSeven D¶s of STROKE Care

DetectionDetection ± ±of STROKE symptomsof STROKE symptoms

DispatchDispatch± ± of EMSof EMS

DeliveryDelivery ± ± to a facility prepared to manage STROKEto a facility prepared to manage STROKE

Door to treatmentDoor to treatment± ± rapid diagnosis and decisionrapid diagnosis and decisionmakingmaking

DataData± ± CT ScanCT Scan

DecisionDecision± ± Ischemic or Hemorrhagic, does the patientIschemic or Hemorrhagic, does the patientmeet the criteriameet the criteria

DrugDrug ± ± thrombolytics when appropriatethrombolytics when appropriate

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EMS Has a Critical RoleEMS Has a Critical Role

Educate your communityEducate your community

At first signs of a possible STROKE call At first signs of a possible STROKE call

EMSEMS ³³Don¶t guess call EMS!!´ Don¶t guess call EMS!!´

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Use a ³Use a ³FAST FAST ́ STROKE´ STROKE

Assessment Assessment Modification of Cincinnati PreModification of Cincinnati Pre--HospitalHospitalStroke ScreenStroke Screen

FaceFace Arm Arm

SpeechSpeechTime of onsetTime of onset

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FACEFACE

Look for Facial DroopLook for Facial Droop

Have the patient smile or show his/her teethHave the patient smile or show his/her teeth

NORMALNORMALB

oth sides of theB

oth sides of theface move equallyface move equally

ABNORMAL ABNORMAL One side of One side of

the patient¶s face droopsthe patient¶s face droops

or does not moveor does not move

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ARMS ARMS

Motor Weakness: Look for arm drift by askingMotor Weakness: Look for arm drift by askingthe patient to close eyes and lift arms, palms upthe patient to close eyes and lift arms, palms up

NORMALNORMAL-- arms remainarms remain

extended equally or driftextended equally or drift

downward equallydownward equally

ABNORMAL ABNORMAL ± ± One armOne arm

drifts down compareddrifts down comparedto the other to the other

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SPEECHSPEECH

Ask the patient to say Ask the patient to say ³Y ou can¶t teach an³Y ou can¶t teach an

old dog new tricks´ old dog new tricks´

NORMALNORMAL ± ±Phrase repeated clearly andPhrase repeated clearly andplainlyplainly

ABNORMAL ABNORMAL ± ± Words slurred, abnormal or Words slurred, abnormal or unable to speakunable to speak

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Abnormal Speech Abnormal Speech

Slurring of speechSlurring of speech

Unable to think of wordsUnable to think of words

Inappropriate wordsInappropriate words Expressive aphasiaExpressive aphasia ± ± unable to speakunable to speak

wordswords

Receptive aphasiaReceptive aphasia ± ± unable to understandunable to understandwordswords

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TIME OF ONSETTIME OF ONSET

The window of opportunity to effectivelyThe window of opportunity to effectivelytreat STROKE is 3 hours (180 minutes)treat STROKE is 3 hours (180 minutes)

May be extended to 4 ½ hoursMay be extended to 4 ½ hours

Need to know ³ last known well´.Need to know ³ last known well´.

Difficult whenDifficult when

Patient lives alonePatient lives alone

Woke up with symptomsWoke up with symptoms

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Assessing the Stroke Patient Assessing the Stroke Patient

Initial AssessmentInitial Assessment

General ImpressionGeneral Impression

Airway Airway Airway!!Airway Airway Airway!!

HighHigh--flow O2flow O2

CirculationCirculation HIGH PRIORITY! For transportHIGH PRIORITY! For transport

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Focused history and physical examFocused history and physical exam Perform thorough neurologic exam.Perform thorough neurologic exam.

Cincinnati PreCincinnati Pre--hospital Stroke Screenhospital Stroke Screen

GlasgowComa ScaleGlasgowComa Scale

History of History of

SeizuresSeizures

HeadacheHeadache

Nausea/vomitingNausea/vomiting

Neck painNeck pain

GetGet DETAILEDDETAILED OPQRST and SAMPLEOPQRST and SAMPLE

Obtain baseline set of vitalsObtain baseline set of vitals

Recheck Vital Signs frequentlyRecheck Vital Signs frequently

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PrePre--hospital priorities of carehospital priorities of care

Conduct general medical assessmentConduct general medical assessment TraumaTrauma ± ± recent or within last monthrecent or within last month

Recent seizureRecent seizure

Could be a subdural hematomaCould be a subdural hematoma

Cardiovascular Cardiovascular ± ± on heart medicationson heart medications Does the patient have atrial fibrillationDoes the patient have atrial fibrillation

Does the patient take blood thinnersDoes the patient take blood thinners

Pulse oximetry > 94%Pulse oximetry > 94%

Blood sugar treat if ableBlood sugar treat if able Low blood sugars mimic a strokeLow blood sugars mimic a stroke

PupilsPupils

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PositionPosition

Protect potentially paralyzed partsProtect potentially paralyzed parts

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EMS Packaging Check ListEMS Packaging Check List

Stroke identificationStroke identification

Use of FAST ScreenUse of FAST Screen

Securing A B CsSecuring A B Cs

EKG

monitoring if ableEKG

monitoring if able Oxygen saturation of > 94%Oxygen saturation of > 94%

Management of blood glucoseManagement of blood glucose

IV access if ableIV access if able

Blood specimens obtained if ableBlood specimens obtained if able

Head of Bed elevated 15 degreesHead of Bed elevated 15 degrees

Early communication with EDEarly communication with ED

Urgent transportUrgent transport

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Could this be anything other Could this be anything other

than a STROKE?than a STROKE?

Transient Ischemic AttackTransient Ischemic Attack

HypoglycemiaHypoglycemia

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Goals of STROKE Care 2010Goals of STROKE Care 2010

Standardized assessments, vocabulary,Standardized assessments, vocabulary,protocols and goalsprotocols and goals

Door to treatment goal in ED is 60 minutesDoor to treatment goal in ED is 60 minutes Early EMS identification of candidates andEarly EMS identification of candidates and

packagingpackaging

Direct transport from preDirect transport from pre--hospital to CThospital to CTscan through EDscan through ED

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Putting a Patient Through thePutting a Patient Through the

ProcessProcess EMS is dispatchedEMS is dispatched

EMS Initial Assessment using FAST ScreenEMS Initial Assessment using FAST Screen

ED notified by EMS EARLYED notified by EMS EARLY

Paramedic draws labsParamedic draws labs

CT scan notified by EDCT scan notified by ED

Pharmacy notified by EDPharmacy notified by ED

EMS briefly stops at registration to get labels for EMS briefly stops at registration to get labels for lab tubeslab tubes

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EMS stops briefly in ED for physicianEMS stops briefly in ED for physicianassessmentassessment

EMS and ED nurse take patient directly toEMS and ED nurse take patient directly toCT scan and place the patient on the tableCT scan and place the patient on the table

ED physician talks with familyED physician talks with family

ED RN validates assessment and historyED RN validates assessment and historyusing NIH Stroke Scaleusing NIH Stroke Scale

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ED RN evaluates and treats BPED RN evaluates and treats BP

Radiologist reads CT scan and sendsRadiologist reads CT scan and sends

report to EDreport to ED ED physician makes decision regardingED physician makes decision regarding

treatment with thrombolyticstreatment with thrombolytics

ED calls pharmacy and requests tPAED calls pharmacy and requests tPA

ED RN administers tPAED RN administers tPA

Admission to CCU Admission to CCU

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NINDS Recommended GoalsNINDS Recommended Goals

Door to doctor Door to doctor 10 minutes10 minutes

Door to CT completionDoor to CT completion 25 minutes25 minutes

Door to CT readDoor to CT read 45 minutes45 minutes

Door to treatmentDoor to treatment 60 minutes60 minutes Access to neurological expertise* Access to neurological expertise* 15 minutes15 minutes

Access to neuro Access to neuro--surgical expertise*surgical expertise* 120 minutes120 minutes

Admit to monitored bed Admit to monitored bed 180 minutes180 minutes

* by phone or in person* by phone or in person

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Case Study 1: 6:30 pmCase Study 1: 6:30 pm

ALS ambulance is dispatched to a ALS ambulance is dispatched to ashopping mall for a collapsed female.shopping mall for a collapsed female.

W hat could be the problem?W hat could be the problem?

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What could be the problem?What could be the problem?

SeizureSeizure

CodeCode

Myocardial infarctionMyocardial infarction

Diabetic reactionDiabetic reaction

Over doseOver dose

Anxiety attack Anxiety attack

TraumaTrauma

STROKESTROKE

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6:35 pm6:35 pm

Upon arrival, you find an AfricanUpon arrival, you find an African--American Americanwoman sitting on a bench. She iswoman sitting on a bench. She isconfused, but responds to verbal stimuli.confused, but responds to verbal stimuli.

W hat assessments do you need?W hat assessments do you need?

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Airway and ventilations are adequate Airway and ventilations are adequate

Regular pulse and good perfusionRegular pulse and good perfusion

Speech is garbledSpeech is garbled Unable to move her right arm and legUnable to move her right arm and leg

Denies chest pain.Denies chest pain.

BP 195/105, pulse 90, respirations 18BP 195/105, pulse 90, respirations 18

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The patient¶s daughter reports that her mother The patient¶s daughter reports that her mother felt fine while shopping, when suddenly her armfelt fine while shopping, when suddenly her armfelt funny. She sat down on the bench, and didfelt funny. She sat down on the bench, and did

not fall or hit her head. She did not losenot fall or hit her head. She did not loseconsciousness and did not have a seizure.consciousness and did not have a seizure.

The woman did not complain of a headache,The woman did not complain of a headache,and has no history of seizures, diabetes, chestand has no history of seizures, diabetes, chestpain or palpitations.pain or palpitations.

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6:43 pm6:43 pm

This patient, Mrs. Short, is 65 years old.This patient, Mrs. Short, is 65 years old.She has left sided facial drooping and rightShe has left sided facial drooping and rightarm and leg weakness. She can move thearm and leg weakness. She can move theright arm and leg slightly, but with greatright arm and leg slightly, but with greatdifficulty. Her speech is slurred. All of difficulty. Her speech is slurred. All of these signs and symptoms are new in thethese signs and symptoms are new in the

last half hour.last half hour.

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FASTFAST

How does Mrs. Short fare on the FASTHow does Mrs. Short fare on the FASTScreen?Screen?

FaceFace

Arm Arm

SpeechSpeech

TimeTime

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Case 1 contCase 1 cont

FaceFace ---- left sided facial droopingleft sided facial drooping

Arm Arm ± ± right arm and leg weaknessright arm and leg weakness

SpeechSpeech ± ± speech is slurredspeech is slurred Time last known wellTime last known well ---- unsureunsure

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HIGH PRIORITYHIGH PRIORITY

Determine precise time of onset of signsDetermine precise time of onset of signsand symptoms.and symptoms.

If thrombolytic therapy is to be considered,If thrombolytic therapy is to be considered,itsits infusioninfusion must begin within 3 hours of must begin within 3 hours of the onset of symptoms.the onset of symptoms.

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Elicit cues to determine exactElicit cues to determine exactonsetonset

The daughter remembers that she and her The daughter remembers that she and her mother were walking past the electronicsmother were walking past the electronicsstore and stopped to watch the weather onstore and stopped to watch the weather on

the local news program. The weather isthe local news program. The weather isalways on at 6:20. The symptoms beganalways on at 6:20. The symptoms beganwhen they stopped.when they stopped.

The 180 minute clock started at 6:20 pm.The 180 minute clock started at 6:20 pm.

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Provide preProvide pre--arrival notification to receivingarrival notification to receivinghospital of potential stroke patient.hospital of potential stroke patient.

Rapid transport to an appropriate facility.Rapid transport to an appropriate facility.

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6:50 pm6:50 pm

Enroute vital signs are:Enroute vital signs are:

BP 198/120BP 198/120

Pulse 92Pulse 92

Respirations 22Respirations 22

Do you want to treat the blood pressure at thisDo you want to treat the blood pressure at this

time?time?

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Do not treat the high blood pressure. ItDo not treat the high blood pressure. Itmay be the only perfusion for her may be the only perfusion for her distressed brain.distressed brain.

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Does Mrs. Short meet the criteria so far toDoes Mrs. Short meet the criteria so far tobe on the Primary STROKE Care track tobe on the Primary STROKE Care track toreceive thrombolytics (tPA)?receive thrombolytics (tPA)?

YES, Proceed to a hospital ready toYES, Proceed to a hospital ready tomanage an acute STROKEmanage an acute STROKE

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Case Study 2: 0635 HoursCase Study 2: 0635 Hours

70 year 70 year--old woman, Mrs. Blackold woman, Mrs. Black

Awake with slight weakness and tingling Awake with slight weakness and tinglingin her left side.in her left side.

Speech is hesitant and slightly slurredSpeech is hesitant and slightly slurred

Vision seems to be normalVision seems to be normal

No facial droopingNo facial drooping Good eye contactGood eye contact

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Case 2 cont.Case 2 cont.

Symptoms began 0530 per husbandSymptoms began 0530 per husband

Speech was fine before thatSpeech was fine before that

Blood sugar 50 mg/dlBlood sugar 50 mg/dl

No emesis or seizureNo emesis or seizure

BP 150/90, Pulse 80, Respirations 16BP 150/90, Pulse 80, Respirations 16

O2 sat 92%O2 sat 92%

Weighs 140 poundsWeighs 140 pounds

No aspirin intakeNo aspirin intake

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FASTFAST

How does Mrs. Black fareHow does Mrs. Black fare

on the FAST Screen?on the FAST Screen?

FaceFace Arm Arm

SpeechSpeech

TimeTime

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FaceFace ---- no droopingno drooping

Arm Arm ± ± slight weakness and tinglingslight weakness and tingling

SpeechSpeech ---- Speech is hesitant and slightlySpeech is hesitant and slightlyslurredslurred

Time known wellTime known well ---- 65 minutes ago65 minutes ago

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Case Study 3Case Study 3

1400 hours1400 hours

80 year 80 year--old man, Mr. Schmidtold man, Mr. Schmidt

Daughter found him 15 minutes agoDaughter found him 15 minutes ago

Unknown down timeUnknown down time

Awake Awake

Drooping left side of faceDrooping left side of face

No movement of right arm and legNo movement of right arm and leg

Speech too slurred to understandSpeech too slurred to understand

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Case 3 cont.Case 3 cont.

Seems to see youSeems to see you

Looks only to leftLooks only to left

Blood sugar 200 mg/dlBlood sugar 200 mg/dl No evidence of seizure or emesisNo evidence of seizure or emesis

BP 180/100, pulse 72, respirations 15BP 180/100, pulse 72, respirations 15

Unsure of aspirinUnsure of aspirin

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FASTFAST

How does Mr. Schmidt fareHow does Mr. Schmidt fare

on the FAST Screen?on the FAST Screen?

FaceFace Arm Arm

SpeechSpeech

TimeTime

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FaceFace ----Drooping left side of faceDrooping left side of face

Arm Arm ± ± No movement of right arm and legNo movement of right arm and leg

SpeechSpeech ± ± Speech too slurred toSpeech too slurred tounderstandunderstand

Time known wellTime known well ± ± unknown, daughter unknown, daughter

found him 15 minutes ago, but she had notfound him 15 minutes ago, but she had nothad contact with him since yesterdayhad contact with him since yesterday

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Case 3 Cont.Case 3 Cont.

Time of onset = unknownTime of onset = unknown

Severe Headache = unknownSevere Headache = unknown

Emesis = noEmesis = no ASA = unknown ASA = unknown

Seizures = noSeizures = no

Consenting party = yesConsenting party = yes Blood sugar = OKBlood sugar = OK

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Case 3Case 3

Time window has closed. Not a candidateTime window has closed. Not a candidatefor thrombolytic treatment. Transport tofor thrombolytic treatment. Transport toED for acute care.ED for acute care.

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QuizQuiz

What are the 2 general types of stroke?What are the 2 general types of stroke? 1.1.

2.2.

What condition is equivalent to ³angina´ of theWhat condition is equivalent to ³angina´ of thebrain?brain? 3.3.

What are 3 risk factors for stroke that can beWhat are 3 risk factors for stroke that can bemodified?modified? 4.4.

5.5.

6.6.

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What are 2 risk factors for stroke that cannot beWhat are 2 risk factors for stroke that cannot bemodified?modified?

7.7.

8.8. What are you measuring in a FAST StrokeWhat are you measuring in a FAST Stroke

Screen?Screen?

9.9.

10.10.

11.11.

12.12.

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In the 21In the 21stst century, some patients sufferingcentury, some patients sufferingfrom STROKE can be treated using whatfrom STROKE can be treated using whattype of medication?type of medication?

13.13.

What is the time deadline that must be metWhat is the time deadline that must be metin order to use the aggressive medicationin order to use the aggressive medication

in the question above?in the question above? 14.14.

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How can EMS make a difference in earlyHow can EMS make a difference in earlyrecognition of STROKE in their recognition of STROKE in their community?community?

15.15.

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Answers Answers

1. Hemorrhagic stroke1. Hemorrhagic stroke

2. Ischemic stroke2. Ischemic stroke

3. TIA (transient ischemic attack)3. TIA (transient ischemic attack)

4.4. ± ± 6.6. High BPHigh BP

Cigarette smokingCigarette smoking High blood cholesterolHigh blood cholesterol

Sedentary lifestyleSedentary lifestyle Carotid CongestionCarotid Congestion

ObesityObesity Uncontrolled diabetesUncontrolled diabetes

SeasonsSeasons Atrial fibrillation Atrial fibrillation StressStress Uncontrolled heart diseaseUncontrolled heart disease

Alcohol intake Alcohol intake

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77--88 Age Age prior strokesprior strokes

Gender Gender heredityheredity

RaceRace Sickle cell diseaseSickle cell disease

9. Face9. Face

10. Arm10. Arm

11. Speech11. Speech

12. Last known well12. Last known well

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Documents

2010 Jan Stroke