StrokeStrokeContinuing EducationContinuing EducationEMS Region 7EMS Region 7May 2010May 2010

MENINGES

1) Dura Mater2) Arachnoid3) Pia Mater

Epidural Hemorrhage Subdural Hemorrhage

Dura Mater creates Potential Space

* Epidural space * Subdural space

CEREBRAL CORTEX

FRONTAL LOBE

Personality Behavior Voluntary motor function Motor speech (Broca’s), Left side dominent Intellectual functions, problem solving Judgment; good/bad, right/wrong

Called the “MOM” portion of the Brain

PARIETAL LOBE

Primary sensory lobe; pain, pressure, vibration, touch Localization of stimuli Object recognition Position sense Sensory association

TEMPORAL LOBE

Primary auditory lobe Long term memory Emotions Cognitive speech (Wernicke’s); organize language, understand and respond to verbal input Uncus discriminates smells

OCCIPITAL LOBE

Processing visual input

INTRACRANIAL DYNAMICS

Three substances in the cranial vault Brain 80% Blood 12% CSF 8%

MONRO-KELLIE DOCTRINEIf one of these substances increase, then one or both of the other must therefore decrease to maintain normal pressure within the cranial vault

BLOOD SUPPLYBLOOD SUPPLY The Brain:The Brain:

Needs constant supply of O2 and Needs constant supply of O2 and glucoseglucose

Receives 15% of cardiac outputReceives 15% of cardiac output Consumes 20% of inspired O2Consumes 20% of inspired O2 Perfused by the Circle of Willis Perfused by the Circle of Willis

Not that Willis…..Not that Willis…..

THE CIRCLE OF WILLIS !THE CIRCLE OF WILLIS !

THE CIRCLE OF WILLISTHE CIRCLE OF WILLIS The brain’s own arterial circulatory

system Connected to the aorta by the

carotid arteries

Stroke is no accident! CVA is now called Stroke or “Brain

Attack” Carries the same urgency as AMI

STROKE DEFINED

Sudden, catastrophic event causing focal neuro impairment due to interruption of cerebral blood flow Most often caused by an occlusion or

rupture of an artery that supplies a specific part of the brain

BRAIN ATTACK / ISCHEMIC BRAIN ATTACK / ISCHEMIC STROKESTROKE Caused by anything that decreases Caused by anything that decreases

blood flow to the brainblood flow to the brain Thrombus /embolus (A-fib, Thrombus /embolus (A-fib,

hypercoagulable state, etc) hypercoagulable state, etc) Carotid artery plaquesCarotid artery plaques VasospasmVasospasm Hypotension with carotid artery Hypotension with carotid artery

stenosis stenosis

Ischemia

Can result from: Vascular injuries Secondary vascular spasm Increased intracranial pressure Focal or more global infarcts can result

No characteristic clinical picture May range from a TIA to infarction of a major

portion of the ipsilateral (on the same side) hemisphere

If adequate intracranial collateral circulation is present, may see no signs or symptoms

Neurological symptoms may include: monoparesis to hemiparesis with or

without a defect in vision impairment of speech or language transient monocular blindness

Most occlusions in the first portion of this artery are due to emboli and typically produce a neurological deficit

Opportunity for collateral circulation is restricted

Neurological symptoms:hemiplegia (paralysis of one side

of the body) hemisensory deficit hemianopsia (blindness in 1/2 of

the visual field) aphasia (if infarct is in the

dominant hemisphere)

Neurological symptoms may include:

weakness of the opposite leg with or without sensory involvement

apraxia (particularly of gait)

possible cognitive impairment

Neurological symptoms may include:severe vertigo, nausea, vomiting, dysphagia, ipsilateral cerebellar ataxia decreased pain and temperature loss of 2 point discrimination diplopia, visual field loss, gaze palsies

Neurological symptoms may include:Alterations in LOC, delerium and coma

possiblehemisensory disturbancesvisual disturbances with possible

blindnessVisual agnosia-lack of recognition or

understanding of visual objects or loss of color

AmenesiaLoss of motor function possible

STROKE STATISTICS Stroke occurs every 40 seconds 3rd leading cause of mortality

143,00 deaths annually Death due to stroke every 3-4 minutes

4.8 million stroke survivors Leading cause of serious long tern disability Life time cost of an ischemic stroke is

$140,000 Strides in prevention are off set by aging

population 80% of strokes are preventable!!!

TIA STATISTICS

200,000-500,000 Per Year Prevalence increases with age Half of those with TIA’s fail to report it

15% of strokes are preceded by a TIA

Following TIA 12% of patients experience a stroke

within the next 30 days 3-17% have a stroke within 90 days 25% die with in 1 year

STROKE AWARENESS:SURVEY

38% aware of 5 stroke signs and would call 911

Stroke pts: 55% able to identify 1 stroke warning

sign! 60% able to identify 1 stroke risk

factor! Huge public education need

Interrupted supply O2 and glucose causing anaerobic metabolism and increasing cellular waste (toxins) causing cell membrane dysfunction causing cellular swelling and pressure on the cells which causes cellular ischemia and death

EFFECT OF STROKE ON BRAIN CELLS

Age >55 risk doubles every decade

Gender Male more common Female higher death rate

Heredity Relative with stroke increased risk

Prior stroke/TIA 25-40% chance of stroke in 5 years

Prior MI Race

Increased in Hispanic/Asian/Pacific Islander African American 2x higher rate than whites

STROKE RISK FACTORS: NON MODIFIABLE

STROKE RISK FACTORS: MODIFIABLE HTN

>140/90 Most important risk factor Most common cause of stroke Increased risk 4-6 times Improved treatment may be responsible

for decreased stroke deaths High Cholesterol

Clogs arteries 107 million in US

STROKE RISK FACTORS: MODIFIABLE Atrial Fibrillation

Pooling blood promotes clots Increases risk by 6 times 15% stroke patients have A-Fib

Diabetes Most have other risk factors as well 2/3 die from stroke or heart disease Increases risk 2-4 times

STROKE RISK FACTORS: MODIFIABLE Tobacco

Damages vessel walls Accelerates arterial stenosis Increases CV workload Increases BP Increasing clotting factors Doubles risk

Alcohol Heavy use related to stroke >2/day may increase risk by 50% Leads to HTN

STROKE RISK FACTORS: MODIFIABLE Obesity

Strains entire cardiovascular system Likely to have DM, HTN and high

cholesterol

NEURO ASSESSEMENT

BASELINE ASSESSMENT IS OF GREAT IMPORTANCE TO

DETERMINE THE HISTORY OF THE PRESENT ILLNESS AND TO ACT

AS A GUIDE FOR FURTHER SERIAL ASSESSMENTS

ASSESSMENT: SYMPTOMS/CHIEF COMPLAINT Headache of unknown cause AMS/Sudden confusion Photophobia, visual deficits Stiff neck Weakness/paralysis Sensory loss face, arm or leg Vertigo, dizziness,syncope,ataxia Trouble speaking or understanding Seizure

ASSESSMENT: CINCINNATI STROKE SCALE 3 Components

Facial (Smile) Arm drift-Unilateral weakness Speech- abnormal speech pattern

Takes less than 1 minute Reliability

1 finding= 72% 3 findings = 85%

However, patients can be having a stroke despite a normal CSS

Correct documentation

CSS: ARM DRIFT

Weakness Clumsiness Heaviness Documentation – in narrative or use

built-in Zoll categories Normal Drift Can’t resist gravity No effort No movement

CSS: SPEECH

Speech Ask the patient to repeat a simple sentence

The sky is blue You can’t teach an old dog new tricks

Assess Ability to form words Abnormal pattern Articulation Hoarseness Phonation Rate

CCS: SMILE

Facial Symmetry Smile/Grimace Show teeth

Does he have a deficit?

BELL’S PALSY vs. STROKE

Bell’s Palsy Total hemiparesis of face

Stroke Can wrinkle both sides of forehead but

has lower facial weakness

STROKE: ABNORMAL PRESENTATIONS Weakness

Quick neuro exam Negative suspect ACS obtain a 12 lead Positive Consider Stroke

Syncope Hx of seizures Exam

GCS ECG Trauma

STROKE: ABNORMAL PRESENTATIONS AMS

Scene size up Differential diagnosis

AEIOUTIPS Other

Visual disturbances Hoarseness “Heavy” sensation Cranial nerve S/S

STROKE: ABNORMAL PRESENTATIONS Strong trend for misdiagnosis <35

50% of those were diagnosed as inner ear disorder

Women AMS (most common) Meaning confusion Disorientation Loss of consciousness Delays in triage, exam and imaging

Lessons learned in Trauma and Cardiac care can be applied to Stroke care: Patients need definitive treatment in

the hospital Outcomes greatly improved with early

access to emergency care

IT’S NEURO TIME!!IT’S NEURO TIME!!

STROKE CHAIN OF SURVIVAL

Goal Minimize brain injury and maximize

recovery Rapid

Recognition and reaction EMS Dispatch EMS transport and pre arrival

notification Diagnosis and treatment

7 D’s OF STROKE CAREPOTENTIAL POINTS OF DELAY Detection Dispatch Delivery with advance notification Door Data Decision Drug/Monitoring

EMS PREHOSPITAL STROKE CARE

ID stroke symptoms Transport to a Stroke Center Medical Center pre arrival notification Safest most efficient method of

transport Manage the life threats Perform targeted neuro assessment ID/treat other causes of symptoms Establish time of symptom onset

OVERVIEW STROKE CARE

Prehospital Identify signs CSS/assessment Time of onset Check glucose Support ABC’s Oxygen Monitor Transport Alert hospital

Glucose checkGlucose check Limit IV attempts to 2 Limit IV attempts to 2 Neuro Exam (GCS, Stroke Scale, Pupils)Neuro Exam (GCS, Stroke Scale, Pupils) Note TIME OF ONSET OF SYMPTOMS!Note TIME OF ONSET OF SYMPTOMS! Protect patient from injury/aspirationProtect patient from injury/aspiration Be attuned to subtle changes/ongoing Be attuned to subtle changes/ongoing

assessmentassessment

MINIMIZE SCENE TIME, BUT MINIMIZE SCENE TIME, BUT ENSURE …ENSURE …

OVERVIEW STROKE CARE

What does the ED do? ABC’s O2 IV access 12 lead Labs Detailed neuro exam CT, MRI Stroke Team

Clot busters• tPA

Clot removal device• MERCI

TREATMENTS FOR ISCHEMIC TREATMENTS FOR ISCHEMIC STROKESTROKE

OVERVIEW STROKE CARE

IV tPA Time: 3 hrs (5/09: up to 4.5 hr) Administered in ED Class I for qualified pts Good outcomes only if given in window ICU admit w/ close monitoring Intra-arterial tPA Med directly to thrombus Class I up to 6 hrs k Qualified interventionalist at specialty

center Beneficial up to 6+ hr of onset

Interventional Therapy • "MERCI" procedure Mechanical Embolus Removal in

Cerebral Intervention Removes thrombus from vessel Useful when tPA contraindicated

TRANSPORT TRANSPORT CONSIDERATIONSCONSIDERATIONS

Time is Brain!Time is Brain!

Stroke Centers?Stroke Centers?Aero medical?Aero medical?

Benefit of stroke centers is also rehab

Swallow evaluation 65% have dysphagia Rehab needs assessment Begin rehab Placement long term, inpatient, outpatient,

home

EMS PLAYS INTEGRAL ROLE IN EMS PLAYS INTEGRAL ROLE IN STROKE CARE!STROKE CARE!

Early access to hospital care is crucial to Early access to hospital care is crucial to optimizing patient outcomeoptimizing patient outcome

Taking care of stroke victims Worrying about becoming stroke victims

Assessment and Evaluation

Prehospital management of the head-injured patient is determined by: Mechanism and severity of injury Patient's level of consciousness Associated injuries

Airway and ventilation Circulation Neurological examination Fluid therapy Drug therapy

AVOID TUNNEL VISION!AVOID TUNNEL VISION! Form a list of differential Form a list of differential

diagnoses for EACH patient. diagnoses for EACH patient. What are some reasons why What are some reasons why

people have alterations in their people have alterations in their mental status?mental status?

Psychiatric causes should always be the Psychiatric causes should always be the last explanation, last explanation, even if the patient has even if the patient has a previous history of psychological a previous history of psychological illness.illness.

Brand New Stroke SMO for 2010 – learn it, love it, live it!

Code 38SUSPECTED STROKE

Perform Cincinnati Pre-Hospital Stroke Scale*

Identify patients last “known normal”

If Stroke scale positive and “last known normal” < 3 hours, transport to the nearest most appropriate facility.

Do not delay scene time. Initiate rapid transport.

Effective 05/01/10ALS

INITIAL MEDICAL CARE

*Cincinnati Prehospital Stroke ScaleFacial Droop (Have the patient show teeth or smile)

•Normal – Both sides of face move equally well•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 both arms do not move at all (other findings, such as pronator grip, may be helpful)•Abnormal – One arm does not move or one arm drifts down compared with the other

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 inappropriate words, or is unable to speak

Blood Glucose GO TO CODE 32

12 Lead EKGOther SMO CODE’s as indicated:

Coma of Unknown OriginSeizures

< 60 or > 400

QUESTIONS

Thank You for Your Attention