PRIMARY STROKE CENTERFirst Responder Update

2009

ObjectivesObjectives Recognize stroke as an emergency Describe the pathophysiology of stroke Identify signs and symptoms of stroke Identify risk factors for stroke Describe the Cincinnati Prehospital Stroke

Scale List the steps for emergency dispatch and

field assessment Describe care actions for a stroke patient Identify the difference between a Primary and

a Comprehensive Stroke Center

BRAIN ATTACKBRAIN ATTACKStroke is a Medical EmergencyStroke is a Medical Emergency

• Every 45 seconds someone in the US experiences a stroke

• Each year more than 795,000 people experience a stroke

• Stroke is the 3rd leading cause of death and leading cause of adult disability

• Stroke is treatable within 3 hours of symptom onset

• EMS transport shortens time to hospital care

• EMS is the first medical contact for over 50% of stroke patients

Brain AttackBrain AttackTime Lost is Brain LostTime Lost is Brain Lost

Increase public awareness

Timely access to 911Deployment of

informed EMS personnel

Delivery to a stroke center

Stroke is treatable

Stroke ClassificationStroke Classification

Ischemic StrokeIschemic Stroke

• Abrupt and dramatic development of a focal neurological deficit caused by an interruption of blood flow to the brain

• Accounts for 80% to 85% of all strokes

Ischemic StrokeIschemic StrokeThromboticThrombotic

• Stationary clot that forms in a blood vessel

• Atherosclerosis – leads to platelet aggregation; coagulation is activated and thrombus develops; decreases blood flow

through carotid artery

Ischemic StrokeIschemic StrokeEmbolicEmbolic

• Emboli travel from other areas of the body and lodge in cerebral vessels

• Common causes – atrial fibrillation, patent foramen ovale (PFO), valvular disease, carotid plaques, foreign substances

Ischemic PenumbraIschemic Penumbra

Hemorrhagic StrokeIntracerebral HemorrhageIntracerebral Hemorrhage

Hemorrhagic StrokeSubarachnoid HemorrhageSubarachnoid Hemorrhage

Risk Factors for StrokeRisk Factors for Stroke

• Uncontrollable

• Controllable

• Lifestyle Modification

Risk FactorsRisk Factors

Uncontrollable• Age• Sex• Race• Prior stroke• Family history

Risk FactorsRisk Factors

Controllable• High blood pressure• High cholesterol• Atrial fibrillation• Diabetes• Blood disorders

Lifestyle ModificationsLifestyle Modifications

Smoking

Weight / Inactivity

Alcohol

Medical ManagementMedical Management

• Antiplatelets

• Statins

• Diabetic meds

• Antihypertensives

• Anti-arrhythmia meds

Surgical ManagementSurgical Management

• Carotid endarterectomy

• Angioplasty

• Stenting

Symptoms of StrokeSymptoms of Stroke

• Sudden numbness or weakness of the face, arm or leg, especially on one side of the body

• Sudden confusion, difficulty with speech/comprehension

• Sudden trouble seeing in one or both eyes

• Sudden trouble walking, dizziness, loss of balance or coordination

• Sudden severe headache with no known cause

Less Common Less Common Symptoms of StrokeSymptoms of Stroke

• Altered level of consciousness

• Respiratory distress

• Difficulty swallowing

• Pupils unequal in size/reaction to light

• Convulsion / seizures

• Loss of bladder / bowel control

• Nausea & vomiting

Stroke Look AlikeStroke Look Alike

• Trauma

• Seizures (postictal)

• Hypoglycemia

• Brain tumor

• Migraine

• Infections (brain abscess)

Transient Ischemic Attack (TIA)Transient Ischemic Attack (TIA)• Neurological deficit lasting <

24 hours – Transient duration of neuro

deficits and complete return to normal

– Majority of TIAs (90%) resolve within 10 minutes

– Half of people with 1 or m more TIAs will later have a stroke within 1 year

– Considered as emergent as a stroke

• Main difference– Short duration of symptoms and

lack of permanent brain injury

Cerebral Blood FlowCerebral Blood Flow

Neuroanatomical EffectsNeuroanatomical Effects

• Right hemisphere

• Left hemisphere

• Cerebellum

• Brain stem

Right Hemisphere StrokeRight Hemisphere Stroke

• Effects left side of body

• Spatial or perceptual abilities

• Impulsive, unaware of their impairments

• Left-sided neglect• Short-term memory

problems• Often non-dominant

Left Hemisphere StrokeLeft Hemisphere Stroke

• Effects right side of body

• Speech and language

• Aphasia• Slow, cautious

behavior• Memory problems

Cerebellar StrokeCerebellar Stroke

• Reflexes• Balance and

coordination• Dizziness• Nausea and

vomiting

Brain Stem StrokeBrain Stem Stroke

• Can be devastating• Controls all

involuntary functions• Respirations, BP,

pulse• Eye movements,

hearing, speech, swallowing

Other Effects of StrokeOther Effects of Stroke

• Environmental adaptations

• Depression

• Changes in relationships

RecoveryRecovery

• Some brain cells may be temporarily damaged

• Another part of the brain may take over for damaged parts

• Some may never recover• Rate of recovery varies• Rehab starts in the hospital as soon as

possible after the stroke

Dispatch and Dispatch and Field AssessmentField Assessment

Chain of Survival• Symptom recognition• Emergency action• EMS arrival and

patient transport• Diagnosis and

treatment

Time is BrainTime is Brain

NINDS NINDS 6 Actions of Dispatch6 Actions of Dispatch

1. Install enhanced 911 systems whenever possible. 2. Utilize a recognized Emergency Medical Dispatch

(EMD) call receiving algorithm. 3. Send the closest unit with high priority. 4. Ask the caller: “When was the patient last seen in

his/her usual state of health before becoming weak, paralyzed or unable to speak clearly?”a. Dispatchers should also try to determine past medical

history and relay all information to EMS providers.

5. Dispatchers should be medically supervised and should have stroke education programs and initiatives in place.

6. Obtain feedback about outcomes from EMS and medical personnel.

EMS ArrivalEMS Arrival10 Steps for Stroke Assessment10 Steps for Stroke Assessment• Evaluate & monitor

ABCs• Blood pressure• Blood glucose• ECG

• O2 per protocol

• Stroke screen• Patient history with

Time Last Normal• Family involvement• Minimize time on

scene• Transport to stroke

center

Prehospital Stroke AssessmentPrehospital Stroke AssessmentCincinnati Stroke ScaleCincinnati Stroke Scale

F – A – S – T • F – Facial Droop• A – Arm Drift• S – Speech• T – Time Last

Seen Normal

If any 1 of these 3signs is abnormal, theprobability of a stroke

is 72%

Cincinnati Stroke ScaleCincinnati Stroke ScaleFacial DroopFacial Droop

Normal – Both sides of face move equally

Abnormal – one side of face does not move as well as other side

Have patient show teeth or smile

Cincinnati Stroke ScaleCincinnati Stroke ScaleArm DriftArm Drift

Patient closes eyes and extends both arms straight out for 10 seconds

Normal – Both arms move the same or both arms do not move at all

Abnormal – one arm does not move or one arm drifts down compared with the other

Cincinnati Stroke ScaleCincinnati Stroke ScaleSpeechSpeech

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 wrong words, or is unable to speak

• Time Last Seen Normal

• Time Symptoms Identified

Cincinnati Stroke ScaleCincinnati Stroke ScaleTimeTime

Chilton Memorial HospitalChilton Memorial HospitalBAT ActivationBAT Activation

• Primary Stroke Center• 3-Hour Treatment Window (IV

tPA)• Brain Attack Team

– First Responder– ED MD & RN– Neurology– Radiology, Lab, Pharmacy– ICU RN– Stroke Program Coordinator

• Goal: Door to Drug less than 60 minutes

• Transfer to Comprehensive Stroke Center if indicated

Ischemic Stroke TreatmentIschemic Stroke Treatment

• Work-Up Starts in Field– Evaluation– Patient history– Physical exam– Lab evaluation– Neuroimaging– Early supportive medical therapy for Acute Ischemic Stroke

Acute Therapies - tPAAcute Therapies - tPA

• Activase works by stimulating the body's own clot-dissolving mechanism by activating plasminogen, a naturally occurring substance secreted by endothelial cells in response to injury to the artery walls that contributes to clot formation.

Acute Therapies - tPAAcute Therapies - tPA

• IV tPA– 3-hour time window– Appropriate for 5-10% of

stroke patients

• IA tPA– ? 6-hour time window– Faster than IV method– Less tPA is needed

MERCI Retrieval SystemMERCI Retrieval System

• Patients ineligible for IV tPA– Symptom onset >3 hours– On oral anticoagulants– Postoperative– In-hospital stroke– Recent stroke or MI– Postpartum

• Patients who “fail” IV tPA– No improvement

• Patients with moderate-to-severe stroke– NIHSS ≥ 8– Large vessel occlusion

Additional TherapiesAdditional Therapies

• Acute antithrombotic therapy

• Blood pressure management

• Care for hemorrhage

• Additional initial measures

• Supportive care

Hemorrhagic Stroke TreatmentHemorrhagic Stroke Treatment

• Lifesaving measures

• Relief of symptoms

• Repair the cause

RememberRemember ! !

… An Emergency… A Brain Attack… Treatable

YOU MAKE A DIFFERENCEYOU MAKE A DIFFERENCE