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Start Show. Notes. 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. ASA Operation Stroke EMS Committee

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  1. Start Show Notes

  2. 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.

  3. ASA Operation Stroke EMS Committee Volunteers including: Bruce Barnhart, Chair Amy Boise, Vice Chair Nancy Parks, RN Charlann Staab, RN Linda Meiner, RN Mike Baros, RN Terry Mason, RN Don Baird, RN Sandy Nygard, CEP AEMS, Inc. Robert Londeree, M.D. Phoenix Fire Department John Gallagher, M.D. Air-Evac Services, Inc. Professional Medical Transport (PMT) Cigna Healthcare Halle Heart Center Dave Heath Special Thanks To:

  4. Stroke An Educational Program for Pre-Hospital Personnel Developed by: EMS Committee Operation Stroke – American Stroke Association Phoenix, Arizona July 2003

  5. Stroke Overview Introduction, Definition, Types and Risks

  6. How Serious Is Stroke in the US? • About 700,000 strokes occur each year. • Over 167,000 deaths each year. • #3 killer. • A leading cause of serious long-term disability in adults. • 4.7 million stroke survivors.

  7. Introduction New emerging therapies offer hope, however the following MUST occur: • Education of at-risk patients. • Early recognition of stroke signs. • Prompt transport to the hospital. • Rapid hospital triage and evaluation.

  8. Introduction With rapid, aggressive prehospital stroke care, at-risk patients can be appropriately managed and quickly assessed for fibrinolytic therapy that may significantly improve their outcome.

  9. Definition of Stroke A stroke is a neurological impairment caused by a disruption in blood supply to a region of the brain.

  10. Classification of Stroke Two major categories: • Ischemic strokes, caused when a blood vessel supplying the brain is occluded by a clot. Responsible for 75% of all strokes. • Hemorrhagic strokes, caused when a cerebral artery ruptures. Both forms are life threatening.

  11. Hemorrhagic Stroke • Hypertension is the most common cause of intracerebral hemorrhage. • Other causes: Aneurysms and Arteriovenous malformations.

  12. Risk Factors for Stroke Although some strokes occur without warning, most stroke victims have prior risk factors. Major strokes can be prevented in many cases, but only if early signs and symptoms are heeded.

  13. Hypertension Smoking Diabetes Asymptomatic Carotid Stenosis Atrial Fibrillation Hyperlipidemia Sickle Cell Disease Other cardiac diseases Well-DocumentedModifiable Risk Factors Goldstein et al. Circulation. 2001:103:163

  14. Obesity Physical Inactivity Poor Diet/Nutrition Alcohol Abuse Drug Abuse Hypercoagulability Hormone Replacement Therapy Oral Contraceptive Use Inflammatory Process Less Well DocumentedPotentially Modifiable Risk Factors Goldstein et al. Circulation. 2001:103:163

  15. Non-modifiable Risk Factors • Age • Sex • Race/Ethnicity • Family History

  16. Stroke Diagnosis Signs and Symptoms of Stroke

  17. Signs and Symptoms of Stroke Consider in anyone who has: • Sudden numbness or weakness of face, arm, or leg, especially on one side of the body • Sudden confusion, trouble speaking or understanding

  18. Signs and Symptoms of Stroke • Sudden trouble seeing in one or both eyes • Sudden trouble walking, dizziness, loss of balance or coordination • Sudden severe headache with no known cause

  19. Signs and Symptoms of Stroke THIS IS A LIFE THREATENING EMERGENCY! Emergency healthcare providers must: • Recognize the importance of these symptoms. • Respond quickly with medical and / or surgical interventions.

  20. Stroke Signs and Symptoms: Hemorrhagic Stroke May present similar to Ischemic stroke. Distinguishing Features: • Appear more seriously ill • Deteriorate more rapidly • Severe headache • Alteration in consciousness • Nausea and/or vomiting • Neck pain • Intolerance of noise or light

  21. Transient Ischemic Attack “Temporary” or “mini” stroke. • 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.

  22. Transient Ischemic Attack • TIA is the most important forecaster of impending stroke.

  23. Stroke Patient Management The Stroke Chain of Survival and Recovery

  24. Seven Step Stroke Chain of Survival and Recovery Pre-arrival: Post-arrival: • Detection4. Door • Dispatch5. Data • Delivery6. Decision 7. Drug

  25. 1. Detection: Early Recognition • Early treatment of stroke depends on the victim, family members, or other bystanders detecting the event. • Mild signs or symptoms may go unnoticed or be denied by the patient or bystander.

  26. 2. Dispatch: Early EMS Activation and Dispatch Instructions • Stroke victims and their families must be taught to activate the EMS system as soon as they detect stroke signs or symptoms. • EMS dispatchers must appropriately prioritize the call to ensure a rapid response within the EMS system.

  27. 3. Delivery:Pre-hospital Transport and Management The goals : • 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

  28. 3. Delivery:Pre-hospital Transport and Management The Cincinnati Pre-hospital Stroke Scale • Facial Droop (have 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.

  29. 3. Delivery:Pre-hospital Transport and Management The Cincinnati Pre-hospital Stroke Scale 2. Arm Drift (patient closes eyes and holds both arms out): 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.

  30. 3. Delivery:Pre-hospital Transport and Management The Cincinnati Pre-hospital Stroke Scale 3. 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.

  31. 3. Delivery:Pre-hospital Transport and Management • The presence of acute stroke is an indication for "load and go“. • 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.

  32. 3. Delivery:Pre-hospital Transport and Management Once stroke is diagnosed, pre-hospital treatment includes management of the ABCs of critical care (Airway, Breathing, and Circulation) and close monitoring of vital signs.

  33. 3. Delivery:Pre-hospital Transport and Management Airway: • Paralysis of the muscles of the throat, tongue, or mouth can lead to partial or complete upper-airway obstruction. • Saliva pools or vomit may be aspirated.

  34. 3. Delivery:Pre-hospital Transport and Management 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.

  35. 3. Delivery:Pre-hospital Transport and Management Circulation: • Monitor both blood pressure and cardiac rhythm as 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.

  36. 3. Delivery:Pre-hospital Transport and Management Circulation: • 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!

  37. 3. Delivery:Pre-hospital Transport and Management Other Supportive Measures: • Intravenous access. • Management of seizures, and diagnosis and treatment of hypoglycemia, can be initiated en route to the hospital if necessary. • Isotonic fluids (Normal Saline or Lactated Ringer's solution) are used for intravenous therapy; hypotonic fluids are contraindicated.

  38. 3. Delivery:Pre-hospital Transport and Management Early Notification: • 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.

  39. 4. Door:Emergency Department Triage Even if a potential stroke victim arrives in the emergency department in a timely fashion, too often hours may elapse before appropriate neurological consultation and diagnostic studies are performed.

  40. 5. Data:Emergency Evaluation and Management ABCs should be reassessed and rechecked frequently.

  41. 5. Data:Emergency Evaluation and Management An emergency neurological stroke assessment should be done quickly focusing on four key issues: • Level of consciousness • Type of stroke (hemorrhagic versus nonhemorrhagic) • Location of stroke (carotid versus vertebrobasilar) • Severity of stroke

  42. 5. Data:Emergency Evaluation and Management • Obtaining the exact time of stroke or onset of symptoms from family or people at the scene is critical.

  43. Emergency Diagnostic Studies • Currently, CT is the single most important diagnostic test. • Goal: CT scan obtained and read within 45 minutes of the stroke victim's arrival at the emergency department.

  44. Emergency Diagnostic Studies • Anticoagulants and fibrinolytic agents should be withheld until CT has ruled out a brain hemorrhage. Hemorrhagic Stroke

  45. Differential Diagnosis: • Unrecognized seizures • Confusional states • Syncope • Toxic or metabolic disorders • Hypoglycemia • Brain tumors • Subdural hematoma Adams et al. Stroke. 2003;34:1056

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