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Acute Stroke - the role of EMS

Acute Stroke - the role of EMS. Diane Handler, RN, MSN, MeD, ANVP Stroke Coordinator Mercy Medical Center, Cedar Rapids. Iowa dhandler@mercycare.org. The Facts. Stroke is an emergency Stroke is treatable Stroke occurs at all ages! 1.9 million brain cells die/minute. Objectives.

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Acute Stroke - the role of EMS

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  1. Acute Stroke - the role of EMS Diane Handler, RN, MSN, MeD, ANVP Stroke Coordinator Mercy Medical Center, Cedar Rapids. Iowa dhandler@mercycare.org

  2. The Facts Stroke is an emergency Stroke is treatable Stroke occurs at all ages! 1.9 million brain cells die/minute

  3. Objectives 1. Understand symptoms of stroke. 2. Know the difference between ischemic stroke and hemorrhagic stroke and treatment guidelines. 3. Review stroke syndromes to better understand stroke presentations. 4. Know times to treat goals for stroke. 5. Review triage considerations and when to divert.

  4. More Facts • 780,000 strokes/ year • Community role- education s/s and call 911 • Dispatch role • Stroke high priority (like AMI) • Screen for stroke symptoms • 60 second turn around

  5. EMS Role 9 minutes to scene 15 minute on scene time Cincinnati stroke scale (arm, speech, droop) Time of onset Check blood glucose Family/witness to ED/ cell phone # OVER TRIAGE -30%

  6. Cincinnati Stroke Scale Arm drift slurred speech facial droop If one is positive = consider stroke

  7. Your Role • History – and why • Time of onset • Meds- on coumadin? • Past medical Hx- HTN, diabetes, past stroke or TIA • A Fib, A Fib, A Fib, A Fib, A Fib…

  8. Acute Stroke Treatment

  9. Treatment • What is tPA? (tissue plasminogen activator) • Approved for stroke in 1996 • Enzyme that activates the clot busting system in the body

  10. Deadlines • IV tPA Symptom onset 4.5 hrs • IV tPA Symptom onset 3 hours • 80 years old • History of both previous stroke and diabetes • Stroke symptoms within 8 hrs- consider Intra-arterial tPA

  11. Why no tPA Too late to ED On Coumadin and INR >1.7 Symptoms rapidly resolving Recent trauma, MI or stroke

  12. Outcomes • NINDS tPA Trial • 30% more likely to have minimal or no disability at 3 months. • 6% risk of symptomatic bleeding with tPA • 17% mortality with tPA and 21% with placebo group

  13. ED goals for time to treat From Arrival to ED Door to Doctor- 10 minutes Door to neurological expertise – 15 minutes (by phone) Door to CT taken – 25 minutes * Door to CT interpretation – 45 minutes Door to treatment with tPA – 60 minutes

  14. History EMS straight to CT Your Role

  15. Why CT fast and first

  16. Typical Stroke What does a typical stroke look like?

  17. Typical Stroke… • Weakness on Left or Right side and may have facial droop • Visual gaze deviation • Inability to speak and or confused

  18. Left Hemisphere Stroke

  19. Left hemisphere stroke R side weakness R facial droop Speech affected- receptive or expressive

  20. Right hemisphere stroke L side weakness L facial droop Impaired decision making

  21. Right hemisphere “Typical Stroke” • 77 yo w, female • Triage 1018 • L facial droop, L hemiparesis, • Last time seen normal 0828 • Did not want to come to hospital • Time to treat with tPA 49 minutes

  22. Why did I have a stroke?Another typical stroke type • Small vessel disease • Hypertension • High cholesterol • Diabetes • Smoking • Sedentary life style

  23. “Zebra” Strokes • Cerebellum • Loss of balance • Brain Stem • Loss of consciousness • Occipital Lobes • Visual changes

  24. Less typical Stroke • 38 yo female from Micronesia • Symptom onset 0445 headache and dizziness, LOB • Posterior circulation Cerebellum stroke • Cause of stroke? Associated problems- heart disease, anemia

  25. Atypical Stroke • 43 yo male, unresponsive • Hx not feeling well and vomiting • Last normal night before • Triage at 0814 • L vertebral artery and basilar artery occulsion, prob dissection (locked in)

  26. Brainstem Stroke Nausea and vomiting Gaze palsy Swallow difficulty, slurred speech Hemiparesis or quadriplegia and sensory loss Decreased level of consciousness

  27. Cranial Nerves

  28. Less typical Stroke • 82 yo male • Sensory loss on left • Visual field cut • Weakness on the left • R Occipital Lobe Stroke

  29. Stroke Mimics • 36 yo female- headache • migraine • 47 yo female- weak R arm + leg, headache, chest pain • Conversion reaction syndrome • 65 yo female- slurred speech, decreased LOC • hypogylcemia • 85 yo male- in restaurant, became unresponsive • Hypo-perfusion of brain due to low BP

  30. Other mimics Seizures with todds paresis Tumor *Call Stroke Alert in any case- over triage by 30% is expected

  31. March 2010, time ED arrival 2230 ,Patient 62 yo, M Symptoms R side weakness, R facial droop, slurred speech (dysarthria), symptoms fluctuated. Time of symptom onset2159 Time to CT taken 25 minute Treated with t-PA?yes Time to needle 61 minutesDisposition of patient- Intensive Care Center for 24 hours then Cardiac Stroke Center for 24 hours. Then home. Comments- Good in transit time for EMS service. Symptoms fluctuated but tPA was given as symptoms could have stabilized to a major stroke. Patient made a good recovery with no rehab issues. EMS Acute Stroke Report

  32. Triage time- 1104, Sept 2010, 1104, 79 yo F Symptoms- R arm weakness, R facial droop, dysarthria, symptom onset “Last normal” 0915 Taken dToCT directly Treated with t-PA? yes Time to needle 43 minutes Disposition of patient -To ICC then Cardiac Stroke Center Comments: Patient has made a good recovery. Patient has a history of A Fib but was not treated with Coumadin as she was a fall risk in previous living situation. On MRI, multiple areas of stroke were noted in left frontal and temporal lobe – likely due to cardio-embolism from the A Fib. Started on Coumadin and will watch in new living area to prevent falls. EMS Acute Stroke Report

  33. Aug 2010, Triage 1723 66 yo, W, M SymptomsWeakness R side, leg greater than arm. Time of symptom onset1300 Time to CT scan takenOn arrival Treated with t-PA?No, Arrived > 3 hours so could not give tPA Disposition of patient To Cardiac Stroke Center, Acute, inpatient rehab and eventually home. Comments: Had patient arrived within time IV tPA could have been given. For patients < 80 years old and with no prior history of stroke and diabetes, IV tPA can be given up to 4 ½ hours of symptom onset. Patients who are > 80 years old and who have both past stroke and diabetes need to be treated within 3 hours of symptom onset. * Education of patient to call 911 right away. EMS Acute Stroke Report

  34. Nov. 2010 56 yo, W, F, Symptoms -R Facial droop, R side weakness. Time of symptom onset- 2130, Time to CT scan immediately, Treated with t-PA? yes Time to needle - 44 minutes Disposition of patient - Intensive Care Center, then Stroke Center and home soon. Comments: Good times to treat. Patient did very well post tPA. Had a small left “subcorticol” stroke (under the cerebral hemispheres). Complete work up done to find the cause in 56 yo female with no known risk factors. EMS Acute Stroke Report

  35. How many brain cells die per minute? What is the goal for response time? What is the goal for on scene time? Why not give tPA past 4.5 hours? Questions 

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