Stroke, CVA and Aphasia Silver Cross EMS System July 2012 Continuing Medical Education

1. Stroke, CVA and Aphasia Silver Cross EMS SystemJuly 2012 Continuing Medical Education Written and Presented by: Leslie Livett RN MS Provena Saint Joseph Medical Center

2. Acknowledgements • Northwest Community EMS System • EMS Region 8 CME comittee • Jamie Rademacher, RN, Stroke Coordinator, Silver Cross Hospital, New Lenox, IL • Leslie Barna RN MSN CNRN Stroke Coordinator, Provena Saint Joseph Medical Center, Joliet, IL • National Aphasia Association • Reid Hospital and Healthcare Services, Richmond, IN • Brookfield Police Department

3. Objectives • Review brain anatomy, physiology and vascular supply • Review difference between ischemic/thrombotic and hemorrhagic stroke • Review signs and symptoms of stroke and highlight differences in special populations • Review Region 7 Standard Operating Procedures for stroke • Discuss aphasia as related to stroke/CVA and field implications • (ALS only) Strip O’ the Month: Prolonged QT intervals and Torsades

4. Stroke, aka Brain Attack • A sudden, catastrophic event • Focal neurologic impairment • Most often caused by occlusion or rupture of an artery that supplies a specific region of the brain

5. Statistics • In the US, almost 800,000 people suffer new or recurrent strokes each year (ASA, 2009) • 55% die or survive disabled • 3rd leading cause of death in developed nations (behind heart disease and cancer) • $68.9 billion cost of treatment and disability (2009) • Death / Disability rates higher in African-Americans • 60% of strokes happen to males • Strokes in females more likely to be fatal • Most preventable of catastrophic conditions

6. Lifestyle Risk Factors • Tobacco use • Obesity, elevated cholesterol, elevated lipids • Physical • Excessive alcohol intake • Use of illegal drugs, particularly cocaine in any form or any injected drug

7. Barriers to Stroke Care-Why? • Knowledge • Financial • Educational needs • Ethics • Research • Man power

8. “TIME IS BRAIN” • 2 million brain cells dying every minute • Public doesn’t understand that strokes are nearly “curable” if transport happens quickly

9. A & P Review - Lobes • Cerebrum • Largest, most developmentally advanced • Higher functions • Cerebellum • Balance, movement, coordination • Brainstem • Final pathway between cerebral structures and the spinal cord • Automatic functions (respiration, heart rate, blood pressure, wakefulness)

10. A & P Review - Layers • Gray matter • aka cerebral cortex • 20 mm thick (3/4”) • Contains centers of cognition, personality and complicated movements • White matter • Network of fibers that enable the regions of the brain to communicate with each other

12. A & P Review – Control Centers

14. Circle of Willis • Actually the Oval of Willis • Joins the two systems before they enter the brain • When either system is blocked, collateral circulation may occur through this loop

15. Major Brain Arteries Anterior Cerebral Artery Middle Cerebral Artery Posterior Cerebral Artery

16. Classification of Stroke

18. Ischemic – Embolic • Partial or complete blockage of a cerebral artery from embolic material, • generally composed of cholesterol, plaque, blood, air, or tumor tissue that migrates to the brain • Often occur without warning • Symptoms may fluctuate • due to continuing movement of the embolic matter within the blood vessel

19. Hemorrhagic - Subarachnoid • Aneurysms, arteriovenous malformations and other vascular hematomas may bleed • producing a subarachnoid hemorrhage • Especially prevalent in 35 to 65-year-olds • Accounts for ~ 7% of all strokes

20. Hemorrhagic – Intracerebral (ICH) • Small, deeply penetrating arteries in brain tissue susceptible to loss of elasticity in chronic htn • The expanding mass of blood can grow to the size of a golf ball or larger • Can project 2 to 3 cm into the brain tissue • The mass causes pressure on cerebral tissues and nerves • leading to death of neurons • The hematoma can disturb normal intracranial dynamics • causes a sudden rise in intracranial pressures

21. Transient Ischemic Attack • “mini-stroke” or TIA • Defined as transient focal brain ischemia without radiologic evidence of infarction • TIA a strong indicator of possible future stroke • American Stroke Association guidelines recommend approaching TIA with the same urgency as stroke • 15% of strokes preceded by a TIA ignored by patients • After TIA, 12% experience stroke within 30 days, and up to 17% within 90 days • 25% of TIA patients die within a year

22. Signs and Symptoms • Carotid Region • visual disturbance (ophthalmic artery) • Contralateral motor or sensory deficits to face or limbs (MCA/ACA) • Aphasia (MCA) • Homonymous hemianopsia (MCA) • Vertebrobasilar Region • nausea/vomiting • dysphagia/dysarthria • dizziness/vertigo/gait disturbance/ataxia • numbness/weakness of face • nystagmus • ”Locked-in” syndrome • quadriplegia/weakness face and pharyngeal muscles

23. Key Concept for EMS • WHEN WAS THE PATIENT LAST SEEN NORMAL?! • If at all possible, pin down the time of the attack

24. Stroke Assessment Note: BLS and ALS stroke SMO’s are nearly identical, due to not wanting to waste time in transport

29. Differential Diagnosis of Stroke • Seizure • Complicated migraine • Mass lesion • Demyelinating disease • Inflammation • Hypoglycemia

30. Diagnostic Studies (in hospital) • Non-contrast CT brain or MRI • Blood glucose • Serum electrolytes/renal function • ECG • Cardiac enzymes • PT/PTT/INR • Oxygen saturation

31. Stroke in Special Populations • Women • Stroke kills twice as many women as breast cancer every year • Women can have unique stroke symptoms • Face and limb pain • Hiccups • General weakness • Nausea • Young people and children • CDC notes increased risk of stroke among younger population including children and teens • Young adults with stroke are often misdiagnosed • Majority of cases are mistaken as inner ear disorder; also alcohol intoxication, migraine, and vertigo

32. Extended IV t-PA Windowto 4.5 hours • Used to be 2-3 hours before patient couldn’t get t-PA anymore. • But American Stroke Guidelines expanded IV t-PA window in May 2009 • For certain candidates • ADDITIONAL IV t-PA EXCLUSION CRITERIA FOR 3-4.5 HRS -Over 80 years old -NIHSS > 25 -History stroke and diabetes -On any Oral anticoagulation

33. Endovascular Procedures • Neuro Endovascular Surgeon • Neuro Endovascular suite • IA-t-PA • Clot retrieval device • Goal: recanulazation of vessel

34. Pre Post

35. 1 min. of brain ischemia can kill 2 million nerve cells and 14 billion synapses • IMPORTANT ! • Patients need to access 911 as soon as symptoms are recognized • EMS must rapidly assess patients and recognize stroke • EMS must notify receiving facility ASAP so Stroke Team can be activated

36. APHASIA

37. Objectives • What is Aphasia • Stroke and other causes of Aphasia • How do you communicate with a patient with Aphasia • EMS implications • Community Resources

38. What is Aphasia • Aphasia is an impairment of language. • An acquired communication disorder that impairs a person’s ability to process language, but does not affect intelligence. • Impairs ability to speak and understand others. • Most people with aphasia experience difficulty reading and writing.

39. Types of Aphasia • Global Aphasia – Most severe form • Produce few recognizable words • Understands little or no spoken speech • Can neither read or write • Usually patient has suffered a stroke • May rapidly improve if the damage has not been too extensive. • Greater brain damage, more severe and lasting disability.

40. Types of Aphasia • Broca’s Aphasia – speech output severely reduced • Limited mainly to short utterances, less than four words • Vocabulary access limited • Formation of sounds laborious/clumsy • May read and understand speech, but can’t write. • Halting and effortful quality of speech

41. Types of Aphasia • Mixed non-fluent aphasia- • Sparse and effortful speech resembling Broca’s • Limited in comprehension of speech • Patients do not read or write beyond an elementary level

42. Types of Aphasia • Anomic Aphasia – inability to supply words for things. • Significant in nouns and verbs • Understand speech well, read adequately • Poor writing ability

43. What causes Aphasia • Most common cause of aphasia is stroke • About 23 – 40% of stroke survivors acquire aphasia. • Estimated one million people in US have acquired aphasia, or 1 in 250 people.

44. What causes Aphasia • More common than Parkinson’s Disease, cerebral palsy or muscular dystrophy. • About 1/3rd of severely head-injured persons have aphasia.

45. Recovery from Aphasia • After stroke – If symptoms last longer than 2-3 months, complete recovery is unlikely • People continue to improve over a period of time • Slow process for both patient and FAMILY • Need to learn compensatory strategies for communicating

46. EMS Do’s and Don’ts • Do not immediately assume aphasia patient is drunk or mentally ill/challenged. • Always check blood sugar, just in case. • Talk to patient as an adult, not as a child • Minimize or eliminate background noise • Use all modes of communication • Speech/writing/drawing/yes-no responses

47. Communication • Give them time to talk and permit a reasonable amount of time to respond • Accept all communication attempts • Keep your own communication simple but adult • Simplify sentence structure and reduce your rate of speech

48. Communication • Keep your voice at a normal level and emphasize key words • Augment speech with gesture and visual aids when possible • Repeat statements when necessary • Do not attempt to finish the patients statement for them

49. Resources • Windshield / Window sticker • Part of national campaign • Patient places sticker in the left rear passenger side of car • For home, placed at front or rear entrance

50. Silver Cross EMS Strip o’ the Month • Prolonged QT intervals and Torsades de Pointes