Pre-hospital Care In StrokePre-hospital Care In Stroke

Todd J. Crocco, MDTodd J. Crocco, MD

DirectorDirectorDivision of EMSDivision of EMS

University of CincinnatiUniversity of CincinnatiCincinnati, OHCincinnati, OH

Todd Crocco, MD

Stroke ChainStroke Chainof Survival & Recoveryof Survival & Recovery

• Detection

• Dispatch

• Delivery

• Door

• Data

• Decision

• Drug

Todd Crocco, MD

Prehospital Stroke SurveyPrehospital Stroke Survey

• Findings from a nationwide survey of paramedics and advanced EMTs:–TIA awareness is lacking

–Many felt strokes could be managed non-emergently

–Less than half were aware of the 3-hour time window

Crocco, PEC, 1999

Todd Crocco, MD

EMS Evaluation of Acute StrokeEMS Evaluation of Acute Stroke

• Paramedic diagnosis of stroke/TIA correct in 72% of cases

• EMS dispatchers correctly identify stroke/TIA in 52% of cases

• ED evaluation and CT scan times shorter for ALS vs. BLS responses

Kothari, Stroke, 1995

Todd Crocco, MD

The True Time of OnsetThe True Time of Onset

• Multiple sources– Friends, family, bystanders– EMS has unique opportunities to discover

time of onset

• Times of reference– The time the basketball game started

• How normal were they?– Some patients will have previous neurologic

deficits

Todd Crocco, MD

Prehospital Stroke AssessmentPrehospital Stroke Assessment

• Cincinnati Prehospital Stroke Scale

• Los Angeles Prehospital Stroke Scale

Todd Crocco, MD

The Impact Of 911The Impact Of 911

0

50100

150200

250300

350400

911 Private MD Hospital

First Contact

Time from Symptom Onset to ED Arrival (Mins)

Mean

Median

Barsan, Arch Int Med, 1993

Todd Crocco, MD

Managing The Acute Stroke PatientManaging The Acute Stroke Patient

• Airway, Breathing, Circulation• Assess vital signs• Neurologic exam• Check serum blood sugar• Determine time of onset• En route: IV, O2, monitor• Notify the ED quickly• Transport as soon as possible

Todd Crocco, MD

And Remember…And Remember…

• Do not delay transport

• Do not give large volumes of fluid (unless patient in shock)

• Do not give dextrose (unless hypoglycemic)

• Do not lower blood pressure

• Do not forget to determine time of onset

Todd Crocco, MD

Stroke Treatment in 2000Stroke Treatment in 2000

• Increased public education

• Development of protocols and teams

• Pivotal and expanding role of prehospital care

Todd Crocco, MD

Stroke SummaryStroke Summary

• EMS personnel deserve more stroke education

• Always determine the time of onset

• Call early, transfer immediately

• Stroke is an EMERGENCY!