emergency medical services stroke training curriculum · face arm speech test (f.a.s.t.)24 time to...

Emergency Medical ServicesStroke Training Curriculum

3. Pre-hospital phase The Difference that EMS can make

Introduction

Timely recognition of stroke symptoms is an important factor in the successful delivery of provenacute therapies.1

Stroke symptoms typically begin suddenly and are dependant on the affected region of the brain.2,3

Initial patient assessments are based on the principle of assessing the ABCDEs and the vital signs andon performing a neurological assessment.4,5

1. Saver JL. Time is brain- Quantified. Stroke 2006;37:263-266. 2. What is stroke. National Stroke association® [cited 2019 April 12]. Available from: https://www.stroke.org/understand-stroke/what-is-stroke/ 3.Signs of a stroke. The heart andstroke foundation South Africa [cited 2019 April 12]. Available from: http://www.heartfoundation.co.za/recognise-a-stroke/ 4. Thim T, Vinther NH, Grove EL et al. Initial assessment and treatment with the Airway, Breathing, Circulation,Disability, Exposure (ABCDE) approach. International journal of general medicine 2012;5:117-121. 5. Jauch EC, Saver JL, MD, HP Adams et al. Guidelines for the early management of patients with acute ischemic stroke: A guideline forhealthcare professionals from the American Heart Association/American Stroke Association. Stroke 2013;44:870-947.

How can you change a life in 60 minutes? Video 1

Stroke – treatment pathway5

RAPID PATIENT RECOGNITION AND

REACTION TO STROKE WARNING SIGNS

RAPID EMERGENCY MEDICAL SERVICES

(EMS) DISPATCH

RAPID EMS SYSTEM TRANSPORT

AND HOSPITALPRE-NOTIFICATION

DELIVERY DIRECT TO IMAGING

RAPID IN-HOSPITAL DIAGNOSIS AND

TREATMENT

EFFECTIVE EMS SYSTEMS CAN MINIMISE DELAYS IN PRE-HOSPITAL DISPATCH, ASSESSMENT, AND TRANSPORT, AND INCREASE THE NUMBER OF STROKE PATIENTS REACHING THE HOSPITAL AND RECEIVING OPTIMAL TREATMENT.5,6,7

5. Jauch EC, Saver JL, MD, HP Adams et al. Guidelines for the early management of patients with acute ischemic stroke: A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke2013;44:870-947. 6. Deng YZ, Jacobs RVS, Birbeck GL et al. IV tissue plasminogen activator use in acute stroke. Experience from a statewide registry. Neurology 2006;66:306-312. 7. Wojner-Alexandrov AW, Alexandrov AV, Rodriguez D etal. Houston paramedic and emergency stroke treatment and outcomes study (HoPSTO). Stroke 2005;36:1512-1518.

8. Canadian Stroke Strategy 2011. Paramedic prompt card for acute stroke protocol; Issue 110, version 1.0.

EMERGENCY SERVICES

TRANSPORT > 50 % OF SUSPECTED

STROKE PATIENTS

THE EARLIER TREATMENT IS INITIATED, THE

BETTER THE OUTCOME

DIAGNOSIS REQUIRES

STROKE EXPERTISE

TREATMENT CARRIES A RISK AND

REQUIRES MONITORING

THROMBOLYSIS IS UNDERUSED

STROKE UNIT CARE IMPROVES

OUTCOMES

The situation at large8

Emergency stroke care depends on a 4-step chain

RECOGNISE STROKE SYMPTOMS

REACT APPROPRIATELY

IDENTIFY STROKE SYMPTOMS

PRIORITY DISPATCH OF EMS

PROMPT EVALUATION & STABILISATION

PRIORITY TRANSFER TO STROKE FACILITIES

PRE-NOTIFICATION OF HOSPITAL

IMMEDIATE TRIAGE, ASSESSMENT AND IMAGING

MULTIDISCIPLINARY STROKE TEAM

ACCURATE DIAGNOSIS

TREAT APPROPRIATELY

GENERAL PUBLIC9,10,11,12 EMERGENCYCALL CENTRE11,12 STROKE UNIT11,12EMERGENCY

MEDICAL SERVICES11,12

PRIORITY TRANSPORT & TREATMENT

9. Kothari RU, Brott T, Broderick JP et al. Emergency physicians. Accuracy in the diagnosis of stroke. Stroke 1995;26;2238-2241. 10. Kothari R, Barsan W, Brott T et al. Frequency and accuracy of prehospital diagnosis of acute stroke.Stroke 1995;26:937-941. 11. Kaste M, Olsen TS, Orgogozo JM. Organizations of strke care: Education, stroke units and rehabilitation. Cerebrovascular diseases 2000;10(3):1-11. 12. Jauch EC, Cucchiara B, Adeoye O et al. Part 11: Adultstroke: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation 2010;122:S818-S828.

#1 Target for EMS

EMS ARE THE FIRST POINT OF FMCTHEIR PRIMARY GOAL IS TO IDENTIFY SUSPECTED STROKE AND TRIGGER FAST TRACK FOR STROKE TREATMENT10,11

10. Kothari R, Barsan W, Brott T et al. Frequency and accuracy of prehospital diagnosis of acute stroke. Stroke 1995;26:937-941. 11. Kaste M, Olsen TS, Orgogozo JM. Organizations of strke care: Education, stroke units and rehabilitation. Cerebrovascular diseases 2000;10(3):1-11.

Every 15 minutes saved in treatment time = 4 % reduction in mortality & 4 % increase of chance of surviving the stroke with Life intact13

5

60 120 150 210 240 300 330

0

1

2

3

4

Odds ratio (OR)

OTT (MIN)

OD

DS

RA

TIO

AN

D 9

5 %

CI

270 36018090

NNT 4 - 5 NNT 9 NNT 14 NNT 21

Favourable outcome (mRS 0 - 1) vs. Time14

NNT, Number needed to treat; OTT, Time from stroke onset to start of treatment; mRS, modified Rankin Scale

13. Saver JL, Fonarow GC, Smith EE et al. Time to treatment with intravenous tissue plasminogen activator and outcome from acute ischemic stroke. Journal of the American medical association 2013;309(23): 2480-2488.14. Lees KR, Bluhmki E, von Kummer R et al. Time to treatment with intravenous alteplase and outcome in stroke: an updated pooled analysis of ECASS, ATLANTIS, NINDS, and EPITHET trials. Lancet 2010;375:1695-1703.

Saving 30 minutes early after symptom onset could provide a greater increase in likelyhood of favourable outcome than saving the same amount of time later14

5

60 120 150 210 240 300 330

0

1

2

3

4

Odds ratio (OR)

OTT (MIN)

OD

DS

RA

TIO

AN

D 9

5 %

CI

270 36018090

NNT 4 - 5 NNT 9 NNT 14 NNT 21

Favourable Outcome (mRS 0 - 1) vs. Time90 – 120

mins240 – 270

mins

NNT, Number needed to treat; OTT, Time from stroke onset to start of treatment; mRS, modified Rankin Scale

14. Lees KR, Bluhmki E, von Kummer R et al. Time to treatment with intravenous alteplase and outcome in stroke: an updated pooled analysis of ECASS, ATLANTIS, NINDS, and EPITHET trials. Lancet 2010;375:1695-1703.

Guidelines - EMS pre-hospital management

5. Jauch EC, Saver JL, MD, HP Adams et al. Guidelines for the early management of patients with acute ischemic stroke: A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2013;44:870-947.

GUIDELINES5

PATIENTS OR MEMBERS OF THE PUBLIC ARE ENCOURAGED TO CALL THE EMERGENCY SERVICESIF A STROKE IS SUSPECTED (CLASS I, LOE B)

CALL CENTRES SHOULD SEND OUT THE EMS AS A PRIORITY DISPATCH AND TIME DELAYSSHOULD BE MINIMISED (CLASS I, LOE B)

EMS STAFF SHOULD USE PRE-HOSPITAL STROKE ASSESSMENT TOOLS (SUCH AS LAPSS)TO DETECT STROKE (CLASS I, LOE B)

TRANSPORT OF PATIENTS TO THE NEAREST AVAILABLE STROKE CENTRE OR MOST APPROPRIATEEMERGENCY STROKE CARE IS RECOMMENDED (CLASS I, LOE A)

EMS SHOULD PRE-NOTIFY THE RECEIVING CENTRE THAT A POTENTIAL STROKE PATIENTIS EN ROUTE (CLASS I, LOE B)

Goals of the EMS in stroke12

12. Jauch EC, Cucchiara B, Adeoye O et al. Part 11: Adult stroke: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation 2010;122:S818-S828.

DISPATCH & RAPID RESPONSE,TO MINIMISE DELAY TO FMC

EVALUATION

STABILISATION

NEUROLOGICAL EVALUATION

TRANSPORT DIRECTLY TO A STROKE-READYHOSPITAL (WHERE AVAILABLE)

PRE-NOTIFICATION OF THE RECEIVING UNIT (HOSPITAL, STROKE CENTRE)

PRIORITY

RAPID

EARLY

STANDARDISED

ADVANCED

MINIMISE BRAIN INJURY AND

MAXIMISE THE PATIENT’S

RECOVERY12

RAPID

Guidelines - EMS dispatch

5. Jauch EC, Saver JL, MD, HP Adams et al. Guidelines for the early management of patients with acute ischemic stroke: A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke2013;44:870-947. 15. The European Stroke Organization (ESO) executive committee and the ESO writing committee. Guidelines for management of ischaemic stroke and transient ischaemic attack 2008. Cerebrovascular disease2008;25:457–507.

IMMEDIATE EMS CONTACT AND PRIORITY DISPATCH ARE RECOMMENDED (CLASS II, LEVEL B)15

STROKE PATIENTS NEED TO BE TRANSPORTED TO THE NEAREST STROKE FACILITY WITHOUT DELAY(CLASS III, LEVEL B) 15

THE TIME FROM CALL TO EMS DISPATCH SHOULD BE < 90 SECONDS5

DISPATCHERS AND AMBULANCE PERSONNEL SHOULD BE TRAINED TO RECOGNISE STROKE USING SIMPLE TESTS, E.G. FACE-ARM-SPEECH-TEST (CLASS IV, GCP) 15

EMS RESPONSE TIME SHOULD BE < 8 MIN (CALL TO ARRIVAL ON SCENE)5

ON-SCENE TIME SHOULD BE < 15 MIN5

TELEMEDICINE SHOULD BE CONSIDERED IN REMOTE OR RURAL AREAS (CLASS II, LEVEL B)15

OTHER TRANSPORT METHODS (E.G. HELICOPTER) SHOULD BE CONSIDERED IN REMOTEOR RURAL AREAS (CLASS II, LEVEL B)15

Summary

5. Jauch EC, Saver JL, MD, HP Adams et al. Guidelines for the early management of patients with acute ischemic stroke: A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke2013;44:870-947. 15. The European Stroke Organization (ESO) executive committee and the ESO writing committee. Guidelines for management of ischaemic stroke and transient ischaemic attack 2008. Cerebrovascular disease 2008;25:457–507. 16. Berglund A, Svensson L, Sjostrand C et al. Higher prehospital priority level of stroke improves thrombolysis frequency and time to stroke unit. The Hyper Acute Stroke Alarm (HASTA) study. Stroke 2012;43:2666-2670. 17. Nagaraja N,Bhattacharya P, Norris G et al. Arrival by ambulance is associated with acute stroke intervention in young adults. Journal of the neurological sciences 2012;316:168-169. 18. Hacke W, Donnan G, Fieschi C et al. Association of outcome with earlystroke treatment: pooled analysis of ATLANTIS, ECASS, and NINDS rt-PA stroke trials. Lancet.2004 March 6;363(9411):768-74.

EMERGENCY SERVICES NEED TO

ASSIGN STROKE CALLS THE HIGHEST

PRIORITY16

ACTIVATION OF THE EMERGENCY CALL

AND PRIORITY DISPATCH OF EMS TO

THE SUSPECTED STROKE PATIENT IS RECOMMENDED5,15

THE FASTER TREATMENT IS INITIATED, THE

GREATER THE BENEFIT FOR PATIENTS WITH ACUTE ISCHAEMIC

STROKE18

ARRIVAL BY AMBULANCE AND PRE-NOTIFICATION

OF THE ED / SU INCREASE THE

CHANCE OF THROMBOLYSIS16,17

ED, EMERGENCY DEPARTMENT SU, STROKE UNITEMS, EMERGENCY MEDICAL SERVICES

1. Diagnosing stroke – Call Centre

1. Diagnose stroke

Stroke call centre and dispatch

DISPATCH GUIDELINES

DISPATCH ALGORITHM

CALL CENTRE ROLE

EMERGENCY CALL CENTRES AND DISPATCHERS HAVE AN IMPORTANTROLE IN RECOGNISING POTENTIAL STROKE PATIENTS AND DISPATCHINGAN EMERGENCY RESPONSE TEAM WITHOUT DELAY5

PROTOCOLS ARE AVAILABLE TO HELP IDENTIFY STROKE SYMPTOMS5

Call centre role

*see notes

*Specific words include stroke, facial droop, weakness/fall, or communicationproblems. In some countries, such as France (SAMU system), the calls aretaken and triaged by an MD.5

DISPATCHERS CAN CORRECTLY IDENTIFYUP TO 80 % OF ALL

STROKE CALLS IF SPECIFIC WORDS

ARE MENTIONED5,19*

5. Jauch EC, Saver JL, MD, HP Adams et al. Guidelines for the early management of patients with acute ischemic stroke: A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke2013;44:870-947. 19. Reginella RL, Crocco T, Tadros A, Shackleford A, Davis SM. Predictors of stroke during 9-1-1 calls: opportunities for improving EMS response. Prehospital emergency care 2006;10:369–373.

First call to emergency servicesDispatcher identification algorithm20

Adapted from: Krebes S, et al. Stroke 2012;43:776-781.

REASON FOR CALL

TYPICAL STROKE SYMPTOMS

(SUDDEN) SPEECH PROBLEMS

UNILATERAL NEUROLOGICAL DEFICITS (EXCEPT PAIN)

SUDDEN ONSET, SEVERE HEADACHE

OTHER SUDDEN ONSET NEUROLOGICAL SYMPTOMS

CALLER SPONTANEOUSLY MENTIONS "STROKE"

ATYPICAL STROKE SYMPTOMSFALLS

MOVEMENT DISORDERS (PERSON IS ALERT, BUT E.G. UNABLE TO GET UP OFF THE FLOOR)

CONFUSION

IMPAIRED CONSCIOUSNESS (PERSON IS BREATHING)

OTHER SYMPTOMS (DEFINITELY NON-STROKE)

ALARM CODE

STROKE

INFORM HOSPITAL OF

TIME OF SYMPTOM

ONSET

FACE-ARM-SPEECH TEST

ALARM CODE NON-STROKE

EVIDENCE FOR NON-

STROKE AETIOLOGY?

+

-

+

20. Krebes S, Ebinger M, Baumann Am et al. Development and validation of a dispatcher identification algorithm for stroke emergencies. Stroke 2012;43:776-781.

Priority dispatch and rapid responseImportance of time

5. Jauch EC, Saver JL, MD, HP Adams et al. Guidelines for the early management of patients with acute ischemic stroke: A guideline for healthcare professionals from the American Heart Association/American Stroke Association.Stroke 2013;44:870-947. 12. Jauch EC, Cucchiara B, Adeoye O et al. Part 11: Adult stroke: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation 2010;122:S818-S828.

EMS ARE OFTEN THE FIRST MEDICAL CONTACT(FMC) FOR STROKE PATIENTS

THE PATIENT SHOULD BE ASSESSED AND TRANSPORTED

TO A STROKE FACILITY WITHOUT DELAY

TIME IS CRITICAL5,12

CLEAR PROTOCOLS SHOULD BE IN PLACE, DETERMINING WHICH PROCEDURES AND

INVESTIGATIONS NEED TO BE PERFORMED AT EACH STAGE OF THE

PATIENT’S MANAGEMENT

INITIAL ASSESSMENT AND TREATMENT SHOULD BE CARRIED OUT AS RAPIDLY AS POSSIBLE

ONLY ESSENTIAL TESTS AND INVESTIGATIONSSHOULD BE PERFORMED

1. Diagnosing stroke

1. Diagnose stroke

Mild stroke patient

video 2

Moderate stroke patient

video 3

Severe stroke patient

video 4

Pre-Hospital Recognition of Stroke

Assessment tools have been developed to help enhance the recognition of stroke symptoms and to improve theability to identify stroke patients in the field.5 The most common and well-investigated tools are the CincinnatiPrehospital Stroke Scale and the Los Angeles Prehospital Stroke Screen. 5 Newer stroke identification tools includethe Face Arm Speech Test (FAST), which is similar to the Cincinnati Prehospital Stroke Scale, and the MelbournePrehospital Stroke Scale, which is similar to the Los Angeles Prehospital Stroke Screen. Tools for rating strokeseverity in the field have also been developed including a shortened version of the NIH Stroke Scale (NIHSS) and theLos Angeles Motor Scale (see Table 1).21

Evidence-based practice: The use of a stroke rating scale, preferably the National Institutes of Health Stroke Scale(NIHSS), is recommended by the American Stroke Association. 5

5. Jauch EC, Saver JL, MD, HP Adams et al. Guidelines for the early management of patients with acute ischemic stroke: A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke2013;44:870-947. 21. Summers D, Leonard A, Wentworth D et al. Comprehensive overview of nursing and interdisciplinary care of the acute ischemic stroke patient. A scientific statement from the American Heart Association. Stroke2009;40:2911-2944.

Pre-Hospital Recognition of Stroke21

21. Summers D, Leonard A, Wentworth D et al. Comprehensive overview of nursing and interdisciplinary care of the acute ischemic stroke patient. A scientific statement from the American Heart Association. Stroke2009;40:2911-2944.

Pre-Hospital Recognition of Stroke

The majority of patients with an acute ischemic stroke will present to the Emergency Department in ahemodynamically stable condition. However, ischaemic strokes involving the posterior circulation as well asintracranial bleeding or subarachnoid haemorrhage may require immediate airway management, especially if thepatient has an altered level of consciousness. Circulatory collapse or cardiac arrest, although possible, is uncommonin isolated ischaemic stroke but may be an early complication of severe subarachnoid haemorrhage. In addition,cardio circulatory failure may indicate accompanying medical conditions such as acute myocardial infarction, atrialfibrillation, or congestive heart failure.21

21. Summers D, Leonard A, Wentworth D et al. Comprehensive overview of nursing and interdisciplinary care of the acute ischemic stroke patient. A scientific statement from the American Heart Association. Stroke2009;40:2911-2944.

Stroke Scales22

22. Maggiore, W. A. 'Time is Brain' in prehospital stroke treatment. Journal of emergency medical services 2012;1-9.

68

93

0

20

40

60

80

100

STROKE ASSESSMENTTOOL TRAINING

% O

F ST

RO

KE

IDEN

TIFI

CA

TIO

NSE

NSI

TIV

ITY

NOTRAINING IN

USE OF STROKEASSESSMENT

TOOL

TRAINING INUSE OF STROKE

ASSESSMENTTOOL

STROKE ASSESSMENT TOOLS HELP EMS IDENTIFY STROKE SYMPTOMS QUICKLY

STROKE ASSESSMENT TRAINING RAISES THE ACCURACY OF STROKE IDENTIFICATION

EMS PERSONNEL DEMONSTRATED A SENSITIVITY OF 61 - 66 % WITHOUT STROKE ASSESSMENT TRAINING AND

86 - 97 % WITH TRAINING

68

96

7970

95

77

0

20

40

60

80

100

FACIAL PARESIS ARM PARESIS SPEECH DISTURBANCE

STR

OK

E PA

TIEN

TS (

%)

PARAMEDIC

PHYSICIAN

Agreement between ambulance paramedic - and physician - recorded neurological signs with FAST*23

*FAST = Face Arm Speech Test .

23. Nor AM, McAllister C, Louw SJ et al. Agreement between ambulance paramedic-and physician-recorded neurological signs with Face Arm Speech Test (FAST) in acute stroke patients. Stroke 2004;35:1355-1359.

Face Arm Speech Test (F.A.S.T.) 24

TIME TO CALL the emergency

services*

FACE DROOPING or asymmetry

on smiling

ARM WEAKNESS or paralysis on

one side

SPEECH DIFFICULTY or slurring of

speech

TO CHECK FOR STROKE SYMPTOMS, REMEMBER F.A.S.T.

*112 is an emergency services call number that can be dialed free of charge from any telephone or mobile phone in numerous European countries, as well as several other countries in the world.

FACE ARMS SPEECH TIME

24. American Stroke Association. Stroke symptoms. [cited 2019 May 13]. Available from:https://www.strokeassociation.org/en/about-stroke/stroke-symptoms

FACE DROOPING

ASK THE PATIENT TO SMILE AND SHOW THEIR TEETH.DOES ONE SIDE OF THE FACE DROOP OR IS IT NUMB?

ARM WEAKNESS

ASK THE PATIENT TO RAISE BOTH ARMS. IS ONE ARM WEAKOR NUMB? DOES ONE ARM DRIFT DOWNWARD?

SPEECH DIFFICULTY

ASK THE PATIENT TO REPEAT A SIMPLE SENTENCE. IS THE SENTENCE REPEATED CORRECTLY? ARE THEY UNABLE TO

SPEAK, OR ARE THEY HARD TO UNDERSTAND?

FAST scale 24

24. American Stroke Association. Stroke symptoms. [cited 2019 May 13]. Available from:https://www.strokeassociation.org/en/about-stroke/stroke-symptoms

STROKE SCREENING24

FAST-ED scale25

25. Lima FO, Silva GS, Furie KL et al. Field assessment stroke triage for emergency destination. A simple and accurate prehospital scale to detect large vessel occlusion strokes. Stroke 2016;47:1997-2002.

FAST-ED SCALE WAS BASED ON ITEMS OF THE NIHSS WITH HIGHER PREDICTIVE VALUE FOR

LARGE VESSEL OCCLUSION (LVOS)25

FACIAL DROP1

NORMAL OR MINOR PARALYSIS = 0

PARTIAL OR COMPLETE PARALYSIS = 1

ARM WEAKNESS - ASK THE PATIENT TO HOLD BOTH ARMS OUT WITH PALMS DOWN AND EYES CLOSED FOR 10 SECONDS. IF PATIENT CANNOT UNDERSTAND HOLD HIS/HER ARMS UP AND THEN LET THEM GO

2

NO DRIFT = 0

DRIFT OR SOME EFFORT AGAINST GRAVITY = 1 (ONE ARM DRIFTS DOWN IN < 10 SECONDS BUT HAS ANTIGRAVITY STRENGTH)

NO EFFORT AGAINST GRAVITY OR NO MOVEMENT = 2

SPEECH CHANGES - CHECK SPEECH CONTENT + ASK THE PATIENT TO NAME 3 COMMON ITEMS3

ABSENT = 0

MILD TO MODERATE = 1

SEVERE, GLOBAL APHASIA, OR MUTE = 2

EYE DEVIATION - ASK THE PATIENT TO FOLLOW YOUR FINGER AS YOU MOVE IT FROM RIGHT TO LEFT AND BACK FROM LEFT TO RIGHT5

ABSENT = 0

PARTIAL = 1 (GAZE PREFERENCE: PATIENT HAS CLEAR DIFFICULTY WHEN LOOKING TO ONE SIDE)

FORCED DEVIATION = 2 (EYES ARE DEVIATED TO ONE SIDE AND DO NOT MOVE; CANNOT FOLLOW FINGER)

FAST-ED scale25

Receptive aphasia – Ask “Show me 2 fingers”4

PATIENT SHOWS TWO FINGERS = 0

PATIENTS DOES NOT UNDERSTAND E.G. DOES NOT SHOW TWO FINGERS = 1

DENIAL/NEGLECT - ASK “ARE YOU WEAK ANYWHERE?” AND CHECK IF THE PATIENT RECOGNIZES HIS/HER WEAKNESS AND SHOW THE PATIENT HIS/HER WEAK ARM AND ASK “WHOSE ARM IT THIS?”. CHECK IF THE PATIENT RECOGNIZES HIS/HER WEAK ARM AS HIS/HER OWN

6

ABSENT = 0

EXTINCTION TO BILATERAL SIMULTANEOUS STIMULATION IN ONLY 1 SENSORY MODALITY = 1 (PATIENT IS WEAK BUT DOES NOT RECOGNIZE IT OR PATIENT DOES NOT RECOGNIZES HIS/HER WEAK ARM)

DOES NOT RECOGNIZE OWN HAND OR ORIENTS ONLY TO ONE SIDE OF THE BODY = 2 (PATIENT IS WEAK BUT DOES NOT RECOGNIZE IT AND PATIENT DOES NOT RECOGNIZES HIS/HER WEAK ARM)

25. Lima FO, Silva GS, Furie KL et al. Field assessment stroke triage for emergency destination. A simple and accurate prehospital scale to detect large vessel occlusion strokes. Stroke 2016;47:1997-2002.

Field assessment of stroke - LAPSS

LOS ANGELES PRE-HOSPITAL STROKE SCREEN (LAPSS) HAS BEEN SHOWN TO BE MORE ACCURATE THAN THE F.A.S.T. STROKE SCREEN26,27

AGE OVER 45 YEARS

SCREENING CRITERIA YES NO

NO HISTORY OF SEIZURE DISORDER

NEW ONSET OF NEUROLOGICAL SYMPTOMS IN JUST 24 HOURS

PATIENT WAS AMBULATORY AT BASELINE (PRIOR TO EVENT)

BLOOD GLUCOSE BETWEEN 60 AND 400

FACIAL SMILE/GRIMACE DROOP DROOP

EXAM RIGHT LEFT

GRIPWEAK GRIPNO GRIP

WEAK GRIPNO GRIP

ARM WEAKNESSDRIFTS DOWNFALL RAPIDLY

DRIFTS DOWNFALL RAPIDLY

NORMAL

26. Kidwell C, Starkman S, eckstein M et al. Identifying stroke in the field. Prospective validation of the Los Angeles Prehospital Stroke Screen (LAPSS). Stroke 2000;31:71-76. 27. Brandler E, Sharma M, Sinert RH et al. Prehospital stroke scales in urban environments. Neurology 2014;82:2241-2249.

Comparison of pre-hospital stroke screening tools28

82 %(76 TO 88)

83 %(77 TO 89)

SENSITIVITY (95 % CI) SPECIFICITY (95 % CI)

≥ 1 ITEM: 85 %(80 TO 90)

≥ 1 ITEM: 79 %(73 TO 85)

FACE ARM SPEECH TEST (FAST)

STROKE SCREENING TOOL

CINCINNATI PREHOSPITAL STROKE SCREEN (CPSS)

91 % (76 TO 98)

97 % (93 TO 99)

90 %(81 TO 96)

74 %(53 TO 88)

LOS ANGELES PREHOSPITAL STROKE SCREEN (LAPSS)

MELBOURNE AMBULANCE STROKE SCREEN (MASS)

28. Yew KS, Cheng E. acute stroke diagnosis. American academy of family physicians 2009;80:33-40.

Cincinnati Pre Hospital Stroke Screen(CPSS)29

29. Kothari RU, Pancioli A, Liu T et al. Cincinnati prehospital stroke scale: reproducibility and validity. Annals of emergency medicine 1999;33(4):373-378.

How to perform comprehensive NIHSS Assessment video 5

National Institute of Health Stroke Scale (NIHSS)

NIH STROKE SCALE

The NIHSS is a scoring system for the assessment of acute stroke in the context of neurological diagnosticassessment. It is used for early detection and follow-up studies of strokes and as a basis for the indication of drugtherapy options. NIHSS is routinely used in clinical practice.5

The system tests eleven functions. The summation of the data from the tests shows a maximum of 42 points. Thehigher the score, the more extensive is the stroke. A thrombolysis for ischaemic infarction is generally indicated byan NIHSS score of between 6 and 22 points.30

The advantages of the NIHSS system are that it is highly practical, very comparable and has a high degree ofreliability. Moreover, the performance of the scale and the documentation are easy to learn.21

5. Jauch EC, Saver JL, MD, HP Adams et al. Guidelines for the early management of patients with acute ischemic stroke: A guideline for healthcare professionals from the American Heart Association/American StrokeAssociation. Stroke 2013;44:870-947. 21. Summers D, Leonard A, Wentworth D et al. Comprehensive overview of nursing and interdisciplinary care of the acute ischemic stroke patient. A scientific statement from theAmerican Heart Association. Stroke 2009;40:2911-2944. 30. NIH stroke scale. [cited 2019 May 13]. Available from: https://www.stroke.nih.gov/documents/NIH_Stroke_Scale_508C.pdf

National Institute of Health Stroke Scale (NIHSS)30

30. NIH stroke scale. [cited 2019 May 13]. Available from: https://www.stroke.nih.gov/documents/NIH_Stroke_Scale_508C.pdf

National Institute of Health Stroke Scale (NIHSS) 30

30. NIH stroke scale. [cited 2019 May 13]. Available from: https://www.stroke.nih.gov/documents/NIH_Stroke_Scale_508C.pdf

2. Choose hospital

1. Diagnose stroke

EMS ROLE – First Medical Contact5

TIMELY STROKE SYMPTOMS

RECOGNITION

PRE-NOTIFICATION

RAPID TRANSPORT TO A

DESIGNATED STROKE CENTRE


Choose most appropriate hospital that can provide the patients with recanalization therapy, and stroke unit care5

Choose hospital

31

5. Jauch EC, Saver JL, MD, HP Adams et al. Guidelines for the early management of patients with acute ischemic stroke: A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2013;44:870-947. https://www.stroke.nih.gov/documents/NIH_Stroke_Scale_508C.pdf 31., Improving acute stroke care- The European angels initiative. European Stoke Association [cited 2019 April 12]. Available from: https://eso-stroke.org/angels-initiative/

Transport to nearest appropriate stroke facility

RANGE OF STROKE CENTRE CAPABILITIES

1 in24/7 STATE-OF-THE-ART CARE

WITH ALL THE LATEST EQUIPMENT AND FACILITIES

FROM ACUTE STROKE TO REHABILITATION5,32

EVIDENCE-BASED STROKE CARE, PROVIDING EXCELLENT

ACUTE PHASE TREATMENT, USUALLY WITH TRANSFER FOR

FURTHER CARE5

EFFECTIVE DIAGNOSIS AND TREATMENT IN THE VERY

ACUTE PHASE, WITH TRANSFER FOR FURTHER

CARE5

ACUTE STROKE FACILITY

PRIMARY STROKE CENTRE

COMPREHENSIVESTROKE CENTRE

5. Jauch EC, Saver JL, MD, HP Adams et al. Guidelines for the early management of patients with acute ischemic stroke: A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2013;44:870-947. 32. Xian Y, Holloway RG, Chan PS et al. Association between stroke center hospitilization for acute ischemic stroke mortality. The Journal of the American Medical Association 2011;305(4):373-380.

3. Emergency transport

1. Diagnose stroke

5. Jauch EC, Saver JL, MD, HP Adams et al. Guidelines for the early management of patients with acute ischemic stroke: A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2013;44:870-947. 33. Lin CB, Peterson ED, Smith EE et al. Emergency and medical service hospital prenotification is associated with improved evaluation and treatment of acute ischemic stroke. Circulation: cardiovascular and quality outcomes 2012;5:514-522.

Collect as much information as possible that could be relevant to treatment decision for example drugs taken and scene description5,33

Do not waste unnecessary time at the scene, transport patient emergently (< 15 minutes)5

Emergency Transport

5 5 5

Leaving as little as possible to be done after hospital arrival

Oxygen saturation Blood pressure IV access Glucose test Pre-Notify Hospital

Do as much as possible before hospital arrival5


Rapid evaluation - initial assessment of patient

5. Jauch EC, Saver JL, MD, HP Adams et al. Guidelines for the early management of patients with acute ischemic stroke: A guideline for healthcare professionals from the American Heart Association/American Stroke Association.Stroke 2013;44:870-947. 12. Jauch EC, Cucchiara B, Adeoye O et al. Part 11: Adult stroke: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation 2010;122:S818-S828. 15. The European Stroke Organization (ESO) executive committee and the ESO writing committee. Guidelines for management of ischaemic stroke and transient ischaemic attack 2008. Cerebrovascular disease 2008;25:457–507. 26. Kidwell C, Starkman S, eckstein M et al. Identifying stroke in the field. Prospective validation of the Los Angeles Prehospital Stroke Screen (LAPSS). Stroke 2000;31:71-76.

TRAINING IN STROKE ASSESSMENT

ENABLES PARAMEDICS TO IDENTIFY 86 – 97 % OF

STROKES26

INTERNATIONAL GUIDELINES5 RECOMMEND THE FOLLOWING

MEASURE BLOOD PRESSURE

CHECK ARTERIAL OXYGEN LEVEL (PULSE OXIMETRY) –CONSIDER OXYGEN MASK

ESTABLISH IV ACCESS

MEASURE BLOOD GLUCOSE

RECORD ECG12

PERFORM FAST ASSESSMENT15

ESTABLISH TIME OF ONSET OF SYMPTOMS (IF POSSIBLE)

PRE-NOTIFY HOSPITAL/STROKE UNIT

IF POSSIBLE, TAKE RELATIVE OR CARER TO THE HOSPITAL, AS A SOURCE OF INFORMATION ABOUT THE PATIENT5

ASSESS AND MANAGE ABCDE

ABCDE Approach

The ABCDE approach was developed as a way to prioritise the order of assessmentand treatment of trauma patients.4

4. Thim T, Vinther NH, Grove EL et al. Initial assessment and treatment with the Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach. International journal of general medicine 2012;5:117-121.

Airway

Breathing

34

34

34

34

5. Jauch EC, Saver JL, MD, HP Adams et al. Guidelines for the early management of patients with acute ischemic stroke: A guideline for healthcare professionals from the American Heart Association/American Stroke Association.Stroke 2013;44:870-947. 34. Peate I, Dutton H. Acute nursing care. Recognising and responding to medical emergencies. Essex, Routledge. 2012.

5

Circulation

5

60/min 100/min

5. Jauch EC, Saver JL, MD, HP Adams et al. Guidelines for the early management of patients with acute ischemic stroke: A guideline for healthcare professionals from the American Heart Association/American StrokeAssociation. Stroke 2013;44:870-947. 34. Peate I, Dutton H. Acute nursing care. Recognising and responding to medical emergencies. Essex, Routledge. 2012. 35. Kallmunzer B, Breuer L, Kahl N et al. Serious cardiacarrhythmias after stroke. Incidence, time course, and predictors- A systematic, prospective analysis. Stroke 2012;43:2892-2897. 36. About arrhythmia. American Heart Association [cited 2019 April 13]. Available from:https://www.heart.org/en/health-topics/arrhythmia/about-arrhythmia

5

5,34,35,36

Disability

34

34

5. Jauch EC, Saver JL, MD, HP Adams et al. Guidelines for the early management of patients with acute ischemic stroke: A guideline for healthcare professionals from the American Heart Association/American Stroke Association.Stroke 2013;44:870-947. 34. Peate I, Dutton H. Acute nursing care. Recognising and responding to medical emergencies. Essex, Routledge. 2012.

5

Exposure

34

34. Peate I, Dutton H. Acute nursing care. Recognising and responding to medical emergencies. Essex, Routledge. 2012.

Guide to ABCDE34

34. Peate I, Dutton H. Acute nursing care. Recognising and responding to medical emergencies. Essex, Routledge. 2012.

Abrupt blood pressure lowering should be avoided.15

Cautious blood pressure lowering is recommended in patients with extremely high blood pressures (> 220/120 mmHg) on repeated measurements, or with severe cardiac failure, aortic dissection, or hypertensive encephalopathy.15

Patients with the highest and lowest levels of blood pressure in the first 24 hours after stroke are more likely to have early neurological decline and poorer outcomes. 37

Blood pressure can usually be raised by adequate rehydration with crystalloid (saline) solutions. 15

ABC’s - Blood pressure

5. Jauch EC, Saver JL, MD, HP Adams et al. Guidelines for the early management of patients with acute ischemic stroke: A guideline for healthcare professionals from the American Heart Association/American Stroke Association.Stroke 2013;44:870-947. 15. The European Stroke Organization (ESO) executive committee and the ESO writing committee. Guidelines for management of ischaemic stroke and transient ischaemic attack 2008. Cerebrovasculardisease 2008;25:457–507. 37. Castillo J, Leira R, Garcia MM et al. Blood pressure decrease during the acute phase of ischemic stroke is associated with brain injury and poor stroke outcome. Stroke 2004;35:520-526.

5

5

15

Assess airway compromise. Occurs more frequently in older patients, those with a severe stroke, or those with symptoms of dysphagia.38

Use of supplementary oxygen to maintain oxygen saturation above 94 %. Beyond 94 %, oxyhemoglobin is saturated and no further physiologic benefit is derived.5

5. Jauch EC, Saver JL, MD, HP Adams et al. Guidelines for the early management of patients with acute ischemic stroke: A guideline for healthcare professionals from the American HeartAssociation/American Stroke Association. Stroke 2013;44:870-947. 15. The European Stroke Organization (ESO) executive committee and the ESO writing committee. Guidelines for management ofischaemic stroke and transient ischaemic attack 2008. Cerebrovascular disease 2008;25:457–507. 38. Sulter G, Elting JW, Stewart R, et al. Continuous pulse oximetry in acute hemiparetic stroke. Journal ofthe neurological science 2000;179:65-9.

ABC’s - Oxygen saturation

5,15

15

5,15

5. Jauch EC, Saver JL, MD, HP Adams et al. Guidelines for the early management of patients with acute ischemic stroke: A guideline for healthcare professionals from the American Heart Association/American Stroke Association.Stroke 2013;44:870-947. 15. The European Stroke Organization (ESO) executive committee and the ESO writing committee. Guidelines for management of ischaemic stroke and transient ischaemic attack 2008. Cerebrovasculardisease 2008;25:457–507. 21. Summers D, Leonard A, Wentworth D et al. Comprehensive overview of nursing and interdisciplinary care of the acute ischemic stroke patient. A scientific statement from the American HeartAssociation. Stroke 2009;40:2911-2944. 22. Maggiore, W. A. (2012). 'Time is Brain' in prehospital stroke treatment. Journal of emergency medical services 2012;1-9.

Start 2 large bore IV access (One could be used for thrombolytic therapy and the second to give contrast to identify patients for thrombectomy)21

However, transport should not be delayed for this. 21

No strong evidence supports or refutes routinely giving fluid boluses to stroke patients. Patients with low systolic blood pressure and no contraindications should be given a bolus of IV fluids.5,15

ABC’s - Establish an IV access

15

5,15

5,15

5,15

15

ABC’s - Blood sugar test

5. Jauch EC, Saver JL, MD, HP Adams et al. Guidelines for the early management of patients with acute ischemic stroke: A guideline for healthcare professionals from the American Heart Association/American Stroke Association.Stroke 2013;44:870-947. 15. The European Stroke Organization (ESO) executive committee and the ESO writing committee. Guidelines for management of ischaemic stroke and transient ischaemic attack 2008. Cerebrovasculardisease 2008;25:457–507. 39. Capes SE, Hunt D, Malmberg K, Pathak P et al. Stress hyperglycemia and prognosis of stroke in nondiabetic and diabetic patients: a systematic overview. Stroke 2001;32(10):2426-2432.

Hypoglycemia could mimic stroke.5

Measuring glucose levels can help differentiate between stroke and hypoglycemia. 5

Symptoms such as hemiparesis hemiplegia, speech or visual disturbances, confusion, and poor coordination can all present in patients with hypoglycemia and can be corrected with administration of dextrose. 5

Provide dextrose to those patients with glucose below 3,5 mmol/L.5,15

Pre-existing hyperglycaemia worsens the clinical outcome of acute stroke.5

Nondiabetic ischemic stroke patients with hyperglycaemia have a 3-fold higher 30-day mortality rate than do patients without hyperglycaemia. In diabetic patients with ischemic stroke, the 30-day mortality rate is 2-fold higher. 39

5,15

5,15

15

5,15

5,15

Responders must document:5

Patient last seen normal time

Current medication list, pay special attention to medication to treat coagulation disorders

Use of specific language, facilitates clear communication

Medical history

Current and recent medical history5 Current medication )please list)

Initial assessment form

5. Jauch EC, Saver JL, MD, HP Adams et al. Guidelines for the early management of patients with acute ischemic stroke: A guideline for healthcare professionals from the American Heart Association/American Stroke Association.Stroke 2013;44:870-947.

Relevant medical history5


STROKE RISK FACTORS

CARDIAC DISEASE

MEDS

CONDITIONS THAT MAY PREDISPOSE TO BLEEDING COMPLICATIONS

STROKE MIMICS – MARKERS

DRUG ABUSE

ORAL CONTRACEPTIVES

INFECTION

TRAUMA

MIGRAINE

RULE OUT STROKE MIMICS

ESPECIALLY INYOUNGER PATIENTS

Head injuries: bed at 30 degrees alleviates elevated intracranial pressure.40,41,42

Cerebral blood flow and cerebral perfusion pressure improved with the patient in a supine position.5,43

Patients should be laid flat as tolerated, unless precluded by clinical issues such as compromised respiratory status, secretions, or aspiration risk. 5,43

Patient position

5. Jauch EC, Saver JL, MD, HP Adams et al. Guidelines for the early management of patients with acute ischemic stroke: A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke2013;44:870-947. 40. Feldman Z, Kanter MJ, Robertson CS et al. Effect of head elevation on intracranial pressure, cerebral perfusion pressure, and cerebral blood flow in head-injured patients. Journal of Neurosurgery 1992;76:207-11.41. Schwarz S, Georgiadis D, Aschoff A et al. Effects of body position on intracranial pressure and cerebral perfusion in patients with large hemispheric stroke. Stroke 2002;33:497-501. 42. Ng I, Lim J, Wong HB. Effects of head postureon cerebral hemodynamics: its influences on intracranial pressure, cerebral perfusion pressure, and cerebral oxygenation. Neurosurgery. 2004;54:593-7. 43. Favilla CG, Mesquita RC, Mullen M et al. Optical bedside monitoring ofcerebral blood flow in acute ischemic stroke patients during head-of-bed manipulation. Stroke 2014;45:1269-1274.

Level of function and independence prior to onset of symptoms

Continued care of patient en route5

4. Pre-notification

1. Diagnose stroke

5. Jauch EC, Saver JL, MD, HP Adams et al. Guidelines for the early management of patients with acute ischemic stroke: A guideline for healthcare professionals from the American Heart Association/American Stroke Association.Stroke 2013;44:870-947. 15. The European Stroke Organization (ESO) executive committee and the ESO writing committee. Guidelines for management of ischaemic stroke and transient ischaemic attack 2008. Cerebrovasculardisease 2008;25:457–507. 33. Lin CB, Peterson ED, Smith EE et al. Emergency and medical service hospital prenotification is associated with improved evaluation and treatment of acute ischemic stroke. Circulation: cardiovascularand quality outcomes 2012;5:514-522.

LOWER ONSET TO DOOR TIMES OBSERVED (113 MIN VS. 150 MIN)

INCREASE IN THE AMOUNT OF PATIENTS WITH DOOR-TO-

IMAGING TIMES WITHIN 25 MIN

SHORTER SYMPTOM ONSET TO HOSPITAL ARRIVAL

STUDIES HAVE SHOWN:33

Pre-notification

5

5,15

5

BENEFITS12,44

ALLOWS HOSPITALS TO PREPARE AND MOBILIZE RESOURCES

SUCH AS IMAGING BEFORE THE PATIENT ARRIVES

REDUCES IN-HOSPITAL DELAY

STROKE TEAM PRESENT ON PATIENTARRIVAL AT THE DOOR

COLLECT RELEVANT INFO

APPROPRIATE INFORMATION ALLOWS PATIENT TO BE REGISTERED IN

HOSPITAL SYSTEMS BEFORE ARRIVAL

(INFORMATION NEEDED INCLUDE: NAME, DATE OF BIRTH, INSURANCE NUMBER)

HOW?

HOSPITAL BUSINESS CARD IN AMBULANCES

STROKE PHONE IN HOSPITAL

PRENOTIFICATION IS THE KEY THAT ALLOWS PATIENTS TO BE TREATED FASTER

Pre-notification

12. Jauch EC, Cucchiara B, Adeoye O et al. Part 11: Adult stroke: 2010 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Circulation 2010;122:S818-S828. 44. McKinney SJ,Mylavarapu K, Lane J et al. Hospital prenotification of stroke patients by emergency medical services improves stroke time targets. Journal of Stroke and Cerebrovascular Diseases 2013;(22):113-118.

Importance of EMS notification

44. McKinney SJ, Mylavarapu K, Lane J et al. Hospital prenotification of stroke patients by emergency medical services improves stroke time targets. Journal of Stroke and Cerebrovascular Diseases 2013;(22):113-118. 45. AbdullahAR, Smith EE, Biddinger PD et al. Advance hospital notification by EMS in acute stroke is assicaited with shorter door-to-computed tomography time and increased likelihood of administration of tissue-plasminogen activator.Prehospital Emergency Care 2008;12:426-431. 46. Casolla B, Bodenant M, Girot M et al. Intra-hospital delays in stroke patients treated with rt-PA:impact of preadmission notification. Journal of Neurology 2012;260(2):635-639. 47.Patel MD, Rose KM, O’Brien EC et al. Prehospital notification by emergency medical sevices reduces delays in stroke evaluation. Stroke 2011;42:2263-2268.

EMS, emergency medical services

REDUCES IN-HOSPITAL DELAYS IN STROKE EVALUATION, INCLUDING

TIME TO STROKE TEAM ARRIVAL44

TIME TO CT SCAN COMPLETION AND INTERPRETATION44,45

EVEN HIGHER BENEFIT IF EMS SPEAKS DIRECTLY WITH NEUROLOGIST PRIOR TO ARRIVAL46

INCREASES THE NUMBER OF PATIENTS UNDERGOING TIMELY IMAGING AND IMAGE INTERPRETATION BY A PHYSICIAN COMPARED WITH PATIENTS ARRIVING BY PRIVATE TRANSPORT44,45

INCREASED LIKELIHOOD OF ADMINISTRATION OF TISSUE-PLASMINOGEN-ACTIVATOR44,47

Pre-admission Notification

Ischaemic strokes admitted

to the Lille University Hospital

Thrombolysis rate: 22,5 %

Median DTN time: 49 min

Thrombolysis rate: 5,1 %

Median DTN time: 57 min

After call to hospital*

= 50 %No call to hospital*

= 50 %

Not adjusted on case-mix. A part of the difference may be explained by differences in profiles.

The best way to shorten DTN time46

46. Casolla B, Bodenant M, Girot M et al. Intra-hospital delays in stroke patients treated with rt-PA:impact of preadmission notification. Journal of Neurology 2012;260(2):635-639.

Emergency department - activation of “Code Stroke”48

DTN, door-to-needle; ED, emergency departmentEMS, emergency medical servicesNIHSS, National Institutes of Health Stroke Scale

75

IV rt-PA ADMINISTRATION UPON CONSENT

STANDARD STROKE CARE

HAS PATIENT MET REQUIREMENTS FOR

IV rt-PA ADMINISTRATION?

ONSET OF STROKE SYMPTOMS

CALL EMS SELF-PRESENTATION TO ED

ACTIVATE CODE STROKE

CODE STROKE TEAM AND PATIENT ARRIVE DIRECTLY IN IMAGING DEPARTMENT

HISTORY, PHYSICAL EXAMINATION, NIHSS ASSESSMENT

CT / MRI SCAN, ECG, BLOOD TESTS

ISCHAEMIC STROKE?

TRIAGE IN AMBULANCEON THE WAY TO HOSPITAL

TIME FROM SYMPTOM ONSET < 4,5 H SPEECH/MOTOR/FACIAL

DISTURBANCES

EARLY PRE-HOSPITAL CODE STROKE NOTIFICATION

YES

YES

NO

NO

TRIAGE IN ED CLINICAL EVALUATION BY EMERGENCY

PHYSICIANTIME FROM SYMPTOM ONSET < 4,5 H

RETROSPECTIVE DATA FROM 98 PATIENTS

PRE-CODE STROKE AND FROM 189 CODE STROKE PATIENTS

SHOWED AN 18 MIN IMPROVEMENT IN DOOR-TO-NEEDLE TIME FOR THE CODE STROKE PATIENTS (P < 0,001)

CODE STROKE AIMS TO ACHIEVE

RAPID STROKE ASSESSMENT AND

TREATMENT

48. Tai YJ, Weir L, Hand P et al. Does a ‘code stroke’ rapid access protocol decrease door-to-needle time for thrombolysis? Internal Medicine Journal 2012;42:1316-1324.

Pre-notify and provide the following5

5. Jauch EC, Saver JL, MD, HP Adams et al. Guidelines for the early management of patients with acute ischemic stroke: A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2013;44:870-947..

EMS STROKE RECOGNITION AND PRE-NOTIFICATION OF THE IN-HOSPITAL

STROKE TEAM ARE ASSOCIATED WITH SHORTER TIMES FROM ARRIVAL AT

HOSPITAL TO PHYSICIAN ASSESSMENT5

AGE

GENDER

TIME OF ONSET (TIME LAST SEEN “NORMAL”)

FAST TEST

OTHER SYMPTOMS

HISTORY OF OTHER RELEVANT DISEASES(SEIZURES, MIGRAINE, DIABETES, CANCER)

CURRENT MEDICATIONS

RESULTS OF POC TESTS – GLUCOSE

OTHER SIGNS OR RELEVANT DISEASE

ESTIMATED TIME OF ARRIVAL AT HOSPITAL

Simulation video without pre-notification video 6

Simulation video with pre-notification video 7

Summary

.

EMS ARE RESPONSIBLE FOR5

THE ROLE OF THE EMS IN ACUTE STROKE CARE IS CRITICAL FOR THE LONG-TERM PROGNOSIS

RAPID RESPONSE TO A STROKE CALL

MINIMISING PRE-HOSPITAL DELAYS

STABILISATION OF THE PATIENT

RAPID STROKE ASSESSMENT IN THE FIELD

ESTABLISHING TIME OF ONSET OF SYMPTOMS

DIRECT TRANSPORT TO THE NEAREST APPROPRIATE STROKE FACILITY

PRE-NOTIFICATION OF THE IN-HOSPITAL STROKE TEAM

CONTINUED MANAGEMENT OF THE PATIENT ACCORDING TO STANDARDISED PROTOCOLS EN ROUTE TO HOSPITAL

5. Jauch EC, Saver JL, MD, HP Adams et al. Guidelines for the early management of patients with acute ischemic stroke: A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2013;44:870-947..

EMS Heroes– video 8

Multiple Choice Questions – CPD Accreditation

Please see webpage for online questionnaire

Blue button that says:“ACCESS MODULES Q&A”

emergency medical services stroke training curriculum · face arm speech test (f.a.s.t.)24 time to...

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