stroke management for the ems provider

Stroke Management for Stroke Management for the EMS Providerthe EMS Provider

October 2014 CME

Stroke Management for Stroke Management for the EMS Providerthe EMS Provider

At the completion of this module, the At the completion of this module, the EMS Provider will be able to:EMS Provider will be able to:Describe the various types of stroke and their etiology.Describe the various types of stroke and their etiology.Discuss the imperatives for best practice in regard to EMS Discuss the imperatives for best practice in regard to EMS stroke management.stroke management.List 5 or more risk factors for acute stroke.List 5 or more risk factors for acute stroke.Define “penumbra” and how this concept is important in Define “penumbra” and how this concept is important in stroke.stroke.Generally describe the major vessels involved in acute Generally describe the major vessels involved in acute ischemic stroke.ischemic stroke.Discuss the “therapeutic window” for thrombolytic therapy in Discuss the “therapeutic window” for thrombolytic therapy in stroke.stroke.Identify interventions that individual EMS providers can make Identify interventions that individual EMS providers can make to improve outcomes in stroke.to improve outcomes in stroke.

Is STROKE a health problem in the US Is STROKE a health problem in the US today?today?

700,000 strokes every year700,000 strokes every year

• 5 million stroke survivors, but with substantial morbidity:• 18% unable to return to work• 4% require total custodial care

• Stroke is the leading cause of serious, long term disability

• One person dies of stroke every 3 minutes

• Stroke is the 3rd leading cause of death

Only 50-70% of stroke survivors Only 50-70% of stroke survivors regain functional independenceregain functional independence

• Locally, African-Americans have 50% more strokes than Caucasians, and twice as many as Asians and Hispanics (Statistics from the American Stroke Association)

• 22% of men & 25% of women die within 1 year of their first stroke

• 20% are institutionalized within 3 months

Is STROKE a health problem in the US Is STROKE a health problem in the US today?today?

Women & StrokeWomen & Stroke

Stroke kills more than twice as many Stroke kills more than twice as many

American women every year as breast cancerAmerican women every year as breast cancer

More women than men die from strokeMore women than men die from stroke

Women over age 30 who smoke and take Women over age 30 who smoke and take

high-estrogen oral contraceptives have a high-estrogen oral contraceptives have a

stroke risk stroke risk 22 times higher22 times higher than average than average

(National Stroke Association)

Is STROKE a health problem in Is STROKE a health problem in the US today?the US today?

YES, stroke is a major health problem YES, stroke is a major health problem in the US today.in the US today.

EMS Providers are closely involved with this patient EMS Providers are closely involved with this patient population and are a vital component of the population and are a vital component of the “Stroke Chain of Survival”.“Stroke Chain of Survival”.

Increased knowledge and personal motivation on Increased knowledge and personal motivation on the part of EMS providers can:the part of EMS providers can: Greatly reduce death and disability due to stroke.Greatly reduce death and disability due to stroke. Improve stroke centers’ ability to provide thrombolytic Improve stroke centers’ ability to provide thrombolytic

therapy.therapy. Make a positive impact on communities’ strides to reduce Make a positive impact on communities’ strides to reduce

costs for healthcare and improve outcomes. costs for healthcare and improve outcomes.

Goals for EMS Provider Care of Goals for EMS Provider Care of Stroke PatientsStroke Patients

1.1. Improve knowledge of identification of Improve knowledge of identification of stroke signs and symptoms.stroke signs and symptoms.

2.2. Develop a rapid assessment process.Develop a rapid assessment process.3.3. Facilitate transfer of stroke victims to Facilitate transfer of stroke victims to

Primary Stroke Centers in the quickest and Primary Stroke Centers in the quickest and safest manner.safest manner.

4.4. Pre-notify the Stroke Center, “Possible Pre-notify the Stroke Center, “Possible acute stroke in route.”acute stroke in route.”

5.5. Encourage family members familiar with the Encourage family members familiar with the patient care to either ride with the transfer patient care to either ride with the transfer vehicle or drive to the stroke center ASAP to vehicle or drive to the stroke center ASAP to provide more patient information.provide more patient information.

Goals for EMS Provider Care of Goals for EMS Provider Care of Stroke PatientsStroke Patients

6.6. Obtain reliable list of meds taken or bring bag Obtain reliable list of meds taken or bring bag of all medications taken.of all medications taken.

7.7. Obtain a set of vital signs and finger stick blood Obtain a set of vital signs and finger stick blood sugar at the site.sugar at the site.

8.8. Reliably identify family’s best estimation of Reliably identify family’s best estimation of when the patient was “last seen normal”.when the patient was “last seen normal”.

9.9. Administer the Cincinnati Pre-hospital Stroke Administer the Cincinnati Pre-hospital Stroke Scale.Scale.

10.10. Provide the receiving facility with a quick, Provide the receiving facility with a quick, complete verbal report that incorporates the complete verbal report that incorporates the information obtained since arrival on scene.information obtained since arrival on scene.

Review: Anatomy & Review: Anatomy & Physiology of Acute Ischemic Physiology of Acute Ischemic

StrokeStroke What is acute ischemic stroke?What is acute ischemic stroke? What is the major vasculature involved?What is the major vasculature involved? When circulation is suddenly reduced, how When circulation is suddenly reduced, how

quickly is brain tissue affected?quickly is brain tissue affected? What is “penumbra”?What is “penumbra”? What are the types and etiologies of What are the types and etiologies of

stroke?stroke? What about different stroke symptoms?What about different stroke symptoms?

What Is Stroke ?What Is Stroke ?What Is Stroke ?What Is Stroke ?

A stroke occurs when blood flow A stroke occurs when blood flow to the brain is interrupted by to the brain is interrupted by

a blocked or burst blood vessel.a blocked or burst blood vessel.

A stroke occurs when blood flow A stroke occurs when blood flow to the brain is interrupted by to the brain is interrupted by

a blocked or burst blood vessel.a blocked or burst blood vessel.

Copyright 2004 MEDRAD, Inc. All rights reserved.

No oxygen, nerve cells die in minutesNo oxygen, nerve cells die in minutes

In first three hours, some cells In first three hours, some cells can be saved (up to 35% recovery)can be saved (up to 35% recovery)

Thrombolytics Thrombolytics ((‘‘clotclot--bustingbusting’’) drugs) drugsdissolve clots; prevent more strokes:dissolve clots; prevent more strokes:

Administered via IV pumpAdministered via IV pump Heparin (mixed results) Heparin (mixed results) tt--PA, PA, ““ActivaseActivase”” (good results)(good results)

What is Stroke?What is Stroke?What is Stroke?

One quarter of cardiacoutput goes to the 5-6pound organ—the brain.The brain needs a constant supply of:•Oxygen•Glucose•Other nutrients

Circulation is suppliedvia 2 pairs of arteries:•Internal carotids•Vertebrals

The Major Circulation to the Brain

PENUMBRA(That tissue surrounding the infarct that is salvageable, but at risk.)

Rapid transfer to the stroke center will allow for protection of penumbrathrough emergency interventions and medical management.

Cerebrovascular Disease: Cerebrovascular Disease: PathogenesisPathogenesis

Ischemic Stroke (83%)Hemorrhagic Stroke (17%)AtherothromboticCerebrovascularDisease (20%)

Embolism (20%)Lacunar (25%)Small vessel disease

Cryptogenic (30%)

IntracerebralHemorrhage (59%)

Subarachnoid Hemorrhage (41%)

Albers GW, et al. Chest. 1998;114:683S-698S.Rosamond WD, et al. Stroke. 1999;30:736-743.

Acute Ischemic StrokeAcute Ischemic Stroke(What do you see?)(What do you see?) Deficits:Deficits:

Unilateral (though not always) weaknessUnilateral (though not always) weakness Unilateral sensory deficitUnilateral sensory deficit Visual deficits (blindness, gaze palsy, double)Visual deficits (blindness, gaze palsy, double) Speech (slurred – a motor dysfunction)Speech (slurred – a motor dysfunction) Language (aphasia – damage to the brain’s Language (aphasia – damage to the brain’s

speech center)speech center) Ataxia (lack of coordinated movement)Ataxia (lack of coordinated movement) Cognitive impairmentCognitive impairment

Like real estate—Location, Location, Like real estate—Location, Location, Location Location

What Parts of What Parts of the Brain Are the Brain Are

Affected by Stroke?Affected by Stroke?

What Parts of What Parts of the Brain Are the Brain Are

Affected by Stroke?Affected by Stroke?

What Are the Effects What Are the Effects of Stroke?of Stroke?

Left BrainLeft Brain Left BrainLeft Brain

What Are the Effects What Are the Effects of Stroke?of Stroke?

Right BrainRight Brain Right BrainRight Brain

Stroke Assessment ScaleStroke Assessment Scale(Cincinnati Pre-hospital Stroke Scale)(Cincinnati Pre-hospital Stroke Scale)

“The sky is blue in Cincinnati.”

Any abnormality means anabnormal Cincinnati scalefor stroke.

Probably accurately detectsstroke 80% of the time.

Act Act F.A.S.TF.A.S.T for stroke for stroke

The National Stroke Association The National Stroke Association recommends using the recommends using the FASTFAST method method for recognizing and responding to stroke for recognizing and responding to stroke symptoms.symptoms.

FF (face) (face) AA (arms) (arms) S S (speech) (speech) TT (time) (time)

Stroke Assessment in the Stroke Assessment in the FieldField

Administer Cincinnati Scale.Administer Cincinnati Scale. If abnormal, facilitate a rapid transfer If abnormal, facilitate a rapid transfer

to an approved stroke center. to an approved stroke center. Pre-notify the receiving stroke centerPre-notify the receiving stroke center

—”possible acute stroke in route”.—”possible acute stroke in route”.

Identify Time “Last Seen Identify Time “Last Seen Normal”Normal”

A 75 year old man with HTN and diabetes finishes dinner with a A 75 year old man with HTN and diabetes finishes dinner with a friend at 8pm. He drives himself the short distance home that friend at 8pm. He drives himself the short distance home that night, and a daughter stops by the next morning to find him night, and a daughter stops by the next morning to find him still in bed and with right side weakness and severe aphasia. still in bed and with right side weakness and severe aphasia. When do we assume the stoke occurred? (Answer: “last seen When do we assume the stoke occurred? (Answer: “last seen normal at 8pm)normal at 8pm)

A 35 year old hypertensive man who is known to be non-A 35 year old hypertensive man who is known to be non-compliant with meds is found slumped over in his car in a job compliant with meds is found slumped over in his car in a job site parking area at 3pm. In the ED he was found to have a site parking area at 3pm. In the ED he was found to have a massive left hemispheric ischemic stroke. His wife said he left massive left hemispheric ischemic stroke. His wife said he left for work at 7am that morning as normal, and she had a clear for work at 7am that morning as normal, and she had a clear and normal cell phone conversation with him at 12:30pm. At and normal cell phone conversation with him at 12:30pm. At 1pm a co-worker stated the man said he wasn’t feeling well 1pm a co-worker stated the man said he wasn’t feeling well and was going to his car to rest. At the time the co-worker and was going to his car to rest. At the time the co-worker noticed his speech was slurred. What time can we use as the noticed his speech was slurred. What time can we use as the time “last seen normal”? (Answer: 12:30pm)time “last seen normal”? (Answer: 12:30pm)

Types of Acute Ischemic Types of Acute Ischemic StrokesStrokes

Middle Cerebral Artery StrokeMiddle Cerebral Artery Stroke Vertebral—Basilar Artery StrokesVertebral—Basilar Artery Strokes Lacunar StrokesLacunar Strokes

Types of StrokesTypes of Strokes(Middle Cerebral Artery – MCA)(Middle Cerebral Artery – MCA)

CT Scan of Acute Ischemic Stroke(Left MCA territory stroke)

Types of StrokesTypes of Strokes(Middle Cerebral Artery – MCA)(Middle Cerebral Artery – MCA)

The most common artery occluded in AIS—The most common artery occluded in AIS—can be proximal or from carotid circulation.can be proximal or from carotid circulation.

Features:Features: Motor/Sensory Deficit: face, arm, legMotor/Sensory Deficit: face, arm, leg Speech deficit – dysarthria (slurred speech)Speech deficit – dysarthria (slurred speech) Language deficit – if in dominant hemisphereLanguage deficit – if in dominant hemisphere Gaze palsy – eyes directed towards side of AISGaze palsy – eyes directed towards side of AIS

Blindness – visual field cut Blindness – visual field cut (homonymous hemianopsia)(homonymous hemianopsia)

Types of StrokesTypes of Strokes(Vertebral—Basilar Artery)(Vertebral—Basilar Artery)

Features:Features: Cranial nerve involvement – hearing, Cranial nerve involvement – hearing,

visual, facial, swallowingvisual, facial, swallowing Can have bilateral weaknessCan have bilateral weakness Cerebellar signs – ataxiaCerebellar signs – ataxia Sensory deficitsSensory deficits Vertigo – often nystagmusVertigo – often nystagmus Nausea and vomitingNausea and vomiting Common to have waxing and waning Common to have waxing and waning

symptomssymptoms

Lacunar StrokesLacunar Strokes

These strokes are These strokes are ischemic in nature.ischemic in nature. Mainly caused by Mainly caused by

HTN. HTN. Occurs in the small Occurs in the small

penetrating arteries of penetrating arteries of the brain.the brain.

Presentation – affects Presentation – affects the arm, leg, and the arm, leg, and face, sometimes face, sometimes silent. Deficits are silent. Deficits are equal to all areas.equal to all areas.

Conditions That Mimic AISConditions That Mimic AIS

Bell’s PalsyBell’s Palsy Todd’s ParalysisTodd’s Paralysis Hemorrhagic StrokeHemorrhagic Stroke Subdural HematomaSubdural Hematoma Other conditionsOther conditions


Bell’s PalsyBell’s Palsy

Bell’s Palsy is a viral infection of the facial nerve which causes stroke-likesymptoms: unilateral facial droop, sensory deficit, dysarthria, etc.


Differential dx:Differential dx: Hx: women, pregnancy, Hx: women, pregnancy,

viral illnessviral illness Can’t close eye completely Can’t close eye completely

or raise foreheador raise forehead May have facial painMay have facial pain No other stroke symptomsNo other stroke symptoms May have no risk factors May have no risk factors

for strokefor stroke


Todd’s ParalysisTodd’s Paralysis: unilateral weakness : unilateral weakness that occurs after a seizure.that occurs after a seizure. Can involve speech, language, visual and Can involve speech, language, visual and

sensorysensory May be due to hyperpolarization in the May be due to hyperpolarization in the

area of the seizurearea of the seizure Resolves within 48 hoursResolves within 48 hours Key concern in regard to thrombolytic Key concern in regard to thrombolytic

therapytherapy

Conditions That Mimic AISConditions That Mimic AIS HypoglycemiaHypoglycemia Metabolic conditions – fever, Metabolic conditions – fever,

hyponatremia, drugs, etc.hyponatremia, drugs, etc. PsychogenicPsychogenic Complex migrainesComplex migraines Hypertensive crisisHypertensive crisis

What are the risks factors for What are the risks factors for Ischemic Stroke?Ischemic Stroke?

Modifiable RisksModifiable Risks HTNHTN CAD/Carotid CAD/Carotid

Disease/PVDDisease/PVD Atrial FibrillationAtrial Fibrillation DiabetesDiabetes WeightWeight High Cholesterol/DietHigh Cholesterol/Diet Lack of exerciseLack of exercise ETOH/Drug abuseETOH/Drug abuse Coagulopathy- Cancer, Coagulopathy- Cancer,

Sickle Cell AnemiaSickle Cell Anemia

Non-Modifiable RisksNon-Modifiable Risks Age->55Age->55 Race- African Americans Race- African Americans

have 2x the risk of death have 2x the risk of death and disability. Asians and disability. Asians have 1.4x the risk of have 1.4x the risk of death and disability.death and disability.

Sex- 9% greater chance Sex- 9% greater chance in men. (61% of stroke in men. (61% of stroke deaths occur in women)deaths occur in women)

Previous Stroke or TIAPrevious Stroke or TIA Family History of StrokeFamily History of Stroke

Goals for Treatment in the Goals for Treatment in the EDED

EMS rapid identification & pre-notification of EMS rapid identification & pre-notification of the Emergency Dept.the Emergency Dept.

Quick evaluation in ED. Quick evaluation in ED. Last seen normal < 3 hr.Last seen normal < 3 hr. Door-to-CT scan Door-to-CT scan < 25 minutes< 25 minutes CT-to-Radiologist Reading CT-to-Radiologist Reading < 20 < 20

minutesminutes IV TPA administrationIV TPA administration < 15 minutes< 15 minutes (Door-to-needle within 60 minutes.)(Door-to-needle within 60 minutes.)

What can be done for an acute What can be done for an acute ischemic stroke?ischemic stroke?

These patients may be appropriate for These patients may be appropriate for “clot busting” drugs. Tissue Plasminogen “clot busting” drugs. Tissue Plasminogen Activator (TPA).Activator (TPA).

Requires a rapid, coordinated response.Requires a rapid, coordinated response. IV TPA can only be given within the first 3 IV TPA can only be given within the first 3

hours of symptom onset.hours of symptom onset. Expected response: “60 minutes from Expected response: “60 minutes from

door to needle.”door to needle.”

Tissue Plasminogen ActivatorTissue Plasminogen Activator

Natural body substance. Recombinant Natural body substance. Recombinant TPA converts Plasminogen to plasmin, TPA converts Plasminogen to plasmin, which in turn breaks down fibrin and which in turn breaks down fibrin and fibrinogen, thereby dissolving the clot.fibrinogen, thereby dissolving the clot.

IV window of opportunity is < 3 hours of IV window of opportunity is < 3 hours of known symptom onset.known symptom onset.

TransitionTransition

Hemorrhagic StrokeHemorrhagic Stroke

Hemorrhagic StrokeHemorrhagic Stroke(Intracranial Hemorrhage—ICH & Subarachnoid Hemorrhage—(Intracranial Hemorrhage—ICH & Subarachnoid Hemorrhage—

SAH)SAH) Intracranial Hemorrhage (Hypertensive):Intracranial Hemorrhage (Hypertensive):

> twice as common as SAH> twice as common as SAH more likely to result in death or severe more likely to result in death or severe

disabilitydisability 37,000 Americans/year37,000 Americans/year 35-52% dead within 1 month (half of deaths 35-52% dead within 1 month (half of deaths

in the first 2 days)in the first 2 days) Only 10% living independently in 1 month; Only 10% living independently in 1 month;

improves to only 20% within 6 months improves to only 20% within 6 months


SAH)SAH)

Risk factors:Risk factors: HypertensionHypertension Advancing ageAdvancing age Coagulation disorders & therapyCoagulation disorders & therapy ETOH abuseETOH abuse Drug use (meth, cocaine, crack, etc.)Drug use (meth, cocaine, crack, etc.) Ischemic stroke—hemorrhagic Ischemic stroke—hemorrhagic

transformationtransformation


SAH)SAH)

Presenting signs:Presenting signs: Sudden—signs over minutes to hoursSudden—signs over minutes to hours HeadacheHeadache Nausea and vomitingNausea and vomiting Decreasing LOCDecreasing LOC Extremely elevated blood pressureExtremely elevated blood pressure (All of these are signs of increased ICP)(All of these are signs of increased ICP)


SAH)SAH)

Differential Diagnosis:Differential Diagnosis:

AIS—often high BPAIS—rare decreased LOCAIS—rare or vague H.A.AIS—rare nausea & vomitingAIS—often wake up with the symptoms

ICH—usually very high BPICH—50% of the time ↓ LOCICH—40% of the time H.A.ICH—50% of time vomitingICH—rarely wake up with symptoms (15%)

• Final diagnosis is by CT scan.

Weakened blood vessels in a Weakened blood vessels in a Hypertensive BleedHypertensive Bleed

Autopsy of Intracerebral Hemorrhage

Small hemorrhagic stroke

Large hemorrhagic stroke

ICH: Goals for Early ICH: Goals for Early ManagementManagement

Airway managementAirway management Assure adequate oxygenation & reduce Assure adequate oxygenation & reduce

hypercapnea (Remember: hypercapnea (Remember: ↑CO2 = ↑ ICP)↑CO2 = ↑ ICP) Prevent aspiration (Remember: 50% of ICH Prevent aspiration (Remember: 50% of ICH

patients vomit and have ALOC)patients vomit and have ALOC) SeizuresSeizures

Versed – If seizure activity > 2-3 minutes Versed – If seizure activity > 2-3 minutes administer 2.5mg IV. May repeat 2.5mg administer 2.5mg IV. May repeat 2.5mg once in 5 minutesonce in 5 minutes

Versed may be given IM if no IV establishedVersed may be given IM if no IV established

OxygenationOxygenation

Oxygen is a free radical, meaning that it is a Oxygen is a free radical, meaning that it is a highly reactive species owing to its two unpaired highly reactive species owing to its two unpaired electrons. From a physics perspective, free electrons. From a physics perspective, free radicals have potential to do harm in the bodyradicals have potential to do harm in the body

Normally, the body fends off free radical attacks Normally, the body fends off free radical attacks using antioxidants. With aging and in cases of using antioxidants. With aging and in cases of trauma, stroke, heart attack or other tissue injury, trauma, stroke, heart attack or other tissue injury, the balance of free radicals to antioxidants shiftsthe balance of free radicals to antioxidants shifts

Cell damage occurs when free radicals outnumber Cell damage occurs when free radicals outnumber antioxidants, a condition called oxidative stressantioxidants, a condition called oxidative stress

OxygenationOxygenation Tissue damage is directly proportionate to the Tissue damage is directly proportionate to the

quantity of free radicals present at the site of injury. quantity of free radicals present at the site of injury. Supplemental oxygen administration during the Supplemental oxygen administration during the initial moments of a stroke may well increase tissue initial moments of a stroke may well increase tissue injury by flooding the injury site with free radicals.injury by flooding the injury site with free radicals.

Oxygen saturations should be measured on every Oxygen saturations should be measured on every patient.patient.

Administer oxygen to keep saturations between 94 Administer oxygen to keep saturations between 94 and 96 percent. Rarely does a patient need oxygen and 96 percent. Rarely does a patient need oxygen saturations above 97 percent.saturations above 97 percent.

ICH: Goals for Early ICH: Goals for Early ManagementManagement

Blood Pressure ManagementBlood Pressure Management:: Very poor outcomes if BP is allowed to stay Very poor outcomes if BP is allowed to stay

very high—more bleedingvery high—more bleeding Very poor outcomes if BP is allowed to drop Very poor outcomes if BP is allowed to drop

precipitously—removes the brain’s attempt precipitously—removes the brain’s attempt to perfuse a “tight” brainto perfuse a “tight” brain

GuidelinesGuidelines:: In general, keep BP about 160/90 or MAP In general, keep BP about 160/90 or MAP

<130<130 In the first 48 hours: no BP drop > 15-25% In the first 48 hours: no BP drop > 15-25%

of presenting valueof presenting value

Hemorrhagic StrokeHemorrhagic Stroke(Subarachnoid Hemorrhage)(Subarachnoid Hemorrhage)

Acute bleeding around the outside of Acute bleeding around the outside of the brain and into the subarachnoid the brain and into the subarachnoid space.space.

Usually from an aneurysm or arterio-Usually from an aneurysm or arterio-venous malformation.venous malformation.

Statistics:Statistics: 50% are fatal50% are fatal 1--15% die before reaching the hospital1--15% die before reaching the hospital Those who survive are often impairedThose who survive are often impaired 1-7% of all strokes1-7% of all strokes

Hemorrhagic StrokeHemorrhagic Stroke(Subarachnoid Hemorrhage)(Subarachnoid Hemorrhage)

Diagnosis:Diagnosis: ““Thunderclap” headache. “It is the Thunderclap” headache. “It is the

worst worst headache of my life!”headache of my life!” Xanthochromic lumbar puncture (blood Xanthochromic lumbar puncture (blood

in the CSF not due to traumatic tap)in the CSF not due to traumatic tap) ““Star pattern” on CT scanStar pattern” on CT scan

Aneurysmal bleedAneurysmal bleed

Classic “Star Pattern” of Subarachnoid Hemorrhage

Subdural HematomaSubdural Hematoma(Not a true strokebut symptoms canmimic stroke.)

Subdural HematomaSubdural Hematoma

Symptoms:Symptoms: Unilateral weakness, sensory deficitUnilateral weakness, sensory deficit Facial weaknessFacial weakness DysarthriaDysarthria Altered level of consciousnessAltered level of consciousness

Onset:Onset: Can be rapidCan be rapid Can take months to show symptomsCan take months to show symptoms

Subdural HematomaSubdural HematomaCausesCauses

Anticoagulation (Heparin, Coumadin)Anticoagulation (Heparin, Coumadin) Antithrombotics (Aspirin, Plavix)Antithrombotics (Aspirin, Plavix) ETOH abuseETOH abuse Trauma (could be recent or months Trauma (could be recent or months

ago)ago) Advanced age (most common cause)Advanced age (most common cause)

Subdural HematomaSubdural Hematoma

Small bridging veins from the dura mater to the brain are stretchedand can rupture releasing blood into the subdural space and causing

pressure on that part of the brain. This leads to the deficits seen.

Subdural Hematoma on CT Subdural Hematoma on CT ScanScan

Subdural HematomaSubdural HematomaTreatment OptionsTreatment Options

Medical Management:Medical Management: Correct CoagsCorrect Coags Monitor neuro signsMonitor neuro signs

Surgical Management:Surgical Management: Correct CoagsCorrect Coags Burr hole drainageBurr hole drainage Craniotomy for removal of solid clotCraniotomy for removal of solid clot

Summing UpSumming Up

The best stroke care is a coordinated The best stroke care is a coordinated approach and developed in a stroke center approach and developed in a stroke center system of care.system of care.

Requires everyone to be on board:Requires everyone to be on board: Patients/FamiliesPatients/Families EMSEMS EDED Stroke UnitStroke Unit Stroke RehabilitationStroke Rehabilitation

Summing UpSumming Up

How well a patient does; whether a How well a patient does; whether a patient has a life-long serious patient has a life-long serious disability; whether he/she lives or disability; whether he/she lives or dies; may depend on dies; may depend on youyou and how and how you respond.you respond.

A few minutes delay may make a A few minutes delay may make a very big difference.very big difference.

What you do What you do reallyreally matters! matters!

Emergent Stroke Care and the Emergent Stroke Care and the Chain of SurvivalChain of Survival

Patient Calling EMS ED Stroke StrokeKnowledge 911 System Staff Team Unit

EMS EMS TreatmentTreatment

SMO Code 38SMO Code 38““Suspected Suspected

Stroke” Stroke”

““Initiate rapid transport.”Initiate rapid transport.”

ESRH – Emergent Stroke Ready Hospital

PSC – Primary Stroke Center

Stroke CentersStroke Centers

On Oct 22, 2013, the Illinois On Oct 22, 2013, the Illinois Legislature’s Joint Committee on Legislature’s Joint Committee on Administrative Rules formally Administrative Rules formally approved the Administrative Rule for approved the Administrative Rule for the 2009 Illinois Primary Stroke the 2009 Illinois Primary Stroke Center Law.Center Law.

The 2009 Primary Stroke Center Law The 2009 Primary Stroke Center Law was designed to improve stroke care in was designed to improve stroke care in two complementary ways: two complementary ways: Help hospitals to improve the quality of Help hospitals to improve the quality of

their in-patient stroke care systemstheir in-patient stroke care systems It would ensure that regional emergency It would ensure that regional emergency

medical services (EMS) medical directors medical services (EMS) medical directors draft and implement stroke care protocols draft and implement stroke care protocols to better identify stroke patients in the field to better identify stroke patients in the field and and take them directly to the nearest take them directly to the nearest designated stroke center for treatment, designated stroke center for treatment, bypassing a less-specialized hospital if bypassing a less-specialized hospital if necessarynecessary. .

Silver Cross Hospital EMS Silver Cross Hospital EMS System System

Within SCEMSS, there are 3 IDPH Within SCEMSS, there are 3 IDPH approved PSC or ESRH facilities:approved PSC or ESRH facilities: Silver Cross Hospital – PSCSilver Cross Hospital – PSC Presence St Joseph Medical Center – PSCPresence St Joseph Medical Center – PSC South Suburban Hospital – PSCSouth Suburban Hospital – PSC

Other associate/participating Other associate/participating facilities within SCEMSS have IDPH facilities within SCEMSS have IDPH applications pending approvalapplications pending approval

Patient advocacy…Patient advocacy…

Per CODE 38Per CODE 38 If the Cincinnati Stroke Scale is positive;If the Cincinnati Stroke Scale is positive; And “last known normal” is less than 3 And “last known normal” is less than 3

hours;hours;

Transport to the closest Primary Stroke Transport to the closest Primary Stroke Center or Emergent Stroke Ready Center or Emergent Stroke Ready HospitalHospital

Initial Medical CareInitial Medical Care Obtain blood glucose reading and Obtain blood glucose reading and

treat appropriatelytreat appropriately Cincinnati Stroke ScaleCincinnati Stroke Scale

If Positive, begin transport to nearest If Positive, begin transport to nearest MOST APPROPRIATE facilityMOST APPROPRIATE facility

Initiate rapid transportInitiate rapid transport 12-Lead EKG12-Lead EKG

““If available” refers to the ability of your cardiac If available” refers to the ability of your cardiac monitor to perform a 12-lead EKG. If you have monitor to perform a 12-lead EKG. If you have 12-lead capabilities, you must perform one.12-lead capabilities, you must perform one.

Other SMO CODE’s as indicatedOther SMO CODE’s as indicated Coma of Unknown OriginComa of Unknown Origin SeizuresSeizures

Code 38 – Suspected Code 38 – Suspected StrokeStroke

Run of the month…Run of the month…

Atrial FibrillationAtrial Fibrillation

1) P waves are absent. 2) There are fibrillation

(f) waves instead of P waves. The f waves result in an oscillating irregular baseline.

3) The R-R intervals are not equal resulting in an irregular rhythm (irregularly irregular)

Atrial rate 400-600bpm

Ventricular rate 75-175bpm

Clinical significance Clinical significance

Atrial fibrillation patients usually have a ventricular rate of 75-175 beats/minute

A lower ventricular rate should suggest AV block or the use of medications decreasing the ventricular rate (digoxin, beta blocker, verapamil, diltiazem, amiodarone)

High ventricular response may cause syncope or even death in these patients

Since the R-R intervals continuously change in atrial fibrillation patients, the heart rate on the monitor also changes continuously. In such patients, the instantaneous heart rates depicted on the monitor usually does not give the average ventricular rate of that patient

Since there is no atrial contraction, the presence of atrial fibrillation decreases cardiac output by 20-25%

Atrial fibrillation results in “atrial statis” which predisposes to the thrombus formation in the atria. This results in increased risk of systemic embolism

Unless contraindicated, patients with atrial fibrillation are generally advised to be on blood thinners

Coumadin (warfarin sodium) is the most common medication prescribed for A-Fib

In patients with a very high ventricular rate, it may be difficult to recognize the irregularity of the R-R intervals at first glance

Adenosine is often used in the clinical setting to slow the rate to differentiate between SVT/V-Tach. A-fib will not respond to the effects of adenosine. THIS IS NOT PART OF REGION VII SMO’s

In some patients, atrial fibrillation is not persistent. (Transient A-Fib)

Assessment/TreatmentAssessment/Treatment

Symptomatic A-Fib patients – Signs of hypoperfusion with elevated heart rate, altered mental status Consider Synchronized Cardioversion

Region VII – Code 83, “Synchronized Cardioversion”

Code 83 - “Synchronized Cardioversion”

Consider use of Versed for pain management and/or sedationConsider use of Versed for pain management and/or sedation 2.5mg to 5mg, slow IVP2.5mg to 5mg, slow IVP Constantly assess pulse oximetry and be prepared to place advanced airway Constantly assess pulse oximetry and be prepared to place advanced airway

if necessary!if necessary! Place patient in safe environment, away from pooled water and metal surfacesPlace patient in safe environment, away from pooled water and metal surfaces Apply monitor-defibrillator electrode pads to patient chest or appropriate Apply monitor-defibrillator electrode pads to patient chest or appropriate

conductive medium paddlesconductive medium paddles Turn on defibrillatorTurn on defibrillator Set energy levelSet energy level Activate “synchronous” modeActivate “synchronous” mode Charge capacitorCharge capacitor Ensure proper placement of electrodes on chest: Apical and high parasternalEnsure proper placement of electrodes on chest: Apical and high parasternal If using hand-held paddles, apply firm pressure and maintain until machine If using hand-held paddles, apply firm pressure and maintain until machine

dischargesdischarges Assure that no personnel are in direct contact with the patient (Call “clear”)Assure that no personnel are in direct contact with the patient (Call “clear”) Deliver shock by depressing discharge button. Hold button down until machine Deliver shock by depressing discharge button. Hold button down until machine

dischargesdischarges Reassess patientReassess patient

Drug of the MonthDrug of the Month

Dextrose 50%

Dextrose 50%Dextrose 50%

Adult Dose/Route

Peds Dose/Route

Action Indications Contra-Indications

Adverse Reactions

25 gm/50ml of 50% solution IVP

> 8 years2 mL/kg of 50% solution

1 – 8 years2 mL/kg of 25% solution

Infants under 2months4 mL/kg of 12.5% solution

Increase blood glucose concentration

Hypoglycemia

Intracranial and intraspinal hemorrhage, hypovolemia, hypotension 2° tachydysrhythmias, delerium tremens.

Hyperglycemia, warmth / burning from IV injection, diuresis, thrombophlebitis, tissue necrosis if IV infiltration.

The End…The End…

Thanks for all you do !!!Thanks for all you do !!!

stroke management for the ems provider

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