Scott

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Scott White EMS Stroke Education

• Jeremiah Lanford, MD
• Stroke Director
• Department of Neurology
• Scott White Healthcare Round Rock

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Goals Objectives

• Ischemic stroke
• Diagnosis/clinical presentation
• Pathophysiology
• Acute treatment
• EMS assessment and management
• Intracerebral Hemorrhage
• Diagnosis/Pathophysiology
• EMS assessment and management
• Subarachnoid Hemorrhage
• Diagnosis/Pathophysiology
• EMS assessment and management

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Stroke Statistics

• Incidence
• 795,000 people/year with new stroke
• Every 40sec stroke in US
• 158/100,000 people
• 1/17 deaths in US
• 3 among causes of death
• Leading cause of disability
• 50 of ischemic stroke

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Stroke Subtypes

• 87 Ischemic
• 10 Hemorrhagic
• 3 Subarachnoid Hemorrhage

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Ischemic Stroke

• Definition
• Abrupt neurologic dysfunction due to focal brain
  ischemia (lack of blood flow) lasting 24hrs
• Unilateral weakness/numbness, vision change,
  incoordination, language changes

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Ischemic Stroke
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ISCHEMIC STROKETOAST CLASSIFICATION

• Large artery Atherosclerosis
• Unilateral weakness, numbness, visual field cut,
  cortical signs- aphasia/neglect, cerebellar Sx
• Carioembolic
• Stroke in multiple vascular regions
• Afib, cardiomyopathy, MI
• Small Vessel Ischemia (lacunar stroke)
• Pure motor, pure sensory, mixed,
  ataxia/hemiparesis, dysarthria clumsy hand
• Other
• Hypercoagulable state, vasculitis
• Unknown (cryptogenic)

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Ischemic StrokePathophysiology

• Ischemic Core
• Cellular necrosis- no oxygen/glucose
• Cerebral edema (swelling)
• Loss of blood-brain barrier
• (hemorrhagic transformation)
• Ischemic Penumbra
• Surrounding tissue with decreased bld flow
• At risk tissue

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Acute Ischemic StrokeRisk Factors

• HTN
• Smoking
• A-fib
• Hyperlipidemia
• Diabetes
• Age
• Physical inactivity/Obesity

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Ischemic Stroke Statistics
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Acute Ischemic Stroke MIMICS

• Hypoglycemia
• Seizure
• Migraine
• Hypertensive Encephalopathy
• Reactivation of old stroke
• Mass lesion
• Intracerebral Hemorrhage
• SAH
• Peripheral vestibulopathy
• Conversion reaction

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Acute Ischemic Stroke Chameleons

• Acute Confusional state
• R cortical, orbitofrontal
• Aphasias
• Chest pain with arm numbness

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Acute Ischemic Stroke Treatment

• IV recombinant tissue-type Plasminogen Activator
• USFDA approval 1996
• Within 3hrs of symptom onset
• 2 Randomized trials
• NINDS rt-PA stroke trial
• IA rt-PA can be used up to 6hrs
• Large MCA distribution strokes
• Merci Retriever
• Mechanical clot retrieval up to 8hrs large MCA

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Acute Ischemic Stroke Treatment

• Near complete to complete neurologic recovery 3
  months after stroke (31-50 of tPA patients
  versus 20-38 of placebo patients)
• 30 more likely to have near complete-complete
  recovery with IV-tPA
• Time brain
• Treatment near complete-to-complete recovery
• Treatment 90-180 minutes 1.69x increased odds
  of near complete-to-complete recovery
• Communicate with EMS to save time

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Acute Ischemic Stroke Treatment

• Communication with EMS results in faster exams
  better outcomes for stroke patients
• Increased tPA use from 2.21 to 8.65 for all
  strokes
• Increase from 14 to 52 in tPA eligible patients
• Morgenstern. Stroke 33 160-166, 2002

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Acute Ischemic Stroke Treatment

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Stroke Chain of Survival

• Detection Recognition of stroke signs and
  symptoms
• Dispatch Call 9-1-1 and priority EMS dispatch
• Delivery Prompt transport and prehospital
  notification to hospital
• Door Immediate ED triage
• Data ED evaluation, prompt laboratory studies,
  and CT imaging
• Decision Diagnosis and decision about
  appropriate therapy
• Drug Administration of appropriate drugs or
  other interventions

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Acute Ischemic Stroke EMS Role

• Recognition/Evaluation of possible stroke
• Look for mimcs
• Prehospital management
• Alert ED of incoming stroke

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LOS ANGELES Patient Name _______________
PREHOSPITAL Rater Name _________________
STROKE SCREEN (LAPSS) Date _____________ Screeni
ng Criteria Yes No 4. Age over 45 years
____ ____ 5. No prior history of seizure
disorder ____ ____ 6. New onset of
neurologic symptoms in last 24 hours ____
____ 7. Patient was ambulatory at baseline
(prior to event) ____ ____ 8. Blood glucose
between 60 and 400 ____ ____ 9. Exam
LOOK FOR OBVIOUS ASYMETRY Normal Right
Left Facial smile / grimace Droop
Droop Grip Weak Grip Weak Grip
No Grip No Grip Arm weakness
Drifts Down Drifts Down Falls
Rapidly Falls Rapidly Based on exam, patient
has only unilateral (and not bilateral) weakness
Yes No 10. If Yes (or unknown) to all items
above LAPSS screening criteria met Yes No
11. If LAPSS criteria for stroke met, call
receiving hospital with CODE STROKE, if not
then return to the appropriate treatment
protocol. (Note the patient may still be
experiencing a stroke if even if LAPSS criteria
are not met.)

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Cincinnati Prehospital Stroke Scale

• The CPSS evaluates for facial palsy, arm
  weakness, and speech abnormalities. Items are
  scored as either normal or abnormal.
• Facial Droop
• (The patient shows teeth or smiles)
• Normal Both sides of face move equally.
• Abnormal One side of face does not move as well
  as the other.
• Arm Drift
• (The patient closes their eyes and extends both
  arms straight out for 10 seconds)
• Normal Both arms move the same, or both arms do
  not move at all.
• Abnormal One arm either does not move, or one
  arm drifts down compared to the other.
• Speech
• (The patient repeats "The sky is blue in
  Cincinnati")
• Normal The patient says correct words with no
  slurring of words.
• Abnormal The patient slurs words, says the wrong
  words, or is unable to speak.

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Cincinnati Prehospital Stroke Scale-Facial Droop

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Cincinnati Prehospital Stroke Scale- Arm Drift

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Guidelines for EMS Management of Patients With
Suspected Stroke

• Recommended Not Recommended
• Manage ABCs Dextrose-containing fluids-
• Cardiac monitoring in nonhypoglycemic patients
• Intravenous access Hypotension/Excessive-
• Oxygen (O2 saturation 92) Blood pressure
  reduction
• Assess for hypoglycemia Excessive intravenous
  fluids
• Nil per os (NPO)
• Alert receiving ED
• Rapid transport to closest appropriate
• facility capable of treating acute stroke

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Stroke Centers

• Admit patients to a stroke unit1
• 17 reduction in death
• 7 increase in living at home
• 8 reduction in length of stay
• Use standardized stroke care order set2
• Improves adherence to best practices for
  treatment of patients with stroke

1. Stroke unit trialists collaboration. BMJ 314
1151-1159, 1997 2. Adams. Stroke 38 1655-1711,
2007
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Acute Ischemic Stroke Take home points

• Recognition of stroke symptoms
• Key mimics- hypoglycemia/Sz
• Time of onset-
• witness/family phone numbers
• Symptom resolution- document
• clocks goes to zero
• Time is Brain
• Give a heads up stroke centers of care

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Patient Presentation
..\My Music\iTunes\iTunes Music\TV Shows\Family
Guy\08 McStroke.m4v
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Intracerebral Hemorrhage

• 10-30 of all hospital stroke admissions
• 30-50 6month mortality
• 20 with functional independence at 6months
• 37,000-52,000 cases/yr USA
• 12-15/100,000 people per year

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Clinical Manifestations

• Primary ICH
• 2nd spontaneous rupture of small arteries or
  arterioles from HTN or cerebral amyloid
• Secondary ICH
• Trauma, aneursym, tumor, AVM

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Pathophysiology

• Risk Factors for Primary ICH
• Chronic HTN- 60-70 of cases
• Location- BG, pons, cerebellum, deep hemispheric
• 2 / yr recurrence with control of BP
• Cerebral amyloid angiopathy- 15 of cases
• Deposition of ß-amyloid in small to medium blood
  vessels
• Location- lobar
• 5-15 / yr recurrence
• Associated with dementia
• Heavy EtOH
• Hypocholesterolemia
• (1)

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Clinical Manifestations

• Acute focal neurlogical deficit
• Asymmetric weakness/numbness, incoordination/ataxi
  a, vision change, abnormal speech
• Signs of increased ICP
• Headache, vomiting, decrease LOC
• Can occur acutely with IVH (acute obstructive
  hydrocephalus)
• 90 will present with BP 160/100
• Dysautonomia
• Central fever, hyperventilation, hyperglycemia,
  tachycardia/bradycardia
• (2)

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Diagnosis

• Clinical presentation can be identical to
  ischemic stroke (except ICP)
• CT scan
• As good as MRI in detecting ICH
• Bleeding pattern can lead to Dx of 2nd cause
• MRI-
• Follow up study to detect 2nd cause

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Treatment

• Airway management
• Medical Management
• Blood Pressure Management
• Surgical Management

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Surgical Treatment

• Surgical Trial in Intracerebral Hemorrhage
• STICH
• 1033 patients
• Randomized within 72hrs surgery within 96hrs
• Clot 2cm diameter
• Surgeon unclear of benefit
• Excluded if GCS
• Primary outcome death and disability
• (5)

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Surgical Treatment

• STICH
• Non statistically significant improvement
• GOS 2.3
• Death 1.2
• mRS 4.7
• BI 4.1
• Subgroup- GCS 9-12, lobar clots,
• 29 relative benefit in functional outcome
• (5)

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Surgical Treatment

• Surgical indications
• Cerebellar Hemorrhages
• 3cm, BS compression, or hydrocephalus
• Young pts
• large lobar hemorrhages
• and
• neurological deterioration
• (5)

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Guidelines for EMS Management of Patients With
Suspected Stroke

• Recommended Not Recommended
• Manage ABCs Dextrose-containing fluids-
• Cardiac monitoring in nonhypoglycemic patients
• Intravenous access Hypotension/Excessive-
• Oxygen (O2 saturation 92) Blood pressure
  reduction
• Assess for hypoglycemia Excessive intravenous
  fluids
• Nil per os (NPO)
• Alert receiving ED
• Rapid transport to closest appropriate
• facility capable of treating acute stroke

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TriviaName that Band
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Subarachnoid Hemorrhage

• Rupture of cerebral aneurysm
• 3-5 of all stroke cases
• 30,000 Americans/yr
• Mortality up to 45
• Age- 40-60

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Subarachnoid Hemorrhage
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Subarachnoid Hemorrhage

• Risk Factors
• FHx
• HTN
• Smoking
• Heavy EtOH

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Subarachnoid Hemorrhage

• Clinical Presentation
• Worst headache of my life
• Nausea/vomiting
• Stiff neck
• Brief loss of consciousness
• Focal neurological deficits
• Sz-20 during 1st 24hrs
• 20 with sentinel bleed

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Subarachnoid HemorrhageEMS Evaluation

• 2/3 of SAH 1st contact
• Consider SAH if 1 of the following
• Headache
• Vomiting
• Decrease LOC
• Focal neurological deficits
• ABCs
• Rapid sequence intubation if needed

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Guidelines for EMS Management of Patients With
Suspected Stroke

• Recommended Not Recommended
• Manage ABCs Dextrose-containing fluids-
• Cardiac monitoring in nonhypoglycemic patients
• Intravenous access Hypotension/Excessive-
• Oxygen (O2 saturation 92) Blood pressure
  reduction
• Assess for hypoglycemia Excessive intravenous
  fluids
• Nil per os (NPO)
• Alert receiving ED
• Rapid transport to closest appropriate
• facility capable of treating acute stroke-

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Subarachnoid Hemorrhage

• Risk of rebleeding during 1st 24hrs
• Prevention
• BP control
• Bed rest
• Secure aneurysm (clipping/coiling)
• Future complications
• Hydrocephalus
• ICP
• Vasospasm- ischemic stroke (2wks)

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The End
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Stroke Alert Case Review

• RB- 66yo male admitted with urosepsis and
  elevated cardiac enzymes and new A-fib 10/5/08
• 10/7/08- pt underwent coronary cath sedated _at_
  1231PM
• Post cath pt Tx to floor
• Once on floor pt noted to have R weakness- 430PM
• Stroke alert called _at_ 436PM
• Initial NIHSS- 6 (ataxia/hemiparasis)
• FSBG- 98 BP 160/92 Plt 88
• NCHCT- nl
• Outcome- no tPA 2nd
• time of onset/last known normal 3hrs
• Platelet count
• /- illness/sepsis
• MRI with multiple foci of acute ischemia L P/T
  region

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Stroke Alert Case Review

• GB- 35yo M DM, HTN, ESRD admitted 10/7/08 with
  ACS
• 10/8/08 745AM nurse found pt unresponsive
• Stroke alert called _at_757AM
• BP 141/70 FSBG- 18
• Last known normal 3AM (nurse notes)
• NIHSS- 5 (LOC and mild L HP)
• NCHCT- 805AM old ischemia no bld
• Outcome- no tPA 2nd
• Clinical syndrome not stroke- hypoglycemia
• Pt improved with dextrose

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Stroke Alert Case Review

• ML 81yo F with prior stroke and R HP
• Pt found minimally responsive in NH EMS
  activated-430PM
• EMS phoned ahead for concern of poss stroke
• Stroke alert called 456PM (prior to pt
  presenting to ED)
• BP 129/44 FSBG 197
• NIHSS- 22 (LOC, L MCA, L wk)
• Last known normal- 11AM
• NCHCT- old L MCA stroke no bld
• Outcome- no tPA 2nd
• Time of onset 3hrs
• Syndrome not completely 2nd stroke
• PHT level 41

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Stroke Alert Case Review

• VG- 77yo F with DM, HTN admitted 12/8/08
• Presented with chest pain - A-fib with RVR
• 12/9/08 1020AM pt found with new R HP on AM
  rounds
• Stroke alert called
• FSBG- 123 BP- 142/90
• NIHSS- 5 (mild R HP)
• NCHCT- nl- old ischemic changes
• Pt awoke with Sx
• Last normal 3AM before sleep
• Outcome- no tPA 2nd
• Time last nl 3hrs
• MRI old ischemia
• Reactivation of prior stroke (pt with similar
  episode with narcotic overuse)