Stroke and EMS Providers

1
Stroke and EMS Providers

• Stroke Continuing Education Series for Illinois
  EMS Professionals
• Michelle Alepra, M.D.
• St. Johns Hospital/SIU School of Medicine

2
Goals

• Improve the understanding of pathophysiology of
  stroke/TIA
• Improve the evaluation of symptoms and
  recognization of stroke/TIA
• Importance of EMS role
• Improve good communication between EMS and stroke
  center
• EMS care en route

3
Quick Statistics

• In US, every 45 seconds someone experiences a
  stroke1
• 780,000/yr experience a stroke in US1
• 3rd leading cause of death and first cause of
  adult disability1
• 8 die within 30 days, 30 die within 1 year3
• Stroke is a medical emergency
• Stroke may be treatable within 3 hours of onset
  of symptoms

4
Definitions

• Stroke
• WHO rapidly developing clinical signs of focal
  (at times global) disturbance of cerebral
  function, lasting more than 24 hours or leading
  to death with no apparent cause other than that
  of vascular origin.
• TIA
• Neuro deficits that resolve within 24 hours
• Reversible ischemic Neurological Deficit
• Neuro deficits that last more than 24 hours and
  less than 3 weeks

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What is a stroke?

• Stroke CVA (cerebralvascular accident)
• 2 types
• Ischemic
• Blockage, not enough blood flow to oxygenate the
  brain tissue
• Hemorrhagic
• Bleeding into and/or around the brain tissue

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Ischemic Stroke

• 80-85 of all CVAs3
• Decrease in the ability to carry oxygen- and
  glucose-containing blood to the brain
• Blockage by thrombosis, plaque or embolism
• Hypoperfusion

7
Hemorrhagic Stroke

• Remaining strokes (15-20)
• Rupture of blood vessel into brain or
  subarachnoid spaces
• Usually caused by hypertension

8
Improve the Evaluation of Symptoms and
Recognition of Stroke/TIA

• Warning signs of stroke
• Extensive Neurological Exams are unnecessary
  prehospital
• Stroke Scales
• Cincinnati Prehospital Stroke Scale6
• Los Angeles Prehospital Stroke Screen7
• ABCD Score8

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Warning Signs of a Stroke1

• SUDDEN numbness or weakness of face, arm or leg
  especially on one side of the body.
• SUDDEN confusion, trouble speaking or
  understanding.
• SUDDEN trouble seeing in one or both eyes.
• SUDDEN trouble walking, dizziness, loss of
  balance or coordination.
• SUDDEN severe headache with no known cause.

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Cincinnati Prehospital Stroke Scale

• National Stroke Association Act FAST
• F Face
• A Arms
• S Speech
• T Time
• Cincinnati Prehospital Stroke Scale

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F Face2,6

• Ask the person to smile.
• Does one side of the Face droop?
• Normal
• Both sides of face move equally
• Abnormal
• One side of face does not move at all

12
A Arms2,6

• Ask the patient to raise both arms.
• Does one arm drift downwards?
• Normal
• Both arms move equally or not at all
• Abnormal
• One arm drifts compared to other

13
S Speech

• Ask the person to repeat a simple sentence
• Are the words slurred?
• Can the person repeat the sentence correctly?
• Normal
• Uses correct words with no slurring
• Abnormal
• Slurred or inappropriate words or mute

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T Time

• If a person shows any of these symptoms, call 911
  immediately.
• Time is essential in treatment.

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Los Angeles Prehospital Stroke Screen7

• LOS ANGELES Patient Name ________________________
  ____
• PREHOSPITAL Rater Name __________________________
  __
• STROKE SCREEN (LAPSS) Date ______________________
  ______
• Screening 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 asymmetry
• Normal Right Left
• Facial smile / grimace Droop Droop
• Grip Weak Grip No Grip Weak Grip No Grip
• Arm weakness Drifts Down Falls Rapidly Drifts
  Down 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

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ABCD Score8

• ABCD Score
• Used to predict the risk of stroke during the
  first seven days after a TIA. Researchers found
  there to be over 30 risk of stroke in TIA
  patients with an 'ABCD score' of six, as compared
  to no strokes in those with a low ABCD score. Can
  be used in routine clinical practice to identify
  high-risk individuals who require emergency
  investigation and treatment.
• ABCD Score
• Risk factor Category Score
• A Age of patient Age gt/ 60 1
• Age lt 60 0
• B Blood pressure at SBP gt 140 or DBP gt/ 90 1
• Assessment Other 0
• C Clinical Features Unilateral weakness 2
• presented with Speech disturbance (no weakness) 1
  
• Other 0
• D Duration of TIA gt/ 60 minutes 2
• symptoms 10-59 minutes 1
• lt10 minutes 0
• ________
• TOTAL 6

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Importance of EMS Roles

• Importance includes all of EMS
• 911 activation and dispatch
• Emergency medical response
• Triage
• Stabilization in the field
• Transport

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Importance of EMS

• EMS facilitates the most important aspect of
  stroke management TIME!
• Patients have 3 hours from the onset of symptoms
  to receive thrombolytic treatment.
• Most rapid, reliable and safe method to reach
  definitive treatment

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EMS Care at Scene and En Route

• ABCD
• Always make sure patient has an airway
• Large amount of hemorrhagic strokes will have
  difficulty maintaining an airway
• Blood pressure, remaining vital signs
• Blood glucose
• History

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EMS Care at Scene and En Route

• Time
• Most important aspect
• Spend only as much time on scene as necessary
• Immediate transport to hospital, as little as 10
  minutes may make a difference

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Good Communication Between EMS and Hospital

• History
• Time, Time, Time
• When did symptoms start?
• Did the patient wake this way?
• Diabetic?
• Have symptoms changed since onset, worse or
  better?
• Trauma?
• Medications?
• Exam Findings/Stroke Scales
• Stabilization measures

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Good Communication Between EMS and Hospital

• This helps the ED to prepare for your patient
• Room, CT scanner, blood draws and neurology
• Possible activation of transfer to Stroke Center
• Early knowledge of possibility for tPA.

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Goals

• Improve the understanding of pathophysiology of
  stroke/TIA
• Improve the evaluation of symptoms and
  recognization of stroke/TIA
• Importance of EMS role
• Improve good communication between EMS and stroke
  center
• EMS care en route

24
References

• National Stroke Association www.stroke.org
• The internet stroke center www.strokecenter.org
• Cort M, Kuo D. Ischemic Stroke Syndromes The
  Challenges of Assessment, Prevention and
  Treatment Part I Risk Factors, Differential
  Diagnosis and Prevention. Emergency Medicine
  Reports 2004 Feb 23
• Cort M, Kuo D. Ischemic Stroke Syndromes The
  Challenges of Assessment, Prevention, and
  Treatment Part II Physical Examination,
  Laboratory Investigations, Imaging and Treatment.
  Emergency Medicine Reports 2004 March 9
• Acker JE, Pancioli A, Crocco TJ, et al.
  Implementation of Strategies for Emergency
  Medical Services within Stroke Systems of Care
  A Policy Statement from the American Heart
  Association/American Stroke Association Expert
  Panel on Emergency Medical Services Systems and
  the Stroke Council. Circulation. 2007
  0(0)000-000

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References

• 6. Kothari RU, Pancioli A, Liu T, Brott T,
  Broderick J. Cincinnati Prehospital Stroke
  Scale reproducibility and validity. Ann Emerg
  Med 1999 Apr33(4)373-8.
• 7. Kidwell CS, Starkman S, Eckstein M, Weems K,
  Saver JL. Identifying stroke in the field.
  Prospective validation of the Los Angeles
  prehospital stroke screen (LAPSS). Stroke 2000
  Jan31(1)71-6
• 8. Rothwell P, Giles M, Flossmann E, Lovelock C,
  Redgrave J, Warlow C, Mehta Z (2005). A simple
  tool to identify individuals at high early risk
  of stroke after a transient ischemic attack the
  ABCD score. The Lancet 36629-36.