Start Show Notes

The following presentation is taken

from the American Heart
Associations Advanced Cardiac
Life Support : Principles and
Practice, Chapter 18, Acute
Stroke: Current Treatments and
Paradigms

Please use this publication as a

reference.
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Special Thanks To:

ASA Operation Stroke Sandy Nygard, CEP

EMS Committee AEMS, Inc.
Volunteers including: Robert Londeree, M.D.
Bruce Barnhart, Chair Phoenix Fire Department
Amy Boise, Vice Chair John Gallagher, M.D.
Nancy Parks, RN Air-Evac Services, Inc.
Charlann Staab, RN Professional Medical
Linda Meiner, RN Transport (PMT)
Mike Baros, RN Cigna Healthcare
Terry Mason, RN Halle Heart Center
Don Baird, RN Dave Heath
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Stroke
An Educational Program
for
Pre-Hospital Personnel

Developed by:
EMS Committee
Operation Stroke American Stroke Association
Phoenix, Arizona

July 2003

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 Stroke Overview

Introduction, Definition, Types and Risks

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How Serious Is Stroke in
the US?
About 700,000 strokes occur each
year.
Over 167,000 deaths each year.
#3 killer.
A leading cause of serious long-term
disability in adults.
4.7 million stroke survivors.

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Introduction
New emerging therapies offer hope,
however the following MUST occur:

Education of at-risk patients.

Early recognition of stroke signs.
Prompt transport to the hospital.
Rapid hospital triage and evaluation.

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Introduction

With rapid, aggressive

prehospital stroke
care, at-risk patients
can be appropriately
managed and quickly
assessed for
fibrinolytic therapy
that may significantly
improve their outcome.

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Definition of Stroke
A stroke is a neurological impairment
caused by a disruption in blood supply
to a region of the brain.

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Classification of Stroke
Two major categories:

Ischemic strokes, caused when a blood

vessel supplying the brain is occluded by a
clot. Responsible for 75% of all strokes.

Hemorrhagic strokes, caused when a

cerebral artery ruptures.

Both forms are life threatening.

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11
Hemorrhagic Stroke
Hypertension is the
most common cause
of intracerebral
hemorrhage.
Other causes:
Aneurysms and
Arteriovenous
malformations.

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Risk Factors for Stroke
Although some strokes occur without
warning, most stroke victims have
prior risk factors.

Major strokes can be prevented in

many cases, but only if early signs and
symptoms are heeded.

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Well-Documented
Modifiable Risk Factors
Hypertension Atrial Fibrillation
Smoking Hyperlipidemia
Diabetes Sickle Cell Disease
Asymptomatic Other cardiac
Carotid Stenosis diseases

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Goldstein et al. Circulation. 2001:103:163
Less Well Documented
Potentially Modifiable Risk
Factors
Obesity Hypercoagulability

Physical Inactivity Hormone Replacement

Therapy
Poor Diet/Nutrition
Oral Contraceptive Use
Alcohol Abuse
Inflammatory Process
Drug Abuse

Goldstein et al. Circulation. 2001:103:163 15

Non-modifiable Risk
Factors

Age
Sex
Race/Ethnicity
Family History

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 Stroke Diagnosis

Signs and Symptoms of Stroke

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Signs and Symptoms of
Stroke
Consider in anyone
who has:

Sudden numbness or
weakness of face, arm,
or leg, especially on one
side of the body

Sudden confusion,
trouble speaking or
understanding

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Signs and Symptoms of
Stroke

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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Signs and Symptoms of
Stroke

THIS IS A LIFE THREATENING EMERGENCY!

Emergency healthcare providers must:

Recognize the importance of these symptoms.
Respond quickly with medical and / or surgical
interventions.

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Stroke Signs and
Symptoms: Hemorrhagic Stroke
May present similar to
Ischemic stroke.

Distinguishing Features:
Appear more seriously ill
Deteriorate more rapidly
Severe headache
Alteration in consciousness
Nausea and/or vomiting
Neck pain
Intolerance of noise or light

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Transient Ischemic Attack
Temporary or mini stroke.

The signs and symptoms of a TIA are

similar to those of a completed stroke;
however, they typically last only a few
minutes to several hours before
resolving.

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23
Transient Ischemic Attack

TIA is the most

important
forecaster of
impending stroke.

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Stroke Patient Management

The Stroke Chain of Survival and

Recovery

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Seven Step Stroke Chain
of Survival and Recovery
Pre-arrival: Post-arrival:
Detection 4. Door
Dispatch 5. Data
Delivery 6. Decision
7. Drug

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27
1. Detection: Early Recognition

Early treatment of stroke depends on

the victim, family members, or other
bystanders detecting the event.
Mild signs or symptoms may go
unnoticed or be denied by the patient
or bystander.

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2. Dispatch: Early EMS
Activation and Dispatch
Instructions
Stroke victims and their families must
be taught to activate the EMS system
as soon as they detect stroke signs or
symptoms.
EMS dispatchers must appropriately
prioritize the call to ensure a rapid
response within the EMS system.

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30
3. Delivery: Pre-hospital
Transport and Management
The goals :
Rapid identification of the stroke
Support of vital functions
Rapid transport of the victim to the
receiving facility
Pre-arrival notification of the receiving
facility

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3. Delivery: Pre-hospital
Transport and Management
The Cincinnati Pre-hospital Stroke Scale

Facial Droop (have patient show teeth or

smile):

Normal - Both sides of face move

equally well.
Abnormal - One side of face does not
move as well as the other side.

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3. Delivery: Pre-hospital
Transport and Management
The Cincinnati Pre-hospital Stroke Scale

2. Arm Drift (patient closes eyes and holds both

arms out):

Normal - Both arms move the same or both

arms do not move at all (other findings,
such as pronator grip, may be helpful).
Abnormal - One arm does not move or one
arm drifts down compared with the other.
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3. Delivery: Pre-hospital
Transport and Management
The Cincinnati Pre-hospital Stroke Scale

3. Speech (have the patient say "you can't

teach an old dog new tricks"):

Normal - Patient uses correct words with

no slurring.
Abnormal - Patient slurs words, uses
inappropriate words, or is unable to
speak.
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3. Delivery: Pre-hospital
Transport and Management
The presence of acute stroke is an indication
for "load and go.
Establish the time of onset of stroke signs
and symptoms!
This timing will have important implications
for potential therapy. If the time of onset of
symptoms is viewed as time "zero," all
assessments and therapies can be related to
that time.

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3. Delivery: Pre-hospital
Transport and Management
Once stroke is diagnosed, pre-hospital
treatment includes management of
the ABCs of critical care (Airway,
Breathing, and Circulation) and close
monitoring of vital signs.

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3. Delivery: Pre-hospital
Transport and Management
Airway:
Paralysis of the muscles of the throat,
tongue, or mouth can lead to partial or
complete upper-airway obstruction.
Saliva pools or vomit may be
aspirated.

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3. Delivery: Pre-hospital
Transport and Management
Breathing:
Breathing abnormalities are
uncommon, except in patients with
severe stroke, and rescue breathing is
seldom needed.
Abnormal respirations, however, are
prominent in comatose patients and
portend serious brain injury.
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3. Delivery: Pre-hospital
Transport and Management
Circulation:
Monitor both blood
pressure and cardiac
rhythm as part of the
early assessment and
treatment of a stroke
patient.
Hypotension or shock is
rarely due to stroke, so
other causes should be
sought.

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3. Delivery: Pre-hospital
Transport and Management
Circulation:
Hypertension is often present in
stroke patients, but it typically
subsides and does not require
treatment.
Treatment of hypertension in the field
is not recommended!

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3. Delivery: Pre-hospital
Transport and Management
Other Supportive Measures:
Intravenous access.
Management of seizures, and diagnosis and
treatment of hypoglycemia, can be initiated
en route to the hospital if necessary.
Isotonic fluids (Normal Saline or Lactated
Ringer's solution) are used for intravenous
therapy; hypotonic fluids are
contraindicated.

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3. Delivery: Pre-hospital
Transport and Management
Early Notification:
Early notification
enables personnel to
prepare for the
imminent arrival of any
seriously ill or injured
patient.

In many hospitals this

notification shortens the
time to evaluation of,
and critical interventions
for, stroke patients.
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43
4. Door: Emergency Department
Triage
Even if a potential stroke victim
arrives in the emergency department
in a timely fashion, too often hours
may elapse before appropriate
neurological consultation and
diagnostic studies are performed.

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5. Data: Emergency Evaluation
and Management

ABCs should be
reassessed and
rechecked
frequently.

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5. Data: Emergency Evaluation
and Management
An emergency neurological
stroke assessment should
be done quickly focusing
on four key issues:
Level of consciousness
Type of stroke
(hemorrhagic versus
nonhemorrhagic)
Location of stroke (carotid
versus vertebrobasilar)
Severity of stroke

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5. Data: Emergency Evaluation
and Management
Obtaining the exact time of stroke or
onset of symptoms from family or
people at the scene is critical.

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Emergency Diagnostic
Studies
Currently, CT is the single most
important diagnostic test.

Goal: CT scan obtained and read

within 45 minutes of the stroke
victim's arrival at the emergency
department.

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Emergency Diagnostic
Studies
Anticoagulants
and fibrinolytic
agents should be
withheld until CT
has ruled out a
brain
hemorrhage.
Hemorrhagic Stroke

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Differential Diagnosis:
Unrecognized seizures
Confusional states
Syncope
Toxic or metabolic disorders
Hypoglycemia
Brain tumors
Subdural hematoma

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Adams et al. Stroke. 2003;34:1056
6. Decision: Specific Stroke
Therapies
General care includes, but is not
limited to:
Prevention of aspiration
Management of hypertension
Management of hyper/hypo-glycemia
Management of seizures
Management of intra-cranial pressure
(ICP)

Acute Stroke, 2003 American Heart Association 51

7. Drugs: Fibrinolytic Therapy
for Ischemic Stroke

Intravenous tPA represents the first FDA-

approved therapy for acute ischemic stroke.

In the NINDS trial, patients treated with tPA

within 3 hours of onset of symptoms were at
least 30% more likely to have minimal or no
disability at 3 months compared with those
treated with placebo.

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7. Drugs: Fibrinolytic Therapy
for Ischemic Stroke

However, there were 10-fold increases in the

risk of fatal intracranial hemorrhage in the
treated group (3% vs 0.3%) and the frequency
of all symptomatic hemorrhage (6.4% vs.
0.6%).

This increase in symptomatic hemorrhage did

not lead to an overall increase in mortality in the
treated group.

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7. Drugs: Fibrinolytic Therapy
for Ischemic Stroke

Careful patient selection and strict

adherence to the treatment protocol
are essential!

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7. Drugs: Fibrinolytic Therapy
for Ischemic Stroke

Because of the time criteria and risk

associated with fibrinolytic therapy, it
is important for hospitals to develop
specific strategies and protocols that
will achieve rapid initiation of therapy.

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NINDS-Recommended Stroke Evaluation
Targets for Potential Fibrinolytic
Candidates*
Time Target
Door to doctor 10 minutes
Door to CT completion 25 minutes
Door to CT read 45 minutes
Door to treatment 60 minutes
Access to neurological expertise 15 minutes

Access to neurosurgical expertise 2 hours

Admit to monitored bed 3 hours

*Target times will not be achieved in all cases, but they represent a reasonable goal.

CT indicates computed tomography. 56

By phone or in person.
Management of
Hemorrhagic Stroke
Optimal management:
Prevention of continued bleeding.
Appropriate management of ICP.
Timely neurosurgical decompression
when warranted.

Large intracerebral or cerebellar

hematomas often require surgical
intervention.

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Summary: Pre-hospital Critical
Actions and Management
This is what should happen:

Recognize the signs of stroke and TIA

Rapid neuro exam (Cincinnati Stroke Scale
or similar).
Determine time of symptom onset (if
possible).
Provide rapid transport to an ED capable of
caring for acute stroke (pre-notify).
Perform finger-stick to assess serum
glucose levels.
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Summary: Pre-hospital
UNACCEPTABLE Actions

Failure to recognize signs and

symptoms of stroke/TIA
Failure to attempt to determine
symptom onset.
Delay in transport.
Transporting a potential stroke
patient to an ED not capable of
treating acute ischemic stroke
with fibrinolytic therapy.
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Summary: Pre-hospital
UNACCEPTABLE Actions

Attempts to treat hypertension in

the field.

Failure to notify receiving ED.

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Conclusion:
Now, fibrinolytic and other emerging
therapies offer practitioners the
opportunity to limit neurological insult
and improve outcome in stroke
patients.

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Conclusion:
The challenge with these therapies is
that they require administration
within hours of stroke onset, making
the following measures imperative:

Education of at-risk patients

Early recognition of stroke signs
Prompt transport to the hospital
Rapid hospital triage and evaluation
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