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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.

Special Thanks To:

ASA Operation Stroke
EMS Committee
Volunteers including:
Bruce Barnhart, Chair
Amy Boise, Vice Chair
Nancy Parks, RN
Charlann Staab, RN
Linda Meiner, RN
Mike Baros, RN
Terry Mason, RN
Don Baird, RN

Sandy Nygard, CEP

AEMS, Inc.
Robert Londeree, M.D.
Phoenix Fire
Department
John Gallagher, M.D.
Air-Evac Services, Inc.
Professional Medical
Transport (PMT)
Cigna Healthcare
Halle Heart Center
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

Stroke Overview
Introduction, Definition, Types and
Risks

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.

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.

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

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
Carotid Stenosis

Goldstein et al. Circulation. 2001:103:163

Other cardiac
diseases
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Less Well Documented

Potentially Modifiable Risk
Factors
Hypercoagulability
Obesity
Physical Inactivity
Poor Diet/Nutrition
Alcohol Abuse
Drug Abuse

Goldstein et al. Circulation. 2001:103:163

Hormone
Replacement Therapy
Oral Contraceptive
Use
Inflammatory Process

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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:
1. Detection
2. Dispatch
3. Delivery

Post-arrival:
4. Door
5. Data
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

1. 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, prehospital 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 upperairway 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

1.
2.
3.
4.

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

Adams et al. Stroke. 2003;34:1056

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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

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7. Drugs: Fibrinolytic Therapy for

Ischemic Stroke

Intravenous tPA represents the first FDAapproved 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.

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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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