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BRAIN ATTACK

Understanding and Managing


Acute Stroke
in the
Pre-hospital Setting
EMS Education Stroke
Carolyn Walker RN, BN
January 2011

Whats New in Prehospital care of Acute Stroke?

Change is
Everywhere!
New approach to EMS delivery in Alberta
New EMS Provincial Medical Control Protocols

New Approach to EMS delivery in Alberta

EMS services prior to April 2009


Private, Municipal, Hospital based/Regional

EMS services since April 2009

Governance and Policy Alberta Health and Wellness


Operations and Support Alberta Health Services
>550 ambulances in system across Alberta
300 are AHS
250 are owned and operated by approx. 50 contracted services

New EMS Provincial Medical Control Protocols

Implemented Dec 1, 2010 for both ground and air


Developed by a provincial committee
Ensure evidence based practices
Ensure consistent standards of care throughout Alberta
Clearly defined clinical treatment pathways
STROKE MANAGEMENT PROTOCOL

Introduction

EMS = Prehospital care


Neurological emergencies
Acute Stroke Syndromes
Acute Ischemic Stroke

Used with permission by Genetech

Objectives
Define stroke
Describe acute ischemic stroke
Discuss EMS assessment and management of the suspected
stroke patient
Describe provincial stroke management protocol
Identify requirements for direct transport to the nearest Primary
or Comprehensive Stroke Centre
Explain the importance of rapid reperfusion
Describe how reperfusion is achieved

Case Study

65 year old female


Collapsed
Unable to move right
side
Unable to speak

Define Stroke
Stroke Syndrome sudden vascular event
leading to focal neurological dysfunction

Hemorrhagic -15% (ICH & SAH )


Ischemic- 85% (Thrombotic & Embolic)
Ischemic Stroke 65%
Transient Ischemic Attack 20%
- symptoms resolve
- no brain cell death
- 20-40% of strokes are proceeded by TIA
Used with permission by National Stroke Association

proficient recognize, assess, manage, treat, triage, and transport stroke


patients NAEMSP

Cerebral Perfusion and Acute Ischemic Stroke


Mechanisms of ischemic stroke
Multi-factorial
Risk Factors
Recent prior TIA/ stroke
Diabetes
Atrial fibrillation
Smoking
HTN - 70% of all strokes

Cerebral Blood Flow

32 000 brain cells/ second

Time is Brain
Used with permission by National Stroke Association

EMS Assessment

Primary Assessment

Sudden onset of:

Weakness or numbness on one side


of the body and/or face
Difficulty with speech or understanding

Double vision or loss of vision

Vital signs
BGL
Medical history
o
o
o
o
o

Focused neurological assessment

Last seen normal


Co-morbid diseases cardiac disease,
diabetes, HTN, dyslipidemia
Risk factors smoking, obesity, alcohol
Hemorrhage risk recent trauma, surgery
or bleeding problems
Neuro history TIA, Stroke, TBI

ECG Atrial Fibrillation


Used with permission by The City of Calgary EMS

Stroke Management Protocol

When was patient last seen normal?

EMS Stroke Screen Form

Stroke Screen Form

EMS Assessment - Neurological

Level of Consciousness
o A alert
o V verbal
o P painful
o U unconscious
Speech impairment - Aphasia
and dysarthia
Facial symetry - facial droop?
Arm weakness
o Limb drift
o Hemiplegia vs. hemiparesis
Leg weakness
o Limb drift
Vision abnormalities
Hand Grip Strength - non-specific

Used with permission by AHS EMS

Stroke Screen Form

Positive Stroke Screen Criteria:


Stroke screen criteria are positive when the following
3 criteria are met:

Blood glucose > 3.0 mmol/L

Interval from last seen normal to arrival at nearest PSC


or CSC is < 4.5 hours
(Calgary only- awoke with symptoms OR last seen normal to arrival < 6 hours)

One or more disabling findings are present

Case Study Assessment


Aphasic
Hemiparesis - right arm
Weakness - right leg
Facial weakness
Medical History

o
o

Childhood Rheumatic fever


Mitral valve replacement

Medications
o
o

Previous coumadin
ASA

Used with permission by AHS EMS

EMS Treatment
Airway management - ETI
Oxygen SPO2 > 95%
Positioning supine to 30 degrees
IV minimum1 large bore N/S at 100mL/hr
-no dextrose IV solutions
NO CT Scan
= No Thrombolytics
= No ASA
= No Anti-hypertensives

Used with permission The City of Calgary EMS

Access to Tertiary care


Minimize total ischemic time
Treatment window for t-PA <4.5
hours
Scene time < 10 mins
Rapid transport
(with family/ witness if able or
phone # to contact)
Used with permission by Calgary EMS

Early Notification
Prehospital recognition
=
Time to reperfusion

Time is Brain

Communication and Transport Decision:


Hyperacute - Metro
- EMS Crew identifies hyperacute stroke,
reviews stroke screen form, contacts ADCC
(Ambulance Destination Co-ordination Centre)
- ADCC advises on location and sets up
information patch to ED
- Awaiting ED notified by crew, clinical details,
lytic screen
- ED will contact stroke team to prepare for CT

Bypass Decision:
Rural/Suburban
- Bypass protocol in place, determines
closest PSC location
- Contacts ADCC if coming into
Edmonton for direction to CSC
- Transport to local PSC or to CSC with
pre-notification
- Consultation with Stroke
team/Telestroke

Partners in Acute Ischemic Stroke

Primary Stroke Centre (PSC) criteria:

CT scan availability
Door to CT time less than 20 minutes with a pre-alert
Stroke expertise on-site or available by Telestroke link
r-tPA treatment availability
May not be available 24/7 due to CT/physician availability
Serves surrounding communities in which it is the nearest PSC

Comprehensive Stroke Centre (CSC) criteria:

CT scan availability
Door to CT time less than 20 minutes with a pre-alert
Stroke team on-site
Neurological expertise on-site
Neurointerventional expertise on-site
Central hub of stroke Neurologist expertise in a telestroke network

Be aware of PSC and CSC in your area

Alberta Stroke Centre Locations

2 Comprehensive Stroke Centres


Calgary - Foothills Medical Centre
Edmonton - University of Alberta Hosp
*Grey Nuns Hosp in Edmonton
14 Primary Stroke Centers

Reperfusion: t-PA (Activase), Mechanical Devices


TIME IS BRAIN!!

Alteplase binds to fibrin in a thrombus:


- converts plasminogen to plasmin
- initiates local fibrinolysis with minimal
systemic effects.

Mechanical Thrombectomy Devices:


- MERCI device: Mechanical Embolus Removal in Cerebral Ischemia

- Penumbra device

National and Provincial Stroke Statistics


Prevalence in Canada

3rd leading cause of death


14,000 deaths/ year
50,000 strokes per year or 1 every 10 minutes
300,000 Canadians live with a disability due to stroke
Leading cause of adult disability

Alberta Provincial Stroke Strategy : 2003-2008

20% decline in stroke occurrence from 2003/4 -2007/8


4500 stroke patients admitted to Alberta hospitals
4000 stroke patients ED visits
EMS is involved in majority of TIAs / Strokes

EMS in Stroke Management

proficient recognize, assess, manage, treat, triage, and transport


stroke patients
NAEMSP

"EMS providers are critical to the management of the acute


stroke patient. Early recognition of stroke in-the-field ,
stabilization and transport to a Primary or Comprehensive Stroke
Centre as rapidly as possible are mandatory for acute stroke
treatment and good outcomes.
Dr. Michael Hill, Stroke Neurologist, APSS

Thank you
Alberta Provincial Stroke Strategy
AHS Emergency Medical Services Calgary Zone
Greg Vogelaar
Calgary Stroke Program:
Dr. Michael Hill
Darren Knapp
Paramedic/Quality Assurance Strategist
AHS Emergency Medical Services - Edmonton Zone

References
1. 2005 American Heart Association guidelines for cardiopulmonary resuscitation and emergency
cardiovascular care. Part 9: Adult stroke. Circulation. 2005;112:111-120.
2. Canadian Stroke Network and the Heart and Stroke Foundation of Canada: Canadian Stroke Strategy.
Canadian Best Practice Recommendations for Stroke Care: 2006. Ottawa, 2006.
3. Canadian best practice recommendations for stroke care (updated 2010) Patrice Lindsay, BScN
PhD, Mark Bayley, MD, Chelsea Hellings, BScH, Michael Hill, MSc MD, Elizabeth Woodbury, BCom
MHA, Stephen Phillips, MBBS (Canadian Stroke Strategy Best Practices and Standards Writing Group
on behalf of the Canadian Stroke Strategy, a joint initiative of the Canadian Stroke Network and the Heart
and Stroke Foundation of Canada*). FINAL v.25 October 21, 2010
4. EMS MANAGEMENT OF ACUTE STROKE PREHOSPITAL TRIAGE (RESOURCE DOCUMENT TO
NAEMSP POSITION STATEMENT)
5. T. J. Crocco, J. C. Grotta, E. C. Jauch, S. E. Kasner, R. U. Kothari, B. R. Larmon, J. L. Saver,M. R.
Sayre, S. M. Davis. ABSTRACT. PREHOSPITAL EMERGENCY CARE 2007;11:313317
6. Demchuk AM., Calgary Stroke Program Thrombolysis Update 2008 mostly a 3 to 4.5 hours post stroke
story. December 2007 Lecture presentation
7. Kidwell CS, Alger J, Saver JL. Beyond mismatch: Evolving paradigms in imaging the ischemic
penumbra with multimodal magnetic resonance imaging. Stroke. 2003; 34: 27292735
8. Saver JL. Time is brain--quantified Stroke. 2006 Jan;37(1):263-6. Epub 2005 Dec 8
9. Koeing KL Benefits of Pre-hospital Notification for Stroke Patients. Journal Watch Emergency
Medicine Nov 7, 2008
10. Alberta Provincial Stroke Strategy: Pre-Hospital Care February 2009
11. Government of Alberta Health and Wellness: Alberta Health Services: Emergency Medical Services:
Provincial Medical Control Protocols: Adult and Pediatric, December 1, 2010.

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