Copyright 2006 Seattle/King County EMS Overview of CBT 442 Stroke Complete Course Available at:

© 2006 Seattle/King County EMS Introduction Stroke advancements give hope for restoration of lost neurological function key is clot-busting therapy within 3 hours of onset time lost is brain lost

© 2006 Seattle/King County EMS Practical Skills initial assessment (SICK/NOT SICK) patient history Cincinnati Prehospital Stroke Scale recognition of need for short scene times care for stroke To receive CBT or OTEP credit, you must perform the following practical skills: Practical Skills Checklist Practical Skills Checklist available at EMS Online. EMS Online

© 2006 Seattle/King County EMS Terms atherosclerosis - A condition characterized by the deposit of fatty plaques containing cholesterol and lipids on the innermost layer of the walls of large and medium-sized arteries. embolism - A clot that travels from one part of the body to another until it becomes lodged in one of the small arteries of the brain and blocks blood flow. hemorrhagic stroke - A type of stroke that occurs when a blood vessel bursts inside the brain. infarction - A localized area of cell death due to a lack of oxygenated blood. ischemia - A deficiency of oxygenated blood in a body part as a result of a constriction or blockage of the blood vessel.

© 2006 Seattle/King County EMS Terms stroke (CVA) - A vascular disease that affects the blood vessels supplying blood to the brain. A stroke occurs when a blood vessel bringing oxygen and nutrients to the brain bursts or is clogged by a blood clot or embolus. A stroke can cause neurological deficits. thrombus - A blood clot that typically forms over fatty plaque deposits that form on the inner wall of arteries. This plaque and subsequent narrowing may progress slowly over years, particularly in those patients who smoke or have high cholesterol or high blood pressure. transient ischemic attack (TIA) - A disorder of the brain in which brain cells temporarily stop working because of insufficient oxygen causing stroke-like symptoms that resolve completely within 24 hours of onset.

© 2006 Seattle/King County EMS Three Regions of the Brain The central nervous system is responsible for controlling voluntary and involuntary activities of the human body. Two parts of the central nervous system: 1.brain 2.spinal cord Three regions of the brain are: 1.Cerebrum 2.Cerebellum 3.Brain Stem

© 2006 Seattle/King County EMS Three Regions of the Brain, continued 1.Cerebrum thought personality memory motor skills tactile (touch) speech vision

© 2006 Seattle/King County EMS Three Regions of the Brain, continued 2. Cerebellum coordination balance basic movement muscle tone 1. Cerebrum

© 2006 Seattle/King County EMS Three Regions of the Brain, continued 3. Brain Stem heart function respiration autonomic nervous system digestion glandular secretions 2. Cerebellum 1. Cerebrum

© 2006 Seattle/King County EMS Types of Stroke 1 1 There are generally 2 types of stroke: Ischemic: A blockage caused by a clot. This is the most common type of stroke.

© 2006 Seattle/King County EMS Types of Stroke Ischemic: A blockage caused by a clot. This is the most common type of stroke. 1 1 Hemorrhagic: A rupture caused by a break in a blood vessel. Less common than ischemic stroke but no less serious. 2 2 There are generally 2 types of stroke:

© 2006 Seattle/King County EMS THROMBUS clot that develops at the site of the blockage forms locally near an area of plaque causes a sudden occlusion of the blood vessel produces a sudden onset of neurological deficits Types of Stroke Ischemic

© 2006 Seattle/King County EMS EMBOLUS clot floats to site to form a blockage circulates in bloodstream until it gets stuck in an artery Types of Stroke Ischemic

© 2006 Seattle/King County EMS Types of Stroke ruptured blood vessel on the surface of the brain (subarachnoid) ruptured blood vessel within the brain (intracerebral) puts pressure against the brain Hemorrhagic

© 2006 Seattle/King County EMS Types of Stroke BOTH TYPES OF STROKE: prevent oxygenated blood from reaching the brain tissues

© 2006 Seattle/King County EMS Types of Stroke BOTH TYPES OF STROKE: prevent oxygenated blood from reaching the brain tissues may have only minutes to get patient to definitive treatment Time lost is brain lost; seconds count.

© 2006 Seattle/King County EMS Types of Stroke brain cells stop working because of insufficient oxygen causes stroke-like symptoms that resolve completely within 24 hours Transient Ischemic Attack (TIA)

© 2006 Seattle/King County EMS Risk Factors hypertension smoking age gender heredity prior stroke diabetes carotid artery disease heart disease TIAs Some of the factors that can contribute to stroke include:

© 2006 Seattle/King County EMS Signs and Symptoms paralysis or weakness on one side of the body facial droop on one side altered level of consciousness change in personality or mood headache or dizziness impaired speech blurred vision poor coordination Some of the signs and symptoms of stroke include:

© 2006 Seattle/King County EMS Physical Exam Conduct an initial assessment to determine SICK or NOT SICK: A SICK patient is one who can die quickly unless you initiate aggressive BLS and ALS treatment and rapid transport. A NOT SICK patient is one who can be ill or injured, but not severely enough to be life threatening. SICK or NOT SICK

© 2006 Seattle/King County EMS Physical Exam Key clinical indicators respirations pulse mental status skin signs and color body position Relative to stroke: set of vitals to establish a baseline Cincinnati Prehospital Stroke Scale blood glucometry Look for other explanations of stroke-like symptoms (trauma, medic alert tags, drug use or diabetes). SICK or NOT SICK

© 2006 Seattle/King County EMS Cincinnati Prehospital Stroke Scale a simplified version of the National Institutes of Health Stroke Scale accurate in identifying patients with stroke an abnormal finding in ANY of the three tests strongly suggests a stroke TestNormalAbnormal facial droopboth sides of the face move equallyone side of the face does not move as well as the other arm driftboth arms move the same or both arms do not move at all (palms up, eyes closed) one arm drifts down compared to the other or one arm does not move speechpatient says correct words with no slurring of words patient slurs words, says the wrong words, or is unable to speak

© 2006 Seattle/King County EMS Cincinnati Prehospital Stroke Scale How does this patient appear to you? facial droop

© 2006 Seattle/King County EMS Cincinnati Prehospital Stroke Scale How does this patient appear to you? facial droop arm drift

© 2006 Seattle/King County EMS Cincinnati Prehospital Stroke Scale How does this patient appear to you? facial drift arm drift speech

© 2006 Seattle/King County EMS Cincinnati Prehospital Stroke Scale How does this patient appear to you? facial droop arm drift speech

© 2006 Seattle/King County EMS Cincinnati Prehospital Stroke Scale How about now? facial droop

© 2006 Seattle/King County EMS Cincinnati Prehospital Stroke Scale How does this patient appear to you? facial droop arm drift

© 2006 Seattle/King County EMS Cincinnati Prehospital Stroke Scale How does this patient appear to you? facial droop arm drift speech

© 2006 Seattle/King County EMS Cincinnati Prehospital Stroke Scale How does this patient appear to you? facial droop arm drift speech

© 2006 Seattle/King County EMS Patient History Stroke patients often report a loss of motor function and/or a change in speech pattern. Some patients experience an altered level of consciousness. SAMPLE technique to determine if there is a history of: hypertension blood thinners or anticoagulants arteriovenous malformation (AVM) cerebral aneurysm prior stroke Chief complaint and time of onset are key in the assessment of stroke.

© 2006 Seattle/King County EMS Time of Onset determine time of onset but keep scene and transport times short be conscious of the time it takes for the hospital staff to assess and administer thrombolytic therapy Clot-busting drugs must be given within 3 hours of onset of symptoms.

© 2006 Seattle/King County EMS Care for Stroke protecting patient's airway ensuring adequate respirations removing secretions that can be aspirated providing ventilation assistance proper positioning administering oxygen if saturation level is below 95% or there are signs of hypoxia Care for a victim of stroke includes:

© 2006 Seattle/King County EMS Short Scene Times victims of stroke often deny or rationalize their symptoms patients eligible for clot-busting drugs must be transported immediately notify the hospital that a possible stroke patient is en route avoid delays if the patient waited before calling for help Short scene and transport times are important.

© 2006 Seattle/King County EMS Summary The three regions of the brain are the cerebrum, cerebellum and brain stem. The two basic types of stroke are ischemic (blockage) and hemorrhagic (rupture). An ischemic stroke can be caused by a thrombus which is a clot that forms in a cerebral artery or an embolus which is a clot that travels to the brain.

© 2006 Seattle/King County EMS Summary Signs and symptoms of stroke include: paralysis or weakness on one side of the body facial droop on one side altered level of consciousness (from confusion to unconsciousness) change in personality or mood headache or dizziness impaired speech

© 2006 Seattle/King County EMS Summary, continued The three tests of the Cincinnati Prehospital Stroke Scale are facial droop, arm drift and speech. Determine time of onset of symptoms. This helps determine if a patient meets the three-hour window for clot-busting therapy. Short scene and transport times are vital.

© 2006 Seattle/King County EMS Questions What questions do you have about stroke? Three options: 1.Ask the Doc: 2.Check Guidelines/Standing orders at EMS Online: support: Dr. Mickey Eisenberg Medical Director EMS Online Guidelines and Standing Orders Mike Helbock Training Division Manager