IDPH EMS Region Five Stroke Education

Time is Brain!!!!!

Time is Brain !!!! Stroke refers to any spontaneous damage to the brain caused by an abnormality of the blood supply by means of a clot or bleed. Strokes should be treated emergently. During a stroke, up to 2 million brain cells die every minute. For every hour a stroke continues, up to 200 million nerve cells die and the brain ages 4 years. Intravenous tPA (Activase / alteplase) should be given within 180 minutes of the onset of ischemic stroke, so do not delay transport and minimize scene time. It is recommended to limit scene time to 10 minutes. TIME IS BRAIN!

Cerebrovascular Accident (CVA) Pathophysiology Thrombosis (brain itself) Embolus (head, neck or heart) Hemorrhage (within brain) Ischemia (systemic blood flow)

Predisposing Factors: Modifiable Hypertension Cigarette smoking Diabetes Mellitus Heart disease Hyperlipidemia Cardiovascular disease Chronic atrial fibrillation Sickle cell disease Polycythemia Hypercoagulability Birth control pill use Cocaine use

Predisposing Factors: Unmodifiable Age Gender Race Prior stroke Heredity

CVA Mechanisms

CVA Origin Thrombus Embolus Aneurysm Arrhythmia Hypovolemia

Ischemic Stroke Blood vessel occlusion Thrombosis Embolism Plaque fragments from carotids Chronic atrial fibrillation Fat particles IV substance abuse particulates Systemic hypoperfusion Pump failure Hypovolemia

Ischemic Stroke Syndromes Transient Ischemic Attack (TIA) Neurological deficits that resolve in 24 hours or less (most in 30 minutes) Commonly result from carotid artery disease Same symptoms as CVA Often warning sign of impeding CVA 5% risk of stroke per year

Ischemic Stroke Syndromes Dominant Hemisphere Infarction Contralateral weakness, numbness Contralateral blurring of vision of half the visual field in both eyes Difficulty pronouncing words (dysarthria) Difficulty speaking or understanding speech (dysphasia or aphasia)

Ischemic Stroke Syndromes Nondominant Hemisphere Infarction Contralateral weakness, numbness Contralateral visual field cut Neglect of contralateral extremities Dysarthria Usually NOT dysphasic or aphasic

Hemorrhagic Stroke

Hemorrhagic Stroke Syndromes Intracerebral Hemorrhage Headache, nausea, vomiting precede deficits Patients commonly have decreased LOC with extreme hypertension Contralateral hemiplegia, hemianesthesia Possible aphasia, extremity neglect depending on hemisphere involved

Hemorrhagic Stroke Syndromes Subarachnoid Hemorrhage

Brain can show injury in only three ways: CVA Presentation Brain can show injury in only three ways: Decreased LOC Seizures Localizing signs Hemiparesis or hemiplegia Dysphasia (Receptive or expressive) Visual disturbances Gait disturbances Inappropriate affect Bizarre behavior Incontinence

Cincinnati Stroke Scale To facilitate accuracy in diagnosing stroke and to expedite transport, a rapid neurological examination tool is recommended. The most common prehospital exam used is the Cincinnati Stroke Scale (CSS). One new onset positive sign on the CSS indicates a 72% probability of stroke. Three new onset positive signs on the CSS indicates a greater than 85% probability of stroke.

Cincinnati Stroke Scale: Facial Droop (ask the patient to show their teeth or smile) Normal – Both sides of the face move equally/symmetrically. Abnormal – One side of the face does not move as well as the other.

Cincinnati Stroke Scale: Arm Drift (ask the patient to close their eyes and hold both arms out straight with palms up for 10 seconds). Normal – Both arms move the same. Abnormal –One arm turns over, drifts down compared to the other arm, or is flaccid.

Cincinnati Stroke Scale: Speech (ask the patient to say, “You can’t teach an old dog new tricks”) Normal – The patient says the phrase correctly with no slurring/slowing of words. Abnormal – The patient slurs words, uses the wrong words or is unable to speak.

Cincinnati Stroke Scale: Time (ask the patient/witness when the symptoms started) Time of Onset: the time symptoms actually begin. Last Known Well Time: the last time the patient was known to be without symptoms (asymptomatic).

CRITICAL THINKING ELEMENTS: EMS personnel should ask family members or bystanders the stroke symptom onset time if the patient is unable to provide that information. Consider transporting a witness or obtaining witness’ contact information. Maintain the head/neck in neutral alignment. Elevate the head of the cot 30 degrees if the systolic BP is >100mmHg (this will facilitate venous drainage and help reduce ICP). Be alert for airway problems (swallowing difficulty, vomiting/aspiration) Bradycardia may be present in a suspected stroke patient due to increased ICP. DO NOT give Atropine if the patient’s BP is normal or elevated. Spinal immobilization should be provided if the patient sustained a fall or other trauma. Monitor and maintain the patient’s airway. 87% of strokes are ischemic and should be considered for tPA, while 13% of strokes are hemorrhagic.

Assessment Signs & Symptoms Ischemic S&S usually of slower onset Hemiparesis or hemiplegia Numbness or decreased sensation of face or unilateral Altered LOC or coma Convulsions Visual disturbances Slurred or inappropriate speech Headache or dizziness

Assessment Signs & Symptoms Cerebral Embolus with rapid onset Emboli from valvular HD or Afib rapid onset Often with an identifiable cause (e.g. Afib, Valvular heart disease, recent long bone fracture)

Cerebral hemorrhage associated with rapid onset Assessment Signs & Symptoms Cerebral hemorrhage associated with rapid onset high mortality rate Often with severe HA (“Worst headache ever”) N/V Rapid decrease in LOC or seizure Coma, Cushing’s and Herniation

Assessment Past Medical History Associated Altered LOC or Seizure? Onset/Precipitating factors? Initial symptoms and progression? Dizziness, Severe HA, N/V Previous CVA or TIA? Previous neurological deficits? Concomitant illnesses? Sickle Cell Disease Atrial fibrillation Risk factors for stroke & thrombus formation? BCP, Smoking HTN, CVD

Assessment Physical Exam Mental Status & Behavior Extremity Motor & Sensory Gait Pupils & Vision Cincinnati Prehospital Stroke Scale Evidence of Cushing’s Syndrome (Reflex)or Herniation Blood glucose level

Basic Objective Improve cerebral blood flow and oxygenation CVA Management Basic Objective Improve cerebral blood flow and oxygenation

CVA Management Airway Breathing If no gag reflex, intubate Otherwise, position to ensure drainage of secretions Suction as needed Breathing Oxygen via NRB Ventilate with BVM and O2 if rate or tidal volume inadequate

CVA Management Circulation Check blood glucose level Hypoglycemia may mimic CVA Treat hypoglycemia with D50W Establish IV Access Draw blood samples TKO avoid solutions with glucose (Hypertonic) Monitor ECG 10% of CVAs are associated with cardiac event 12 Lead ECG if suspected ischemia

CVA Management Do not assume patient cannot understand because they cannot talk Position appropriately: If hypertensive, semireclined (head slightly elevated) If normotensive, on affected side If hypotensive, supine

CVA Management Increased Blood pressure treated ONLY if strongly suggestive of ischemic stroke If systolic >220 or diastolic >120 consider gradual blood pressure reduction Labetalol Nitropaste Nitroprusside Controlled reduction Return to pre-CVA levels, NOT to “normal”

CVA Management Thrombolytic agents Consider for all patients with ischemic CVA presenting within 3 hours of onset Early recognition of ischemic stroke and administration of thrombolytics can prevent/limit loss of neurologic function Requires CT scan!!!

CVA Management Think like AMI of the Brain Therapy Mainstays Time is Muscle….. Time is Brain Therapy Mainstays Oxygenation/Ventilation IV Access Rapid assessment & differential Treat associated conditions (hypoglycemia, hypoxia, hypotension) Rapid Transport to appropriate facility CT Scan & Thrombolytics vs. CT Scan & Neurosurgery

Definitions Primary Stroke Center (PSC) – a hospital that is currently certified by The Joint Commission (TJC) or Healthcare Facilities Accreditation Program (HFAP) as a Primary Stroke Center.

Definitions Emergent Stroke Ready Hospital (ESRH) – a hospital which provides emergency care with a commitment to Stroke with recognition by Illinois Department of Public Health that has the following capabilities: CT availability with in-house technician availability 24/7/365 Lab availability 24/7/365 Ability to rapidly evaluate an acute stroke patient to identify patients who would benefit from thrombolytic administration Ability and willingness to administer thrombolytic agents to eligible acute Stroke patients Accepts all patients regardless of bed availability

Definitions Non-Stroke Hospital – No recognized organized treatment for acute stroke.

INTERHOSPITAL TRANSPORT GUIDELINES FOR CONFIRMED STROKE PATIENTS TPA (Activase / alteplase) Transfers Patients with a tPA infusion in progress must be accompanied by a Registered Nurse. Patients that have completed a tPA infusion must be transported by an ILS/ALS ambulance. It is preferred to complete tPA before transferring patient. Hemorrhagic Transfers Keep head of cot elevated at least 30 degrees (if stable) and head positioned midline. Vital Signs and Neuro checks every 15 minutes Notify Medical Control immediately of SBP > 180 mmHg DBP > 105 mmHg Deterioration in level of consciousness Bleeding at any location Severe headache 

Time is Brain !!!!!!!