Assessment and Treatment of the Stroke Patient Clinical Guidelines and Routing Criteria for EMS in Iowa November 2012 Clinical Guidelines and Routing Criteria for EMS in Iowa November

Stroke Fourth leading cause of death in the U.S. Leading cause of disability in the U.S., affecting over 700, million stroke survivors 85% ischemic Less than 25% of eligible thrombolytic candidates are receiving therapy Fourth leading cause of death in the U.S. Leading cause of disability in the U.S., affecting over 700, million stroke survivors 85% ischemic Less than 25% of eligible thrombolytic candidates are receiving therapy

Why we are here today… Stroke system of care in Iowa can work We have laid the groundwork and gave CDC notice They believed us… Funding for 3 years through the Paul Coverdell National Acute Stroke Program Stroke system of care in Iowa can work We have laid the groundwork and gave CDC notice They believed us… Funding for 3 years through the Paul Coverdell National Acute Stroke Program 3

Why we are here today… Studies are unequivocal – EMS / Hospital articulation is one of the most important factors in achieving time to treat. EMS cannot teach/ be taught in standalone mode any longer. We are an integral part of the healthcare system Studies are unequivocal – EMS / Hospital articulation is one of the most important factors in achieving time to treat. EMS cannot teach/ be taught in standalone mode any longer. We are an integral part of the healthcare system 4

Stroke - Goals Understand our shortfalls Review the disease process Apply stroke screening process Discuss current treatment practices Treatment windows Primary stroke center destination Understand our shortfalls Review the disease process Apply stroke screening process Discuss current treatment practices Treatment windows Primary stroke center destination 5

Stroke identification How easy is it to identify a stroke? 90 % in tertiary care hospitals (stroke centers, teaching institutions) 78% in community hospitals How easy is it to identify a stroke? 90 % in tertiary care hospitals (stroke centers, teaching institutions) 78% in community hospitals 6 Cerebrovasc Dis 1999;9: (DOI: / )

Stroke identification Study of 1045 patients transported by EMS; 440 with diagnosis of stroke Paramedics correctly diagnosed 193 (49%) Paramedics missed 247 (56%) Study of 1045 patients transported by EMS; 440 with diagnosis of stroke Paramedics correctly diagnosed 193 (49%) Paramedics missed 247 (56%) 7 Journal of Emergency Medicine 2007;11:092

Stroke identification Study of 1247 patients; 441 diagnosed with stroke Paramedic PPV 47% Paramedic NPV 58% Study of 1247 patients; 441 diagnosed with stroke Paramedic PPV 47% Paramedic NPV 58% 8 Stroke 2007;38:501

Stroke Identification Paramedics demonstrated 61 – 66% sensitivity for identifying stroke after traditional training methods Sensitivity increased to 86 – 97% after receiving training in using a stroke assessment tool, such as the CPSS or LAPSS 2010 CPR & ECC Guidelines; Circulation, October 18, 2010 Paramedics demonstrated 61 – 66% sensitivity for identifying stroke after traditional training methods Sensitivity increased to 86 – 97% after receiving training in using a stroke assessment tool, such as the CPSS or LAPSS 2010 CPR & ECC Guidelines; Circulation, October 18, 2010

What causes a stroke? 77% – 94% ischemic Thromboembolic Cardioembolic 6%-23% hemorrhagic Intracerebral bleed Sub-arachnoid hemorrhage 77% – 94% ischemic Thromboembolic Cardioembolic 6%-23% hemorrhagic Intracerebral bleed Sub-arachnoid hemorrhage 10

11

12

Cerebral Anatomy 13

Homunculus 14

15

Anterior Circulation Internal Carotid (ICA) Ascends through base of skull to give rise to the anterior and middle cerebral arteries, and connect with the posterior half of circle of Willis via posterior communicating artery Internal Carotid (ICA) Ascends through base of skull to give rise to the anterior and middle cerebral arteries, and connect with the posterior half of circle of Willis via posterior communicating artery 16

Anterior Cerebral Artery 17

Anterior Cerebral Artery 18

Middle Cerebral Artery – M 1, 2, & 3 Segments 19

Middle Cerebral Artery 20

Cerebral Anatomy 21

Posterior Circulation Vertebral-Basilar Vertebral ascends from the subclavian arteries, through the transverse foramen of the cervical vertebrae to enter the cranial cavity via the foramen magnum. Gives branch to basilar which terminates into the posterior cerebral arteries 22

Posterior Circulation 23

Cerebral Anatomy 24

Stroke Symptoms Right Hemisphere  Left sided paralysis  Spatial/perception problems.  Distance, size position  Judgment of own abilities  Impulsive behavior  Left sided neglect  Left visual field cut Right Hemisphere  Left sided paralysis  Spatial/perception problems.  Distance, size position  Judgment of own abilities  Impulsive behavior  Left sided neglect  Left visual field cut Left Hemisphere  Right sided paralysis  Speech / language problems  Expressive  Receptive  Slow, cautious behavior  Good judgment about ability / disability  Right visual cut 25

Visual Field Deficits 26

Current Treatments (FDA Approved) Thrombolytics (t-PA) 3 hours Risk factors Thrombolytics (t-PA) 3 hours Risk factors 28

Current Treatments ECASS 3 Extends time window to 4.5 hours for IV t- PA Published Sept in New England Journal of Medicine Not yet FDA approved All primary stroke centers in Iowa use this 4.5 hour standard ECASS 3 Extends time window to 4.5 hours for IV t- PA Published Sept in New England Journal of Medicine Not yet FDA approved All primary stroke centers in Iowa use this 4.5 hour standard 29

Current Treatments (Not FDA Approved) Intra-arterial t-PA 6 hours Risk factors Mechanical Clot Removal 8 hours Risk factors Other Studies Desmotoplase Neuroprotective agents Intra-arterial t-PA 6 hours Risk factors Mechanical Clot Removal 8 hours Risk factors Other Studies Desmotoplase Neuroprotective agents 30

So Now What?! 31

Evidence Based Approach Higher Prehospital Priority Level of Stroke Improves Thrombolysis Frequency andTime to Stroke Unit: The Hyper Acute STroke Alarm (HASTA) Study. Stroke Oct;43(10): Epub 2012 Aug 9. Barriers to the utilization of thrombolysis for acute ischaemic stroke. J Clin Pharm Ther Aug;37(4): doi: /j x. Epub 2012 Mar 4.J Clin Pharm Ther. Prehospital diagnosis and management of patients with acute stroke. Emerg Med Clin North Am Aug;30(3): doi: /j.emc Pre- and in-hospital intersection of stroke care. Ann N Y Acad Sci Sep;1268(1): doi: /j x. Overview of key factors in improving access to acute stroke care. Neurology Sep 25;79(13 Suppl 1):S Higher Prehospital Priority Level of Stroke Improves Thrombolysis Frequency andTime to Stroke Unit: The Hyper Acute STroke Alarm (HASTA) Study. Stroke Oct;43(10): Epub 2012 Aug 9. Barriers to the utilization of thrombolysis for acute ischaemic stroke. J Clin Pharm Ther Aug;37(4): doi: /j x. Epub 2012 Mar 4.J Clin Pharm Ther. Prehospital diagnosis and management of patients with acute stroke. Emerg Med Clin North Am Aug;30(3): doi: /j.emc Pre- and in-hospital intersection of stroke care. Ann N Y Acad Sci Sep;1268(1): doi: /j x. Overview of key factors in improving access to acute stroke care. Neurology Sep 25;79(13 Suppl 1):S

Pre-Hospital Intervention  Good assessments  Physical exams  History taking  Stroke centers  Good assessments  Physical exams  History taking  Stroke centers 33

Reproducible Assessment Accuracy of stroke recognition by emergency medical dispatchers and paramedics--San Diego experience. Prehosp Emerg Care.Prehosp Emerg Care Jul-Sep;12(3): EMD Dispatchers had higher sensitivity and PPV for recognition of stroke than paramedic at pt side Accuracy of stroke recognition by emergency medical dispatchers and paramedics--San Diego experience. Prehosp Emerg Care.Prehosp Emerg Care Jul-Sep;12(3): EMD Dispatchers had higher sensitivity and PPV for recognition of stroke than paramedic at pt side 34

Stroke Assessment NIH stroke scale 42 point scale to look at neurological deficits Great baseline – creates a uniform exam that can be reproduced Good for transition of care Easier to track statistically NIH stroke scale 42 point scale to look at neurological deficits Great baseline – creates a uniform exam that can be reproduced Good for transition of care Easier to track statistically 35

Stroke Assessment – NIH Scale Complete assessment is great tool for baseline Tests all cranial nerves, peripheral nerves for sensation, movement, spatial perception, coordination… TOO LONG FOR PRE-HOSPITAL SCENES Complete assessment is great tool for baseline Tests all cranial nerves, peripheral nerves for sensation, movement, spatial perception, coordination… TOO LONG FOR PRE-HOSPITAL SCENES 36

Cincinnati Prehospital Stroke Scale Facial Droop Arm Drift Speech Facial Droop Arm Drift Speech 37

Stroke Assessment Cincinatti Pre-Hospital Stroke Score (CPSS) Facial droop Speech Arm drift Los Angelas Pre-Hospital Stroke Scale (LAPSS) Miami Emergency Neruologic Defecit Exam (MEND) Cincinatti Pre-Hospital Stroke Score (CPSS) Facial droop Speech Arm drift Los Angelas Pre-Hospital Stroke Scale (LAPSS) Miami Emergency Neruologic Defecit Exam (MEND) 38

39

Stroke Assessment Differential Diagnoses Seizure / postictal Hypoglycemia Bell’s Palsy Migraine Tumor Differential Diagnoses Seizure / postictal Hypoglycemia Bell’s Palsy Migraine Tumor 40

Treatment Goals Oxygenate the brain – there still may be some left! 41

Treatment Goals BP management (?) CPP = MAP – ICP If hypertensive crisis in conjunction with stroke, call medical control before lowering pressure AHA guidelines – drop systolic BP by increments – no more than 25% of initial value, or diastolic approaches 100 BP management (?) CPP = MAP – ICP If hypertensive crisis in conjunction with stroke, call medical control before lowering pressure AHA guidelines – drop systolic BP by increments – no more than 25% of initial value, or diastolic approaches

Treatment Goals Oxygen Blood Glucose check Cardiac Monitor A-fib common cause of emboli AMI another cause IV access Elevate head – facilitate venous drainage Aspirin? Oxygen Blood Glucose check Cardiac Monitor A-fib common cause of emboli AMI another cause IV access Elevate head – facilitate venous drainage Aspirin? 43

What about Stroke Centers? Positive effects of stroke center are comparable to the effects of timely administration of tPA… Preferential routing to stroke centers Positive effects of stroke center are comparable to the effects of timely administration of tPA… Preferential routing to stroke centers 44

Iowa EMS Protocol Utilize CPSS or other reproducible stroke assessment If stroke symptoms are present with an onset of less than 4.5 hours Transport to primary stroke center if transport is 30 minutes or less Transport to closest stroke capable hospital if greater than 30 minutes Utilize CPSS or other reproducible stroke assessment If stroke symptoms are present with an onset of less than 4.5 hours Transport to primary stroke center if transport is 30 minutes or less Transport to closest stroke capable hospital if greater than 30 minutes

Iowa Primary Stroke Centers Iowa Healthcare Collaborative Iowa Healthcare Collaborative 46

Questions???? 47