PRIMARY STROKE CENTER First Responder Update 2009

Objectives Recognize stroke as an emergency Describe the pathophysiology of stroke Identify signs and symptoms of stroke Identify risk factors for stroke Describe the Cincinnati Prehospital Stroke Scale List the steps for emergency dispatch and field assessment Describe care actions for a stroke patient Identify the difference between a Primary and a Comprehensive Stroke Center

BRAIN ATTACK Stroke is a Medical Emergency Every 45 seconds someone in the US experiences a stroke Each year more than 795,000 people experience a stroke Stroke is the 3rd leading cause of death and leading cause of adult disability Stroke is treatable within 3 hours of symptom onset EMS transport shortens time to hospital care EMS is the first medical contact for over 50% of stroke patients

Brain Attack Time Lost is Brain Lost Increase public awareness Timely access to 911 Deployment of informed EMS personnel Delivery to a stroke center Stroke is treatable

Stroke Classification

Ischemic Stroke Abrupt and dramatic development of a focal neurological deficit caused by an interruption of blood flow to the brain Accounts for 80% to 85% of all strokes

Ischemic Stroke Thrombotic Stationary clot that forms in a blood vessel Atherosclerosis – leads to platelet aggregation; coagulation is activated and thrombus develops; decreases blood flow through carotid artery

Ischemic Stroke Embolic Emboli travel from other areas of the body and lodge in cerebral vessels Common causes – atrial fibrillation, patent foramen ovale (PFO), valvular disease, carotid plaques, foreign substances

Ischemic Penumbra

Hemorrhagic Stroke Intracerebral Hemorrhage

Hemorrhagic Stroke Subarachnoid Hemorrhage

Risk Factors for Stroke Uncontrollable Controllable Lifestyle Modification

Risk Factors Uncontrollable Age Sex Race Prior stroke Family history

Risk Factors Controllable High blood pressure High cholesterol Atrial fibrillation Diabetes Blood disorders

Lifestyle Modifications Smoking Alcohol Weight / Inactivity

Medical Management Antiplatelets Statins Diabetic meds Antihypertensives Anti-arrhythmia meds

Surgical Management Carotid endarterectomy Angioplasty Stenting

Symptoms of Stroke Sudden numbness or weakness of the face, arm or leg, especially on one side of the body Sudden confusion, difficulty with speech/comprehension Sudden trouble seeing in one or both eyes Sudden trouble walking, dizziness, loss of balance or coordination Sudden severe headache with no known cause

Less Common Symptoms of Stroke Altered level of consciousness Respiratory distress Difficulty swallowing Pupils unequal in size/reaction to light Convulsion / seizures Loss of bladder / bowel control Nausea & vomiting

Stroke Look Alike Trauma Seizures (postictal) Hypoglycemia Brain tumor Migraine Infections (brain abscess)

Transient Ischemic Attack (TIA) Neurological deficit lasting < 24 hours Transient duration of neuro deficits and complete return to normal Majority of TIAs (90%) resolve within 10 minutes Half of people with 1 or m more TIAs will later have a stroke within 1 year Considered as emergent as a stroke Main difference Short duration of symptoms and lack of permanent brain injury

Cerebral Blood Flow

Neuroanatomical Effects Right hemisphere Left hemisphere Cerebellum Brain stem

Right Hemisphere Stroke Effects left side of body Spatial or perceptual abilities Impulsive, unaware of their impairments Left-sided neglect Short-term memory problems Often non-dominant

Left Hemisphere Stroke Effects right side of body Speech and language Aphasia Slow, cautious behavior Memory problems

Cerebellar Stroke Reflexes Balance and coordination Dizziness Nausea and vomiting

Brain Stem Stroke Can be devastating Controls all involuntary functions Respirations, BP, pulse Eye movements, hearing, speech, swallowing

Other Effects of Stroke Environmental adaptations Depression Changes in relationships .

Recovery Some brain cells may be temporarily damaged Another part of the brain may take over for damaged parts Some may never recover Rate of recovery varies Rehab starts in the hospital as soon as possible after the stroke

Dispatch and Field Assessment Chain of Survival Symptom recognition Emergency action EMS arrival and patient transport Diagnosis and treatment Time is Brain

NINDS 6 Actions of Dispatch Install enhanced 911 systems whenever possible. Utilize a recognized Emergency Medical Dispatch (EMD) call receiving algorithm. Send the closest unit with high priority. Ask the caller: “When was the patient last seen in his/her usual state of health before becoming weak, paralyzed or unable to speak clearly?” Dispatchers should also try to determine past medical history and relay all information to EMS providers. Dispatchers should be medically supervised and should have stroke education programs and initiatives in place. Obtain feedback about outcomes from EMS and medical personnel.

EMS Arrival 10 Steps for Stroke Assessment Evaluate & monitor ABCs Blood pressure Blood glucose ECG O2 per protocol Stroke screen Patient history with Time Last Normal Family involvement Minimize time on scene Transport to stroke center

Prehospital Stroke Assessment Cincinnati Stroke Scale F – A – S – T F – Facial Droop A – Arm Drift S – Speech T – Time Last Seen Normal If any 1 of these 3 signs is abnormal, the probability of a stroke is 72%

Cincinnati Stroke Scale Facial Droop Have patient show teeth or smile Abnormal – one side of face does not move as well as other side Normal – Both sides of face move equally

Cincinnati Stroke Scale Arm Drift Patient closes eyes and extends both arms straight out for 10 seconds Normal – Both arms move the same or both arms do not move at all Abnormal – one arm does not move or one arm drifts down compared with the other

Cincinnati Stroke Scale 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 wrong words, or is unable to speak

Cincinnati Stroke Scale Time Time Last Seen Normal Time Symptoms Identified

Chilton Memorial Hospital BAT Activation Primary Stroke Center 3-Hour Treatment Window (IV tPA) Brain Attack Team First Responder ED MD & RN Neurology Radiology, Lab, Pharmacy ICU RN Stroke Program Coordinator Goal: Door to Drug less than 60 minutes Transfer to Comprehensive Stroke Center if indicated Brain Attack Team

Ischemic Stroke Treatment Work-Up Starts in Field Evaluation Patient history Physical exam Lab evaluation Neuroimaging Early supportive medical therapy for Acute Ischemic Stroke

Acute Therapies - tPA Activase works by stimulating the body's own clot-dissolving mechanism by activating plasminogen, a naturally occurring substance secreted by endothelial cells in response to injury to the artery walls that contributes to clot formation.

Acute Therapies - tPA IV tPA IA tPA 3-hour time window Appropriate for 5-10% of stroke patients IA tPA ? 6-hour time window Faster than IV method Less tPA is needed

MERCI Retrieval System Patients ineligible for IV tPA Symptom onset >3 hours On oral anticoagulants Postoperative In-hospital stroke Recent stroke or MI Postpartum Patients who “fail” IV tPA No improvement Patients with moderate-to-severe stroke NIHSS ≥ 8 Large vessel occlusion

Additional Therapies Acute antithrombotic therapy Blood pressure management Care for hemorrhage Additional initial measures Supportive care

Hemorrhagic Stroke Treatment Lifesaving measures Relief of symptoms Repair the cause

Stroke Is ... Remember ! … An Emergency … A Brain Attack … Treatable YOU MAKE A DIFFERENCE

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