1. Cardiovascular Accidents
Strokes

2. Strokes Emergencies Third leading cause of death in the United States
795,000 Americans suffer strokes each year
144,000 deaths each year
- From 1995 to 2005, the stroke death rate fell 29.7%
6,000,000 stroke survivors

3. Strokes Emergencies The leading cause of adult disability
Up to 80% of all strokes are preventable
Every 45 seconds, someone suffers a stroke

4. Strokes Emergencies
Strokes kill more than twice as many American women every year as breast cancer
More women than men die from stroke
Women over age 30 who smoke and take high-estrogen oral contraceptives have a stroke risk 22 times higher than average

5. Strokes Emergencies
African Americans have a risk that is nearly double that of Caucasians.
African Americans suffer more extensive physical impairments.
African Americans are twice as likely to die from stroke.
High incidence of risk factors for stroke:
Hypertension
Diabetes
Obesity
Smoking
Sickle cell anemia

6. Types of Strokes Ischemic Hemorrhagic
Either type results in inadequate perfusion to an area of the brain.

7. Inadequate Perfusion
Symptoms that develop are a result of the region of the brain involved
Most often the area of the brain that is affected is the area that controls speech, (frontal lobes) muscle function and sensation (cerebellum)
Many patients will suffer paralysis affecting the face and extremities on one side of the body

8. What is a Stroke? Sudden brain damage
Lack of blood flow to the brain caused by a clot or rupture of a blood vessel
Ischemic = Clot (makes up approximately 85% of all strokes)
Hemorrhagic = Bleed
Bleeding around brain
Bleeding into brain

9. Stroke
The term “brain attack” is the most realistic description of a stroke. It also provides a powerful call to action.
A brain attack should warrant the same degree of emergency care as a heart attack. After all, your brain is your mind and your body’s most vital and delicate organ.

10. Stroke
Immediate response is crucial because every minute matters – from the time symptoms first become noticeable to the time treatment is received, more brain cells die. In other words TIME IS BRAIN. The best thing to do is to call 911 for immediate assistance.

11. Stroke
Treatment is available and some options are most effective if administered within the first three hours after experiencing symptoms.

12. Stroke
Your chances of walking out of the hospital with little to no disability are greatly improved if you receive appropriate treatments early.

13. Stroke
Unfortunately, it takes the average American 12 to 24 hours to get to the hospital after experiencing the first stroke symptom. This is why it’s important that everyone learns how to RECOGNIZE stroke symptoms and how to RESPOND.

14. Stroke
Risk Factors
Signs and Symptoms
Management

15. Stroke Changeable Tobacco use Hx of TIAs Hypertension Heart Disease
Under doctor’s care
Tobacco use
Hx of TIAs
Hypertension
Heart Disease
Diabetes Mellitus
Sickle Cell and increased RBC

16. Stroke
Unchangeable
Age
Gender
Race
Previous CVA
Heredity

17. Signs and Symptoms Ischemic Carotid Circulation
Unilateral paralysis (opposite side)
Numbness (opposite side)
Language disturbance
Aphasia – difficult comprehension, nonsense, difficult reading/writing
Dysarthria – slurred speech, abnormal pronunciation.
Visual disturbance (opposite side)
Monocular blindness (same side)

18. Signs and Symptoms Ischemic stroke (Brain Clot)
Vertebrobasilar Circulation
Vertigo
Visual disturbance
Both eyes simultaneously
Diplopia
Ocular palsy – inability to move to one side
Dysconjugate gaze – asynchronous movement
Paralysis
Numbness
Dysarthria
Ataxia

19. Ischemic stroke
Ischemic strokes are caused by a blood clot or blockages in the arteries

20. Stroke
As people age, arteries become narrowed with rough deposits of plaque called "stenosis". Diseased arteries can clog up completely as the plaque accumulates or can be shut down by clotting conditions called "embolism" and "thrombosis".

21. Stroke
When the arteries become plugged, the blood is no longer able to reach the brain and stroke results.

22. Hemorrhagic strokes
Hemorrhagic strokes occur when blood vessels rupture. Ischemic strokes are most commonly caused by blockages in the carotid arteries and are responsible for up to 80% of strokes.

23. Signs and Symptoms Hemorrhagic Brain Bleed Subarachnoid hemorrhage
Sudden severe headache
LOC
Nausea/Vomiting
Neck pain
Intolerance of noise/light
Trouble seeing in one or both eyes
Intracerebral hemorrhage
Focal sx w/ LOC, N/V
Sudden dizziness
Trouble walking
Confusion
Trouble speaking
Numbness or weakness of face, arm or leg

24. Stroke F = Face: ask the person to smile
A = Arm: ask the person to raise both arms
S = Speech: ask the person to speak a simple sentence
T = Time: to call 911
Every minute matters!

25. Management Detection: Early Recognition Dispatch: Early EMS
Public education of Stroke sx
Early access to medical care
Dispatch: Early EMS
Caller triage
EMD recognition of Stroke

26. Questions to ask Is the patient awake / alert? Breathing normally?
Talking normally?
When did it start?
Previous stroke?

27. Management
Delivery: Prehospital care and Transport Prehospital stroke scale
Facial Droop
Arm Drift
Speech

28. Stroke

29. Management Airway Potential problems Manage Aggressively
Paralysis of airway structures
Vomiting esp. w/ hemorrhagic stroke
Coma
Seizures
Cervical trauma due to pt. collapse
Manage Aggressively
High flow O2
If patient appears to be in severe distress, administer oxygen via non-rebreathing mask at 15 L/min. Otherwise, administer oxygen via nasal cannula at 2-6 L/min.

30. Management Breathing Potential Problems Manage Aggressively
Irregular respiratory pattern
Cheyne-Stokes (periodic breathing )
Central Neurogenic hyperventilation (deep rapid breathing)
Paralysis of muscles of respiration
Manage Aggressively
High flow O2

31. Management Circulation Other Treatment Management is supportive
Prompt Transport
Alert MEDIC of potential Stroke patient
Allow patient to sit or lie in a position of comfort.

32. Management Prehospital Critical Actions
Assess and support cardiorespiratory function
Assess and support oxygenation and ventilation
Assess neurologic function
Determine precise time of symptom onset
Determine essential medical information
Provide rapid emergent transport to ED
Notify ED that a possible stroke patient is en route

33. TIA or Mini-Stroke
Transient ischemic attack (TIA) is a warning sign of a future stroke - more than 1/3 of TIA patients will have a future stroke
Symptoms of TIAs are the same as stroke
TIA symptoms can resolve within minutes or hours
It is important to seek immediate medical attention if you suspect that you are having or have had a TIA

34. Stroke Prevention Guidelines
Know your blood pressure. Have it checked at least annually. If it is elevated, work with your doctor to control it.
Find out if you have atrial fibrillation (AF) – a type of irregular heartbeat. If you have it, work with your doctor to manage it.
If you smoke, stop.

35. Stroke 4. If you drink alcohol, do so in moderation.
5. Know your cholesterol number. If it is high, work with your doctor to control it.
6. If you are diabetic, follow your doctor’s recommendations carefully to control your diabetes.

36. Stroke 8. Enjoy a lower sodium (salt) and lower fat diet
7. Include exercise in your daily routine
8. Enjoy a lower sodium (salt) and lower fat diet
If you have circulation problems, work with your doctor to improve your condition.
If you experience any stroke symptoms, call 911 immediately. Every minute matters!

37. Stroke Recovery 10% of stroke survivors recover almost completely
25% recover with minor impairments
40% experience moderate to severe impairments requiring special care
10% require care within either a skilled-care or other long-term care facility
15% die shortly after the stroke

39. Stroke (NCCEP Protocol #33)
Stoke Types
Thromboembolic (85%) Hemorrhagic (15%)
Differential Diagnosis
Drug ingestion
Electrolyte abnormality
Environmental exposure
Hypoglycemia
Hypoxia

40. Stroke (NCCEP Protocol #33)
Post-ictal (Todd’s) paralysis
Psychiatric
Seizure
Shock
Transient ischemic attack (TIA)
Trauma
Tumor

41. Stroke (NCCEP Protocol #33)
Basic Medical Care
1. Medical Initial Assessment Protocol
2. Maintain airway; suction as needed
3. Apply pulse oximeter
4. Assess vital signs
5. Provide supplemental oxygen as indicated per patient condition
A. Provide assisted ventilations with bag-valve mask and 100% oxygen if breathing or ventilatory compromise is apparent

42. Stroke (NCCEP Protocol #33)
6. Assess blood glucose level
A. Administer oral glucose if patient hypoglycemia and alert with intact gag reflex
7. Allow all conscious patients to sit in a position of comfort
8. Perform Cincinnati Prehospital Stroke Screen

43. Stroke (NCCEP Protocol #33)
A. Facial Droop
Ask patient to smile and show their teeth
Normal: Both sides of face move equally
Abnormal: One side of face does not move at all
B. Arm Drift
Ask patient to hold both arms straight out for 10 seconds
Normal: Both arms move equally or not at all
Abnormal: One arm drifts compared to the other
C. Speech
Ask patient to repeat phrase: “You can’t teach an old dog new tricks”
Normal: Patient uses correct words with no slurring
Abnormal: Slurred or inappropriate words or mute

44. Stroke (NCCEP Protocol #33)
9. Identify time of onset of symptoms
A. Note if patient awoke from sleep with symptoms
B. If unclear time of onset, note time patient last known to be normal

45. Stroke (NCCEP Protocol #33)
Additional Considerations
1. CODE STROKE
A. Onset of symptoms < 24 hours
B. 1 or more of the Cincinnati Prehospital Stroke Screen assessments is abnormal
1 of 3 = 72% probability ischemic stroke
3 of 3 = 85% probability ischemic stroke

46. Stroke (NCCEP Protocol #33)
2. Ischemic strokes are more common in patients greater than 45 years of age
A. Hemorrhagic strokes can be seen in any age group
3. If the patient cannot provide historical information, it is imperative to obtain as much
information as possible from family members or friends prior to scene departure

47. Stroke (NCCEP Protocol #33)
4. Acute ischemic strokes typically do not cause seizures, hypotension, or hypoglycemia
A. Seizures are a common presentation for other intracerebral conditions (intracerebral or subarachnoid hemorrhage, tumor, meningitis or other infections, or toxins)
5. Patients with acute stroke symptoms are candidates for thrombolytic therapy if they arrive at the hospital within 6 hours of symptom onset
A. Do not inform the patient or family members that the patient will receive thrombolytic therapy, as they may not meet inclusion criteria