1. DAVID A. HOOKER, MD BMH-DESOTO ASST. ED MEDICAL DIRECTOR EMS Management of Acute Stroke

2. Pop-Quiz 1. What is the most important historical information relating to a stroke patient? a. History of stroke previously b. History of diabetes c. Time of symptom onset (Last known well) d. Recent use of drugs or alcohol 2. At what level should blood pressure be reduced in the pre-hospital setting? a. 140/90 b. 180/105 c. 220/120 d. Never reduce BP in the pre-hospital setting unless per medical command physician 3. Which of the following is NOT an important component of pre-hospital stroke patient care? a. Determine the time of symptom onset (Last known well) b. Call the destination hospital early c. Acquire a 12-lead EKG d. Transfer the patient as soon as possible

3. Objectives Understand the epidemiology surrounding the mortality and morbidity of stroke in the U.S. Understand the two major types of strokes Recognize 5 stroke signs/symptoms Learn risk factors for stroke Understand treatment options for stroke Understand the role of TPA in the treatment of acute ischemic stroke Understand the importance of EMS in the stroke system of care

4. Financial Disclosures None (unfortunately)

5. Stroke Mortality Stroke is the 4 th leading cause of death, killing over 160,000 Americans annually Approximately 795,000 strokes occurs in the United States each year Someone in the U.S. has a stroke every 40 seconds Someone in the U.S. dies of a stroke every 4 minutes

6. Burden of Stroke Stroke is the number one reason for nursing home admission 7 million survivors of stroke >20 years old Up to 74% of stroke survivors require assistance with activities of daily living from informal caregivers Direct / indirect costs of stroke in 2010 in the U.S. were estimated at $73.7 BILLION dollars

7. Personal Impact of Stroke

8. EMS and Outcomes Diagnoses in which EMS plays huge part in patient outcomes  Major Trauma  Cardiac Arrest  Acute MI  Stroke

9. Types of Stroke Ischemic  Clot/plaque blocks flow Hemorrhagic  Blood vessel leaks = bleeding

10. Mimics of Stroke Alcohol intoxication Intracranial or systemic infections Medication reactions Low or high blood surgar Migraines Epilepsy Tumors Dementia Multiple Sclerosis

11. Types of Stroke

12. Transient Ischemic Attacks (TIAs) Commonly called “mini-strokes” 200,000 – 500,000 in the U.S. per year Incidence increased with age Symptoms are same as for stroke, but are temporary and resolve without detectable tissue damage 9% - 20% will go on to have stroke within 90 days Immediate medical attention required

13. Modifiable Risk Factors HTN CAD/Carotid Disease/PVD Atrial Fibrillation Diabetes Obesity High Cholesterol/Diet Lack of exercise ETOH/Drug abuse Coagulopathy- Cancer, Sickle Cell Anemia PFO- Patent Foramen Ovale

14. Non-modifiable Risk Factors Age->55 Race: African Americans have 2x the risk of death and disability. Asians have 1.4x the risk of death and disability. Sex:  9% greater chance in men.  61% of stroke deaths occur in women  Kills more women than breast, ovarian, uterine and cervical cancer combined Previous Stroke or TIA Family History of Stroke

15. Not Just For Old People Prevalence of hospitalization for AIS increased significantly in those <44 years old  53% increase med 15 – 34  47% increase in men 35 – 44  36% increase in women 35 – 44 Nearly 25% of strokes occur in people <65 years old

16. Ischemic Stroke 87% of strokes Occurs when a blood vessel supplying the brain becomes blocked Without oxygen cells in the brain began to die in minutes Without reversal of the occlusion over time more cells die and brain function in that area is permanently lost

17. Signs and Symptoms of AIS Weakness (hemiparesis) of the face, arm or leg – especially on one side of the body (unilateral) Unilateral sensory deficit Visual deficits (blindness, gaze palsy, diplopia) Speech (slurred – a motor dysfunction) Language (aphasia – damage to the brain’s speech center) Ataxia (lack of coordinated movement) Cognitive impairment

18. Selected Stroke Syndromes Anterior (ACA)Contralateral hemiparesis (maximal in the leg), urinary incontinence, apathy, confusion, poor judgment, mutism, grasp reflex, gait apraxia Middle (MCA) (most common)Contralateral hemiparesis (worse in the arm and face than in the leg), dysarthria, hemianesthesia, contralateral homonymous hemianopia, aphasia (if the dominant hemisphere is affected) or apraxia and sensory neglect (if the nondominant hemisphere is affected) Posterior (PCA)Contralateral homonymous hemianopia, unilateral cortical blindness, memory loss, unilateral 3rd cranial nerve palsy, hemiballismus

19. Selected Stroke Syndromes Ophthalmic artery (branch of the MCA)Monocular loss of vision (amaurosis) Vertebrobasilar systemUnilateral or bilateral cranial nerve deficits (eg, nystagmus, vertigo, dysphagia, dysarthria, diplopia, blindness), truncal or limb ataxia, spastic paresis, crossed sensory and motor deficits*, impaired consciousness, coma, death (if basilar artery occlusion is complete), tachycardia, labile BP Lacunar infarctsAbsence of cortical deficits plus one of the following: Pure motor hemiparesis Pure sensory hemianesthesia Ataxic hemiparesis Dysarthria–clumsy hand syndrome

20. Time is Brain!! Penumbra  is a potentially salvageable area the surrounds the core infarct zone The core infarct zone expands over time Every hour without treatment in AIS causes 120 million neurons to be lost and ages the brain by 3.6 years

21. Time frameNeurons lostAges the brain by Every second32,0008.7 hours Every minute1.9 million3.1 weeks Every hour120 million3.6 years 10 hours † 1.2 billion36 years Time is Brain!!

22. Hemorrhagic Stroke 13% of strokes Cerebral blood vessel ruptures or leaks Non-traumatic causes  Hypertension  Subarachnoid hemorrhage  Anticoagulant therapy  Clotting disorders More likely to result in death or severe disability 35-52% dead within 1 month  (½ of those within 48 hours) Only 10% living independently in 1 month; improves to only 20% within 6 months

24. Risk Factors for Hemorrhagic Stroke Hypertension Advancing age Coagulation disorders & therapy ETOH abuse Drug use (meth, cocaine, crack, etc.) Ischemic stroke—hemorrhagic transformation

25. Signs and Symptoms Hemorrhagic Stroke Presentation can be identical to ischemic stroke Sudden—signs over minutes to hours Headache (SAH thunderclap, worse headache of life) Nausea and vomiting Decreasing LOC Extremely elevated blood pressure

26. Subarachnoid Hemorrhage Acute bleeding around the outside of the brain and into the subarachnoid space Usually from an aneurysm or arteriovenous malformation. Statistics:  50% are fatal  1-15% die before reaching the hospital  Those who survive are often impaired  1-7% of all strokes Treatment is neurosurgery

27. AIS vs. Hemorrhagic Stroke often high BP rare ↓ LOC rare or vague H.A. rare nausea & vomiting often wake up with the symptoms usually very high BP ↓ LOC~ 50% of the time H.A.~ 40% of the time Vomiting~50% of time wake up with symptoms only ~15% FINAL DIAGNOSIS MADE BY CT!!!

28. EMS and Stroke 50% of stroke patients call 911 Ability to asses stroke vs. mimics  Hypoglycemia Collection of key information which guide treatment  Onset (Time Last Known Well)  Meds (Anticoagulants)  Blood pressure Direct patient destination Activate the stroke team Prehospital Management and Stabilization

29. EMS and Stroke: Time is Brain NAEMSP believes that:  Expeditious EMS dispatch and response should occur.  EMS personnel should be knowledgeable in the assessment, management and triage of suspected stroke patients. Personnel should be skilled in the performance of pre-hospital stroke screening and in determining the timing, onset and nature of symptoms.  EMS personnel should communicate with the receiving facilities as soon as possible.  Evidence-based EMS protocols should be consistent with local/regional resources.  EMS systems and medical directors should develop local/regional strategies for treating, triaging and transporting patients with acute stroke symptoms -- including the identification of stroke- ready centers and criteria for patients who should be transported to such centers

30. EMS Treatment Recommendations Dispatch  Diagnosis of stroke by emergency medical dispatchers and its impact on the prehospital care of patients Caceres, et al. J Stroke Cerebrovasc Dis. 2013 Nov;22(8):e610-4.J Stroke Cerebrovasc Dis.  67,844 strokes identified by EMS (52.5 % by dispatch)  Advanced Life Support dispatched  Help and Instructions offered to caller  Arrived at facility in shorter time

31. EMS Treatment Recommendations CABs  Oxygen as needed & reduce hypercapnea ( ↑ CO2 = ↑ ICP)  Prevent aspiration (Remember: 50% of ICH patients vomit and have ALOC) Establish / record time Last Known Well Bring witness, family member or caregiver to hospital. If not, get name and cell number of witness or family – even if “coming right on” Bring or record all medications. Especially any “blood thinners”

32. Cincinnati Pre-hospital Stroke Scale Most widely used system to assess for stroke in the pre- hospital setting Test includes  Facial droop – ask patient to smile – abnormal if one side does not move as well  Arm drift – ask patient to hold both arms out for 10 seconds - abnormal if one arm drifts compared to other or doesn’t move  Slurred speech – ask patient to repeat simple sentence – abnormal if speech is slurred, inappropriate or mute  Time last known well / Time to get to stroke-ready hospital Sensitivity of one deficit for acute stroke is 66%, all three 87% Formal screening algorithm can increase paramedic detection of stroke to >90%

33. EMS Treatment of Stroke Rapid transport to closest stroke-ready hospital  Guidelines support bypassing hospitals without stroke resources if stroke center is within reasonable transport range  Air transport when indicated Alert receiving ED as soon as possible Check & record blood glucose en route Check & monitor blood pressure en route Cardiac monitor, IV access en route Seizures can be treated with valium or ativan

34. Radio Report ED Handoff Keep it brief Code Stroke  Symptom  CSS LKWT Vital Signs Symptoms LKWT  Instead of time of symptom onset  Onset is often unknown  Witnesses, contact info Pertinent PMHx Vital Signs, Glucose Exam Stroke Handoff

35. Stroke Hospitals Primary stroke center (PSC)  Acute stroke teams, stroke units, written care protocols and an integrated emergency response system  Support services including 24/7 CT (including interpretation) and rapid lab testing  2011 Brain Attack Coalition guidelines reiterate EMS transport to nearest PSC Comprehensive stroke center  Personnel with specific expertise in many disciplines including neurosurgery and vascular neurology  Advanced neuroimaging such as MRI and cerebral angiography  Surgical and endovascular techniques  ICU and stroke registry

36. Stroke Hospitals Telestroke hub or spoke  Uses technology to connect patients & physicians to remote specialists via:  Telephone/Internet connection  Videoconferencing  Teleradiology  Telestroke is the use of telemedicine for stroke care  Neurologists use an audio/video connection to evaluate and recommend treatment for patients in a remote ED

37. Mississippi Certified Primary Stroke Centers Anderson Memorial Hospital (Meridian) Memorial Hospital at Gulfport Miss. Baptist Medical Center (Jackson) North Miss. Medical Center (Tupelo) Singing River Hospital (Pascagoula) St. Dominic (Jackson) UMMC (Jackson) MEMPHIS: Baptist Memphis, UT Methodist, St. Francis

38. The Thrombolytic Timeline 0 10 20 30 40 50 60 70 80 90 911

39. Use of Thrombolytics in AIS TPA (Alteplase) is FDA approved and indicated for the management of acute ischemic stroke FDA approval is for treatment initiated within 3 hours of onset of symptoms  ECASS-III study has shown TPA may be beneficial up to 4.5 hours after onset of symptoms with additional restrictions; is not currently FDA approved Patient must meet strict inclusion and exclusion criteria Requires a rapid, coordinated response

40. Thrombolytics for AIS Inclusion Criteria 18 years or older Demonstrate a measurable neurologic deficit as defined by the National Institute of Health Stroke Scale (NIHSS) Confirmed diagnosis of acute ischemic stroke Can be treated with 3 hours of stroke symptom onset  Recent ECASS-III shows up to 4.5 hours with additional exclusion criteria

41. Thrombolytics for AIS Exclusion Criteria Evidence of ICH on CT Suspicion of SAH on pretreatment evaluation Serious head trauma or stroke (prior 3 months) Recent intracranial or intraspinal surgery (past 2 weeks) History of ICH (ever) Arterial puncture in a noncompressible site within past 7 days Multilobar infarction on CT (>1/3 cerebral territory) Uncontrolled hypertension at time of treatment (SBP > 185 mm/Hg or DBP > 110mm/Hg) despite 2 doses of medications

42. Thrombolytics for AIS Exclusion Criteria Seizure at onset of stroke Active internal bleeding Intracranial neoplasm, arteriovenous malformation, or aneurysm Known bleeding diathesis  Platelet count <100K  Heparin within last 48 hours with elevated aPTT  Current use of Xa inhibitors  Current use of anticoagulant with INR > 1.7 or PT > 15 secs Blood glucose 400 mg/dL

43. Thrombolytics Warnings Minor or rapidly improving neurological deficits Pregnancy Major surgery or serious trauma with previous 14 days Severe neurological deficit (NIHSS > 22 at presentation) GI/Urinary tract hemorrhage within previous 21 days Acute MI within past 3 months

44. NIHSS  Level of Consciousness Level of Consciousness  A) LOC Responsiveness A) LOC Responsiveness  B) LOC Questions B) LOC Questions  C) LOC Commands C) LOC Commands  Horizontal Eye Movement Horizontal Eye Movement  Visual field test Visual field test  Facial Palsy Facial Palsy  Motor Arm Motor Arm  Motor Leg Motor Leg  Limb Ataxia Limb Ataxia  Sensory Sensory  Language Language  Speech Speech  Extinction and Inattention Extinction and Inattention Score [3] [3] Stroke Severity 0No Stroke Symptoms 1-4Minor Stroke 5-15Moderate Stroke 16-20Moderate to Severe Stroke 21-42Severe Stroke

45. Thrombolytics Outcomes in AIS The NINDS tPA study was the landmark study that use of thrombolytics in AIS is based Thrombolytics showed statistically significant improvement on all 4 outcome measures in Part 2 of NINDS Patients treated with thrombolytics were at least 33% more likely to achieve minimal or no neurologic disability at 90 days versus those given placebo AIS patients given thrombolytics had 6.4% incidence of intracranial hemorrhage vs. 0.65% in the placebo group Mortatlity at 90 days was 17.3% in the thrombolytic group vs. 20.5% in the placebo group

46. Intra-arterial Treatment of AIS Endovascular therapy Performed by neuro-interventionalist Devices that actually remove the clot from the artery  MERCI, Penumbra, Solitaire, Trevo Can be considered in patients  in which TPA contraindicated  TPA is not successful or predicted not to be successful  Past TPA timeline – up to 8 hours

47. Clot Retrieval

48. In Summary Dispatch rapidly with pre-arrival instructions Respond rapidly Minimize on-scene time History of event, preferably with a witness Brief assessment such as the Cincinnati Scale Triage, stabilize and treat the stroke patient Maintenance of circulation, airway and breathing High-priority transport – air transport when indicated Appropriate destination – closest stroke-ready hospital Early notification of receiving ER Present patient to ED with report The best stroke care is a coordinated multi-disciplinary approach

49. Questions