1. Acute Stroke - the role of EMS Diane Handler, RN, MSN, MeD, ANVP Stroke Coordinator Mercy Medical Center, Cedar Rapids. Iowa dhandler@mercycare.org

2.  Stroke is an emergency  Stroke is treatable  Stroke occurs at all ages!  1.9 million brain cells die/minute The Facts

3.  1. Understand symptoms of stroke.  2. Know the difference between ischemic stroke and hemorrhagic stroke and treatment guidelines.  3. Review stroke syndromes to better understand stroke presentations.  4. Know times to treat goals for stroke.  5. Review triage considerations and when to divert. Objectives

4.  780,000 strokes/ year  Community role- education s/s and call 911  Dispatch role  Stroke high priority (like AMI)  Screen for stroke symptoms  60 second turn around More Facts

5.  9 minutes to scene  15 minute on scene time  Cincinnati stroke scale (arm, speech, droop)  Time of onset  Check blood glucose  Family/witness to ED/ cell phone #  OVER TRIAGE -30% EMS Role

6.  Arm drift  slurred speech  facial droop  If one is positive = consider stroke Cincinnati Stroke Scale

7.  History – and why  Time of onset  Meds- on coumadin?  Past medical Hx- HTN, diabetes, past stroke or TIA  A Fib, A Fib, A Fib, A Fib, A Fib… Your Role

8. Acute Stroke Treatment

9.  What is tPA? (tissue plasminogen activator)  Approved for stroke in 1996  Enzyme that activates the clot busting system in the body Treatment

10.  IV tPA Symptom onset 4.5 hrs  IV tPA Symptom onset 3 hours  80 years old  History of both previous stroke and diabetes  Stroke symptoms within 8 hrs- consider Intra- arterial tPA Deadlines

11.  Too late to ED  On Coumadin and INR >1.7  Symptoms rapidly resolving  Recent trauma, MI or stroke Why no tPA

12.  NINDS tPA Trial  30% more likely to have minimal or no disability at 3 months.  6% risk of symptomatic bleeding with tPA  17% mortality with tPA and 21% with placebo group Outcomes

13. ED goals for time to treat From Arrival to ED Door to Doctor- 10 minutes Door to neurological expertise – 15 minutes (by phone) Door to CT taken – 25 minutes * Door to CT interpretation – 45 minutes Door to treatment with tPA – 60 minutes

14. Your Role  History  EMS straight to CT

15. Why CT fast and first

16.  What does a typical stroke look like? Typical Stroke

17.  Weakness on Left or Right side and may have facial droop  Visual gaze deviation  Inability to speak and or confused Typical Stroke…

18. Left Hemisphere Stroke

19.  R side weakness  R facial droop  Speech affected- receptive or expressive Left hemisphere stroke

20.  L side weakness  L facial droop  Impaired decision making Right hemisphere stroke

21.  77 yo w, female  Triage 1018  L facial droop, L hemiparesis,  Last time seen normal 0828  Did not want to come to hospital  Time to treat with tPA 49 minutes Right hemisphere “Typical Stroke”

22.  Small vessel disease  Hypertension  High cholesterol  Diabetes  Smoking  Sedentary life style Why did I have a stroke? Another typical stroke type

23.  Cerebellum  Loss of balance  Brain Stem  Loss of consciousness  Occipital Lobes  Visual changes “Zebra” Strokes

24.  38 yo female from Micronesia  Symptom onset 0445 headache and dizziness, LOB  Posterior circulation Cerebellum stroke  Cause of stroke? Associated problems- heart disease, anemia Less typical Stroke

25.  43 yo male, unresponsive  Hx not feeling well and vomiting  Last normal night before  Triage at 0814  L vertebral artery and basilar artery occulsion, prob dissection (locked in) Atypical Stroke

26.  Nausea and vomiting  Gaze palsy  Swallow difficulty, slurred speech  Hemiparesis or quadriplegia and sensory loss  Decreased level of consciousness Brainstem Stroke

27. Cranial Nerves

28.  82 yo male  Sensory loss on left  Visual field cut  Weakness on the left  R Occipital Lobe Stroke Less typical Stroke

29.  36 yo female- headache  migraine  47 yo female- weak R arm + leg, headache, chest pain  Conversion reaction syndrome  65 yo female- slurred speech, decreased LOC  hypogylcemia  85 yo male- in restaurant, became unresponsive  Hypo-perfusion of brain due to low BP Stroke Mimics

30.  Seizures with todds paresis  Tumor *Call Stroke Alert in any case- over triage by 30% is expected Other mimics

31. EMS Acute Stroke Report  March 2010, time ED arrival 2230,Patient 62 yo, M  Symptoms R side weakness, R facial droop, slurred speech (dysarthria), symptoms fluctuated. Time of symptom onset2159 Time to CT taken 25 minute  Treated with t-PA?yes Time to needle 61 minutes Disposition of patient- Intensive Care Center for 24 hours then Cardiac Stroke Center for 24 hours. Then home.  Comments- Good in transit time for EMS service. Symptoms fluctuated but tPA was given as symptoms could have stabilized to a major stroke. Patient made a good recovery with no rehab issues.

32. EMS Acute Stroke Report  Triage time- 1104, Sept 2010, 1104, 79 yo F  Symptoms- R arm weakness, R facial droop, dysarthria, symptom onset “Last normal” 0915 Taken dTo CT directly Treated with t-PA? yes Time to needle 43 minutes  Disposition of patient -To ICC then Cardiac Stroke Center  Comments: Patient has made a good recovery. Patient has a history of A Fib but was not treated with Coumadin as she was a fall risk in previous living situation. On MRI, multiple areas of stroke were noted in left frontal and temporal lobe – likely due to cardio- embolism from the A Fib. Started on Coumadin and will watch in new living area to prevent falls.

33. EMS Acute Stroke Report  Aug 2010, Triage 1723  66 yo, W, M SymptomsWeakness R side, leg greater than arm. Time of symptom onset1300 Time to CT scan takenOn arrival Treated with t-PA?No, Arrived > 3 hours so could not give tPA  Disposition of patient To Cardiac Stroke Center, Acute, inpatient rehab and eventually home.  Comments: Had patient arrived within time IV tPA could have been given. For patients 80 years old and who have both past stroke and diabetes need to be treated within 3 hours of symptom onset. * Education of patient to call 911 right away.

34. EMS Acute Stroke Report  Nov. 2010  56 yo, W, F, Symptoms -R Facial droop, R side weakness. Time of symptom onset- 2130, Time to CT scan immediately, Treated with t-PA? yes Time to needle - 44 minutes  Disposition of patient - Intensive Care Center, then Stroke Center and home soon.  Comments: Good times to treat. Patient did very well post tPA. Had a small left “subcorticol” stroke (under the cerebral hemispheres). Complete work up done to find the cause in 56 yo female with no known risk factors.

35. Questions  How many brain cells die per minute?  What is the goal for response time?  What is the goal for on scene time?  Why not give tPA past 4.5 hours?