1. Copyright 2009 Seattle/King County EMS Overview of CBT 442 Stroke Complete course available at www.emsonline.net

2. Copyright 2009 Seattle/King County EMS Introduction Stroke Advancements give hope for restoration of lost neurological function Key is clot-busting therapy within 3 hours of onset Time lost is brain lost

3. Copyright 2009 Seattle/King County EMS Practical Skills Initial assessment (SICK/NOT SICK) Patient history Cincinnati Prehospital Stroke Scale Recognition of need for short scene times Care for stroke To receive CBT or OTEP credit, you must perform the following practical skills:

4. Copyright 2009 Seattle/King County EMS Terms atherosclerosis - A condition characterized by the deposit of fatty plaques containing cholesterol and lipids on the innermost layer of the walls of large and medium-sized arteries. embolism - A clot that travels from one part of the body to another until it becomes lodged in one of the small arteries of the brain and blocks blood flow. hemorrhagic stroke - A type of stroke that occurs when a blood vessel bursts inside the brain. infarction - A localized area of cell death due to a lack of oxygenated blood.

5. Copyright 2009 Seattle/King County EMS Terms, continued ischemia - A deficiency of oxygenated blood in a body part as a result of a constriction or blockage of the blood vessel. stroke (CVA) - A vascular disease that occurs when a blood vessel bringing oxygen to the brain bursts or is clogged by a blood clot or embolus. It can cause neurological deficits. thrombus - A blood clot that typically forms over fatty plaque deposits that form on the inner wall of arteries. This plaque and subsequent narrowing may progress slowly, particularly in those patients who smoke or have high cholesterol or high BP. transient ischemic attack (TIA) - A disorder of the brain in which brain cells temporarily stop working because of insufficient oxygen causing stroke-like symptoms that resolve completely within 24 hours of onset.

6. Copyright 2009 Seattle/King County EMS Three Regions of Brain Cerebrum Cerebellum Brain Stem Graphic illustration credit: LifeART(R) image, Copyright 1998, Lippincott Williams & Wilkins. All rights reserved.

7. Copyright 2009 Seattle/King County EMS Cerebrum Thought Personality Memory Motor skills Tactile (touch) Speech Vision Three Regions of Brain, cont.

8. Copyright 2009 Seattle/King County EMS Three Regions of Brain, cont. Cerebellum Coordination Balance Basic movement Muscle tone

9. Copyright 2009 Seattle/King County EMS Three Regions of Brain, cont. Brain Stem Heart function Respiration Autonomic nervous system Digestion Glandular secretions

10. Copyright 2009 Seattle/King County EMS Types of Stroke Ischemic: A blockage caused by a clot. This is the most common type of stroke.

11. Copyright 2009 Seattle/King County EMS Types of Stroke, continued Ischemic: A blockage caused by a clot. This is the most common type of stroke. Hemorrhagic: A rupture caused by a break in a blood vessel. Less common than ischemic stroke but no less serious.

12. Copyright 2009 Seattle/King County EMS Thrombus Clot that develops at site of blockage Near area of plaque Causes a sudden occlusion Sudden onset of neurological deficits Ischemic Stroke

13. Copyright 2009 Seattle/King County EMS Embolus Clot floats to site to form a blockage Circulates in bloodstream until it gets stuck in an artery Ischemic Stroke, continued

14. Copyright 2009 Seattle/King County EMS Hemorrhagic Stroke Ruptured blood vessel on surface of the brain (subarachnoid) Ruptured blood vessel within brain (intracerebral) Puts pressure on the brain

15. Copyright 2009 Seattle/King County EMS Types of Stroke Both types of stroke Prevent oxygenated blood from reaching the brain tissues

16. Copyright 2009 Seattle/King County EMS Types of Stroke Both types of stroke Prevent oxygenated blood from reaching the brain tissues May have only minutes to get patient to definitive treatment Time lost is brain lost; seconds count.

17. Copyright 2009 Seattle/King County EMS Transient Ischemic Attack Brain cells stop working because of insufficient oxygen Causes stroke-like symptoms that resolve completely within 24 hours

18. Copyright 2009 Seattle/King County EMS Risk Factors Hypertension Smoking Age Gender Heredity Prior stroke Diabetes Carotid artery disease Heart disease TIAs

19. Copyright 2009 Seattle/King County EMS Signs and Symptoms Paralysis or weakness on one side of the body Facial droop on one side Altered level of consciousness Change in personality or mood Headache or dizziness Impaired speech Blurred vision Poor coordination

20. Copyright 2009 Seattle/King County EMS Initial Assessment Determine SICK or NOT SICK early in the call SICK or NOT SICK? SICK or NOT SICK?

21. Copyright 2009 Seattle/King County EMS Physical Exam A SICK patient is one who can die quickly unless you initiate aggressive BLS and ALS treatment and rapid transport. A NOT SICK patient is one who can be ill or injured, but not severely enough to be life threatening.

22. Copyright 2009 Seattle/King County EMS Physical Exam Key Clinical Indicators Respirations Pulse Mental status Skin signs and color Body position Relative to stroke Baseline vital signs Cincinnati Prehospital Stroke Scale Blood glucometry SICK or NOT SICK? SICK or NOT SICK?

23. Copyright 2009 Seattle/King County EMS Cincinnati Prehospital Stroke Scale Accurate in identifying patients with stroke An abnormal finding in ANY three tests strongly suggests a stroke TestNormalAbnormal facial droopboth sides of face move equally one side of face does not move as well as the other arm drift both arms move same or both arms do not move at all (palms up, eyes closed) one arm drifts down compared to other or one arm does not move speech says correct words with no slurring of words slurs words, says wrong words, or is unable to speak

24. Copyright 2009 Seattle/King County EMS Patient 1 facial droop

25. Copyright 2009 Seattle/King County EMS Patient 1 facial droop arm drift

26. Copyright 2009 Seattle/King County EMS Patient 1 facial drift arm drift speech

27. Copyright 2009 Seattle/King County EMS Patient 1 facial droop arm drift speech

28. Copyright 2009 Seattle/King County EMS Patient 2 facial droop

29. Copyright 2009 Seattle/King County EMS Patient 2 facial droop arm drift

30. Copyright 2009 Seattle/King County EMS Patient 2 facial droop arm drift speech

31. Copyright 2009 Seattle/King County EMS Patient 2 facial droop arm drift speech

32. Copyright 2009 Seattle/King County EMS Patient History Stroke patients often report loss of motor function and/or a change in speech pattern. Some experience altered LOC. SAMPLE history to determine if there is a history of: Hypertension Blood thinners or anticoagulants Arteriovenous malformation (AVM) Cerebral aneurysm Prior stroke

33. Copyright 2009 Seattle/King County EMS Patient History, continued Chief complaint and time of onset are key in the assessment of stroke.

34. Copyright 2009 Seattle/King County EMS Time of Onset Determine time of onset but keep scene and transport times short Be aware of time it takes for the hospital staff to assess and administer thrombolytic therapy Clot-busting drugs must be given within 3 hours of onset of symptoms.

35. Copyright 2009 Seattle/King County EMS Care for Stroke Protect airway Ensure adequate respirations Remove secretions that can be aspirated Provide ventilation assistance Proper positioning Administer oxygen if saturation level is below 95% or there are signs of hypoxia

36. Copyright 2009 Seattle/King County EMS Short Scene Times Victims of stroke often deny or rationalize their symptoms Patients eligible for clot-busting drugs must be transported immediately Notify hospital that possible stroke pt is en route Avoid delays if patient waited before calling for help Short scene and transport times are important.

37. Copyright 2009 Seattle/King County EMS Summary The three regions of the brain are cerebrum, cerebellum and brain stem. The two basic types of stroke are ischemic (blockage) and hemorrhagic (rupture). An ischemic stroke can be caused by a thrombus which is a clot that forms in a cerebral artery or an embolus which is a clot that travels to the brain.

38. Copyright 2009 Seattle/King County EMS Summary, continued Signs and symptoms of stroke include: Paralysis or weakness on one side of the body Facial droop on one side Altered level of consciousness (from confusion to unconsciousness) Change in personality or mood Headache or dizziness Impaired speech

39. Copyright 2009 Seattle/King County EMS Summary, continued The three tests of the Cincinnati Prehospital Stroke Scale are facial droop, arm drift and speech. Determine time of onset of symptoms. This helps determine if a patient meets the three-hour window for clot-busting therapy. Short scene and transport times are vital.