1. PRIMARY STROKE CENTER First Responder Update 2009

2. 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

3. 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

4. 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

5. Stroke Classification

6. 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

7. 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

8. 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

9. Ischemic Penumbra

12. Hemorrhagic Stroke Intracerebral Hemorrhage

14. Hemorrhagic Stroke Subarachnoid Hemorrhage

16. Risk Factors for Stroke
Uncontrollable
Controllable
Lifestyle Modification

17. Risk Factors
Uncontrollable
Age
Sex
Race
Prior stroke
Family history

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

19. Lifestyle Modifications
Smoking
Alcohol
Weight / Inactivity

20. Medical Management Antiplatelets Statins Diabetic meds
Antihypertensives
Anti-arrhythmia meds

21. Surgical Management
Carotid endarterectomy
Angioplasty
Stenting

22. 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

23. 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

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

25. 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

26. Cerebral Blood Flow

27. Neuroanatomical Effects
Right hemisphere
Left hemisphere
Cerebellum
Brain stem

28. 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

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

30. Cerebellar Stroke Reflexes Balance and coordination Dizziness
Nausea and vomiting

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

32. Other Effects of Stroke
Environmental adaptations
Depression
Changes in relationships .

33. 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

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

35. 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.

36. 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

37. 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%

38. 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

39. 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

40. 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

41. Cincinnati Stroke Scale Time
Time Last Seen Normal
Time Symptoms Identified

42. 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

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

44. 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.

45. 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

46. 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

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

48. Hemorrhagic Stroke Treatment
Lifesaving measures
Relief of symptoms
Repair the cause

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

50. QUESTIONS?