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Notes
The following presentation is taken
from the American Heart
Association’s Advanced Cardiac
Life Support : Principles and
Practice, Chapter 18, Acute
Stroke: Current Treatments and
Paradigms
Please use this publication as a
reference.
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Special Thanks To:
• ASA Operation Stroke
EMS Committee
Volunteers including:
• Bruce Barnhart, Chair
• Amy Boise, Vice Chair
• Nancy Parks, RN
• Charlann Staab, RN
• Linda Meiner, RN
• Mike Baros, RN
• Terry Mason, RN
• Don Baird, RN
• Sandy Nygard, CEP
• AEMS, Inc.
Robert Londeree, M.D.
• Phoenix Fire Department
John Gallagher, M.D.
• Air-Evac Services, Inc.
• Professional Medical
Transport (PMT)
• Cigna Healthcare
• Halle Heart Center
• Dave Heath
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Stroke
An Educational Program
for
Pre-Hospital Personnel
Developed by:
EMS Committee
Operation Stroke – American Stroke Association
Phoenix, Arizona
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Stroke Overview
Introduction, Definition, Types and Risks
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How Serious Is Stroke in the
US?
• About 700,000 strokes occur each
year.
• Over 167,000 deaths each year.
• #3 killer.
• A leading cause of serious long-term
disability in adults.
• 4.7 million stroke survivors.
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Introduction
New emerging therapies offer hope,
however the following MUST occur:
•
•
•
•
Education of at-risk patients.
Early recognition of stroke signs.
Prompt transport to the hospital.
Rapid hospital triage and evaluation.
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Introduction
With rapid, aggressive
prehospital stroke
care, at-risk patients
can be appropriately
managed and quickly
assessed for
fibrinolytic therapy
that may significantly
improve their outcome.
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Definition of Stroke
A stroke is a neurological impairment
caused by a disruption in blood supply
to a region of the brain.
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Classification of Stroke
Two major categories:
• Ischemic strokes, caused when a blood
vessel supplying the brain is occluded by a
clot. Responsible for 75% of all strokes.
• Hemorrhagic strokes, caused when a
cerebral artery ruptures.
Both forms are life threatening.
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Hemorrhagic Stroke
• Hypertension is the
most common
cause of
intracerebral
hemorrhage.
• Other causes:
Aneurysms and
Arteriovenous
malformations.
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Risk Factors for Stroke
Although some strokes occur without
warning, most stroke victims have
prior risk factors.
Major strokes can be prevented in
many cases, but only if early signs and
symptoms are heeded.
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Well-Documented
Modifiable Risk Factors
• Hypertension
• Atrial Fibrillation
• Smoking
• Hyperlipidemia
• Diabetes
• Sickle Cell Disease
• Asymptomatic
• Other cardiac
Carotid Stenosis
diseases
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Goldstein et al. Circulation. 2001:103:163
Less Well Documented
Potentially Modifiable Risk
Factors
• Obesity
• Hypercoagulability
• Physical Inactivity
• Hormone Replacement
• Poor Diet/Nutrition
• Alcohol Abuse
• Drug Abuse
Goldstein et al. Circulation. 2001:103:163
Therapy
• Oral Contraceptive Use
• Inflammatory Process
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Non-modifiable Risk Factors
•
•
•
•
Age
Sex
Race/Ethnicity
Family History
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Stroke Diagnosis
Signs and Symptoms of Stroke
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Signs and Symptoms of
Stroke
Consider in anyone
who has:
• Sudden numbness or
weakness of face, arm,
or leg, especially on one
side of the body
• Sudden confusion,
trouble speaking or
understanding
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Signs and Symptoms of
Stroke
• Sudden trouble seeing
in one or both eyes
• Sudden trouble walking,
dizziness, loss of
balance or coordination
• Sudden severe
headache with no
known cause
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Signs and Symptoms of
Stroke
THIS IS A LIFE THREATENING EMERGENCY!
Emergency healthcare providers must:
• Recognize the importance of these symptoms.
• Respond quickly with medical and / or surgical
interventions.
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Stroke Signs and Symptoms:
Hemorrhagic Stroke
May present similar to
Ischemic stroke.
Distinguishing Features:
•
•
•
•
•
•
•
Appear more seriously ill
Deteriorate more rapidly
Severe headache
Alteration in consciousness
Nausea and/or vomiting
Neck pain
Intolerance of noise or light
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Transient Ischemic Attack
“Temporary” or “mini” stroke.
• The signs and symptoms of a TIA are
similar to those of a completed stroke;
however, they typically last only a few
minutes to several hours before
resolving.
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Transient Ischemic Attack
• TIA is the most
important
forecaster of
impending stroke.
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Stroke Patient Management
The Stroke Chain of Survival and
Recovery
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Seven Step Stroke Chain of
Survival and Recovery
Pre-arrival:
1. Detection
2. Dispatch
3. Delivery
Post-arrival:
4. Door
5. Data
6. Decision
7. Drug
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1. Detection: Early Recognition
• Early treatment of stroke depends on
the victim, family members, or other
bystanders detecting the event.
• Mild signs or symptoms may go
unnoticed or be denied by the patient
or bystander.
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2. Dispatch: Early EMS Activation
and Dispatch Instructions
• Stroke victims and their families must
be taught to activate the EMS system
as soon as they detect stroke signs or
symptoms.
• EMS dispatchers must appropriately
prioritize the call to ensure a rapid
response within the EMS system.
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3. Delivery: Pre-hospital Transport
and Management
•
•
•
•
The goals :
Rapid identification of the stroke
Support of vital functions
Rapid transport of the victim to the
receiving facility
Pre-arrival notification of the
receiving facility
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3. Delivery: Pre-hospital Transport
and Management
The Cincinnati Pre-hospital Stroke Scale
1. Facial Droop (have patient show teeth or
smile):
Normal - Both sides of face move
equally well.
Abnormal - One side of face does not
move as well as the other side.
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3. Delivery: Pre-hospital Transport
and Management
The Cincinnati Pre-hospital Stroke Scale
2. Arm Drift (patient closes eyes and holds both
arms out):
Normal - Both arms move the same or both
arms do not move at all (other findings,
such as pronator grip, may be helpful).
Abnormal - One arm does not move or one
arm drifts down compared with the other.
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3. Delivery: Pre-hospital Transport
and Management
The Cincinnati Pre-hospital Stroke Scale
3. 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
inappropriate words, or is unable to speak.
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3. Delivery: Pre-hospital Transport
and Management
• The presence of acute stroke is an indication
for "load and go“.
• Establish the time of onset of stroke signs
and symptoms!
• This timing will have important implications
for potential therapy. If the time of onset of
symptoms is viewed as time "zero," all
assessments and therapies can be related to
that time.
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3. Delivery: Pre-hospital Transport
and Management
Once stroke is diagnosed, pre-hospital
treatment includes management of
the ABCs of critical care (Airway,
Breathing, and Circulation) and close
monitoring of vital signs.
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3. Delivery: Pre-hospital Transport
and Management
Airway:
• Paralysis of the muscles of the throat,
tongue, or mouth can lead to partial or
complete upper-airway obstruction.
• Saliva pools or vomit may be
aspirated.
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3. Delivery: Pre-hospital Transport
and Management
Breathing:
• Breathing abnormalities are
uncommon, except in patients with
severe stroke, and rescue breathing is
seldom needed.
• Abnormal respirations, however, are
prominent in comatose patients and
portend serious brain injury.
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3. Delivery: Pre-hospital Transport
and Management
Circulation:
• Monitor both blood
pressure and cardiac
rhythm as part of the
early assessment and
treatment of a stroke
patient.
• Hypotension or shock is
rarely due to stroke, so
other causes should be
sought.
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3. Delivery: Pre-hospital Transport
and Management
Circulation:
• Hypertension is often present in
stroke patients, but it typically
subsides and does not require
treatment.
• Treatment of hypertension in the field
is not recommended!
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3. Delivery: Pre-hospital Transport
and Management
Other Supportive Measures:
• Intravenous access.
• Management of seizures, and diagnosis and
treatment of hypoglycemia, can be initiated
en route to the hospital if necessary.
• Isotonic fluids (Normal Saline or Lactated
Ringer's solution) are used for intravenous
therapy; hypotonic fluids are
contraindicated.
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3. Delivery: Pre-hospital Transport
and Management
Early Notification:
• Early notification
enables personnel to
prepare for the
imminent arrival of any
seriously ill or injured
patient.
• In many hospitals this
notification shortens the
time to evaluation of,
and critical interventions
for, stroke patients.
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4. Door: Emergency Department
Triage
Even if a potential stroke victim
arrives in the emergency department
in a timely fashion, too often hours
may elapse before appropriate
neurological consultation and
diagnostic studies are performed.
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5. Data: Emergency Evaluation and
Management
ABCs should be
reassessed and
rechecked
frequently.
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5. Data: Emergency Evaluation and
Management
1.
2.
3.
4.
An emergency neurological
stroke assessment should
be done quickly focusing
on four key issues:
Level of consciousness
Type of stroke
(hemorrhagic versus
nonhemorrhagic)
Location of stroke (carotid
versus vertebrobasilar)
Severity of stroke
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5. Data: Emergency Evaluation and
Management
• Obtaining the exact time of stroke or
onset of symptoms from family or
people at the scene is critical.
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Emergency Diagnostic
Studies
•
Currently, CT is the single most
important diagnostic test.
•
Goal: CT scan obtained and read
within 45 minutes of the stroke
victim's arrival at the emergency
department.
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Emergency Diagnostic
Studies
• Anticoagulants
and fibrinolytic
agents should be
withheld until CT
has ruled out a
brain
hemorrhage.
Hemorrhagic Stroke
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Differential Diagnosis:
•
•
•
•
•
•
•
Unrecognized seizures
Confusional states
Syncope
Toxic or metabolic disorders
Hypoglycemia
Brain tumors
Subdural hematoma
Adams et al. Stroke. 2003;34:1056
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6. Decision: Specific Stroke
Therapies
•
•
•
•
•
General care includes, but is not
limited to:
Prevention of aspiration
Management of hypertension
Management of hyper/hypo-glycemia
Management of seizures
Management of intra-cranial pressure
(ICP)
Acute Stroke, 2003 American Heart Association
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7. Drugs: Fibrinolytic Therapy for
Ischemic Stroke
• Intravenous tPA represents the first FDAapproved therapy for acute ischemic stroke.
• In the NINDS trial, patients treated with tPA
within 3 hours of onset of symptoms were at
least 30% more likely to have minimal or no
disability at 3 months compared with those
treated with placebo.
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7. Drugs: Fibrinolytic Therapy for
Ischemic Stroke
• However, there were 10-fold increases in the
risk of fatal intracranial hemorrhage in the
treated group (3% vs 0.3%) and the frequency
of all symptomatic hemorrhage (6.4% vs.
0.6%).
• This increase in symptomatic hemorrhage did
not lead to an overall increase in mortality in the
treated group.
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7. Drugs: Fibrinolytic Therapy for
Ischemic Stroke
Careful patient selection and strict
adherence to the treatment protocol
are essential!
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7. Drugs: Fibrinolytic Therapy for
Ischemic Stroke
Because of the time criteria and risk
associated with fibrinolytic therapy, it
is important for hospitals to develop
specific strategies and protocols that
will achieve rapid initiation of therapy.
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NINDS-Recommended Stroke Evaluation
Targets for Potential Fibrinolytic
Candidates*
Time Target
Door to doctor
10 minutes
Door to CT† completion
25 minutes
Door to CT read
45 minutes
Door to treatment
60 minutes
Access to neurological expertise‡
15 minutes
Access to neurosurgical expertise‡
2 hours
Admit to monitored bed
3 hours
*Target times will not be achieved in all cases, but they represent a reasonable goal.
†CT indicates computed tomography.
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‡By phone or in person.
Management of Hemorrhagic
Stroke
Optimal management:
• Prevention of continued bleeding.
• Appropriate management of ICP.
• Timely neurosurgical decompression
when warranted.
Large intracerebral or cerebellar
hematomas often require surgical
intervention.
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Summary: Pre-hospital Critical
Actions and Management
This is what should happen:





Recognize the signs of stroke and TIA
Rapid neuro exam (Cincinnati Stroke Scale
or similar).
Determine time of symptom onset (if
possible).
Provide rapid transport to an ED capable of
caring for acute stroke (pre-notify).
Perform finger-stick to assess serum
glucose levels.
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Summary: Pre-hospital
UNACCEPTABLE Actions
• Failure to recognize signs and
symptoms of stroke/TIA
• Failure to attempt to determine
symptom onset.
• Delay in transport.
• Transporting a potential stroke
patient to an ED not capable of
treating acute ischemic stroke
with fibrinolytic therapy.
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Summary: Pre-hospital
UNACCEPTABLE Actions
• Attempts to treat hypertension in
the field.
• Failure to notify receiving ED.
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Conclusion:
Now, fibrinolytic and other emerging
therapies offer practitioners the
opportunity to limit neurological insult
and improve outcome in stroke
patients.
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Conclusion:
The challenge with these therapies is
that they require administration
within hours of stroke onset, making
the following measures imperative:
•
•
•
•
Education of at-risk patients
Early recognition of stroke signs
Prompt transport to the hospital
Rapid hospital triage and evaluation
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