Pre- hospital stroke care presentation to EMS 2012

Acute Stroke - the role of EMS
Diane Handler, RN, MSN, MeD, ANVP
Stroke Coordinator
Mercy Medical Center, Cedar Rapids. Iowa
[email protected]
The Facts
Stroke is an emergency
Stroke is treatable
Stroke occurs at all ages!
1.9 million brain cells die/minute
 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.
More Facts
 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
EMS Role
 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 #
Cincinnati Stroke Scale
 Arm drift
 slurred speech
 facial droop
 If one is positive = consider stroke
Your Role
 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…
Acute Stroke Treatment
 What is tPA? (tissue plasminogen activator)
 Approved for stroke in 1996
 Enzyme that activates the clot busting system in the
 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 Intraarterial tPA
Why no tPA
Too late to ED
On Coumadin and INR >1.7
Symptoms rapidly resolving
Recent trauma, MI or stroke
 NINDS tPA Trial
 30% more likely to have minimal or no disability at 3
 6% risk of symptomatic bleeding with tPA
 17% mortality with tPA and 21% with placebo group
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
Your Role
 History
 EMS straight to CT
Why CT fast and first
Typical Stroke
 What does a typical stroke look like?
Typical Stroke…
 Weakness on Left or Right side and may have facial
 Visual gaze deviation
 Inability to speak and or confused
Left Hemisphere Stroke
Left hemisphere stroke
 R side weakness
 R facial droop
 Speech affected- receptive or expressive
Right hemisphere stroke
 L side weakness
 L facial droop
 Impaired decision making
Right hemisphere “Typical Stroke”
 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
Why did I have a stroke?
Another typical stroke type
 Small vessel disease
High cholesterol
Sedentary life style
“Zebra” Strokes
 Cerebellum
 Loss of balance
 Brain Stem
 Loss of consciousness
 Occipital Lobes
 Visual changes
Less typical Stroke
 38 yo female from Micronesia
 Symptom onset 0445 headache and dizziness, LOB
 Posterior circulation Cerebellum stroke
 Cause of stroke? Associated problems- heart disease,
Atypical Stroke
 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)
Brainstem Stroke
Nausea and vomiting
Gaze palsy
Swallow difficulty, slurred speech
Hemiparesis or quadriplegia and sensory loss
Decreased level of consciousness
Cranial Nerves
Less typical Stroke
 82 yo male
 Sensory loss on left
 Visual field cut
 Weakness on the left
 R Occipital Lobe Stroke
Stroke Mimics
 36 yo female- headache
 migraine
 47 yo female- weak R arm + leg, headache, chest
 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
Other mimics
 Seizures with todds paresis
 Tumor
*Call Stroke Alert in any caseover triage by 30% is expected
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
 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.
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
 Disposition of patient -To ICC then Cardiac Stroke
 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 cardioembolism from the A Fib. Started on Coumadin and will
watch in new living area to prevent falls.
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 with
no prior history of stroke and diabetes, IV tPA can be
given up to 4 ½ hours of symptom onset. Patients who
are > 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.
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.
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?
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