Pre- hospital stroke care presentation to EMS 2012

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Acute Stroke - the role of EMS
Diane Handler, RN, MSN, MeD, ANVP
Stroke Coordinator
Mercy Medical Center, Cedar Rapids. Iowa
[email protected]
The Facts
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Stroke is an emergency
Stroke is treatable
Stroke occurs at all ages!
1.9 million brain cells die/minute
Objectives
 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 #
 OVER TRIAGE -30%
Cincinnati Stroke Scale
 Arm drift
 slurred speech
 facial droop
 If one is positive = consider stroke
Your Role
 History – and why
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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
Treatment
 What is tPA? (tissue plasminogen activator)
 Approved for stroke in 1996
 Enzyme that activates the clot busting system in the
body
Deadlines
 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
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Too late to ED
On Coumadin and INR >1.7
Symptoms rapidly resolving
Recent trauma, MI or stroke
Outcomes
 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
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
droop
 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
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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
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Hypertension
High cholesterol
Diabetes
Smoking
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,
anemia
Atypical Stroke
 43 yo male, unresponsive
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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
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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
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
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
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.
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 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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