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 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 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 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 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 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 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 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?