At the end of this participant you will be able to:
 Know the differences between ischemic and
hemorrhagic stroke
 Recognize signs and symptoms of stroke
 Be able to use the
› Cincinnati Prehospital Stroke Scale
 Discuss major principles of prehospital
assessment and treatment for acute stroke
 Appreciate importance of rapid transport to
Accredited Stroke Center
2





Appreciate importance of notifying ED
before arrival (Calling Stroke Alert)
Discuss major principles of ED stroke care
Importance of rapid triage and early CT for
stroke victims
Understand the potential use of
thrombolytics (IV-tPA) for selected patients
with acute ischemic stroke
Appreciate importance of rapid transport
from an ED to an Accredited Stroke Center
3





Use of National Institutes of Health Stroke
Scale (NIHSS)
Guidelines for managing hypertension in
stroke patients
Clinical differences between ischemic and
hemorrhagic stroke
Treatment differences between ischemic
and
hemorrhagic stroke
Appreciate importance of rapid transport
from an ED to an Accredited Stroke Center
4
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





According to the American Heart Association stroke is the
third leading cause of death in U.S. and leading cause of
disability
Approximately 700,000 people each year will suffer from a
stroke, either for the first time or with a history of stroke; Of
those patients, approximately 158,000 will die as a
consequence of the stroke.
One-third of strokes occur in patients younger than 65 years.
Men are at higher risk than women.
About 85% of strokes are ischemic in nature
About 15% of strokes are hemorrhagic in nature
EMS plays a large role as early recognition and treatment.
This is key in reducing the mortality rates from strokes.

A stroke or Cerebral Vascular Accident (CVA)
or “Brain Attack” is a neurologic deficit that
causes a change in the patient’s ability to
speak, feel, or move.

When these changes are noted, the EMT should
recognize that something has affected the
patient’s central nervous system.

This could be a medical or traumatic cause
This power point will be limited to the presentation
of a nontraumatic brain injury, or stroke.

Stroke
› The symptoms that the
patient presents with is a
reflection of the area of
the brain that has had a
disruption of blood flow.
› Most commonly, strokes
affect the regions of the
brain that control speech,
sensation, and muscle
function.
› Paralysis, facial droop,
monoplegia, hemiplegia,
and speech disturbances
are common findings.
Stroke is classified as hemorrhagic or
ischemic and further subdivided by
etiology
 Ischemic stroke

› Embolic
› Thrombotic
› Hypoperfusion

Hemorrhagic stroke
› Intracerebral hemorrhage
› Nontraumatic subarachnoid
hemorrhage
Ischemic Stroke – This type of stroke is caused by a
sudden occlusion of a blood vessel in the brain, a
similar mechanism that is seen with a heart attack.
Hemorrhagic Stroke – This type of stroke occurs when a
blood vessel in the brain bursts and allows blood to
collect in or around the brain tissue.
In either instance, it is the lack of blood flow and
oxygen that causes the dysfunction in the brain,
and the accompanying signs and symptoms.
› Nausea/vomiting
› Dizziness, weakness
› Headache
› Impaired vision
› Vertigo, tinnitus
› Difficulty speaking,
swallowing
› Abnormal gait,
weak extremities
› Hemiparesis,
quadriparesis
› Sensory loss, seizures
› Pupil abnormalities




Dilated
Constricted
Unreactive
Sluggish
“Hey you …..
Don’t spend a lot of time to
determine the specific cause!
Do Prehospital Clinical Assessment

Cincinnati Prehospital Stroke Scale
(CPSS)
› Assess for
 Facial droop
 Arm drift
 Abnormal speech
Assess
 Facial droop
(have patient smile)
 Normal: Both sides of
the face move equally
 Abnormal: One side of
face does not move
as well
Assess
 Arm drift
(have patient hold arms out
for 10 seconds)
 Normal: Both arms move
equally or not at all
 Abnormal: One arm drifts
compared to the other,
or does not move at all
Assess
 Abnormal speech
(Have the Pt. say)
“you can’t teach an old dog new
tricks”
 Normal: Patient uses correct
words with no slurring
 Abnormal: Slurred or
inappropriate words, or mute
If positive on one or all of the three tests
Transport to the closest
Accredited Stroke Center
and call a
STROKE ALERT

CHRISTUS Spohn Shoreline1-361-881-3811
600 Elizabeth St. Corpus Christi, Tx

CCMC Doctors Regional 1-361-761-1467
3315 S. Alameda Corpus Christi, TX

CCMC Bay Area
1-361- 761-3637
7101 S. Padre Island Dr. Corpus Christi, Tx
Time = Brain!
Assessment and Treatment
of a stroke patient by EMS
can make a difference!
Scene evaluation
 Initial assessment
 Focused History
“SAMPLE history/Vital signs/Check the
blood glucose level”
 Detailed Physical examination (as
needed)
 Ongoing Assessment
 Treatment


Assessment: Scene Size-Up
› Dispatch information may alert you to this
›
›
›
›
emergency if there is knowledge of
neurological deficits or altered mental status.
Look for evidence of trauma, drug use, or
alcohol.
The patient’s clothing may indicate
approximately when the symptoms started.
Call for backup if extrication from the
residence will be difficult.
Remember to take BSI precautions.

Assessment: Initial Assessment
› Establish mental status level (AVPU).
› In-line immobilization if trauma is suspected or I
›
›
›
›
is unknown.
Open the airway manually if needed, and provide
oropharyngeal suctioning of secretions as necessary.
Assess breathing adequacy, being particularly
attentive for inadequate breathing as evidenced by
an abnormal rate, regularity, or depth.
Determine quality of pulses and perfusion.
Assign patient priority status.
Airway
› Ensure an open airway
 Breathing
› Present
› Rate, depth, and adequacy of respirations
 Circulation
› Check pulse
 Disability
› Are circulation, sensation, and motor function
intact in all extremities?
› What is the patient’s mental status?
 Can the patient answer questions
appropriately?
› GCS score


SAMPLE history, continued
› OPQRST
 Onset
 Provocation/palliative measures
 Quality
 Region/Radiation
 Severity
 Time
 Associated Symptoms
 Pertinent Negatives

Assessment: SAMPLE History
› Along with the normal SAMPLE questions, consider the
following:
 When did the symptoms begin?
 Is there any recent history of trauma to the head?
 Does the patient have a history of strokes?
 Was there any known seizure activity prior to
arrival?
 What was the patient doing at symptom onset?
 Is there a history of possible diabetes?
 Any history or presence of a stiff neck or
headache?
 Any dizziness, nausea, vomiting, or weakness?
 Has the patient experienced any slurred speech?

SAMPLE history
› Past medical history of interest
 Hypertension
 Hypercholesterolemia
 Coronary artery disease
 Diabetes
 Atrial fibrillation, valve replacement, recent
acute myocardial infarction (AMI)
 History of smoking
 Transient ischemic attack (TIA)
Do not assume that a patient is unconscious or has an
altered mental status simply because he or she does
not respond to your questions.

Assessment: Detailed Physical Exam
› Do not delay transport to obtain a physical
exam.
› Sensory and motor function should be assessed
in all extremities.
› Document and report any alterations from
earlier assessment findings, to include the
patient’s mental status, speech, sensory
capabilities, and motor function.

Assessment: Ongoing Assessment
› Perform an ongoing assessment every 5
minutes.
› Stroke patients deteriorate rapidly, watch for
airway, breathing, circulation, and mental
status changes.
› Repeat and record the baseline vital signs.
› Communicate any changes in the patient’s
condition to the receiving medical facility.
Maintain the ABC
 Place in recovery position
 Have suction available
 Treat underline cause
 Ongoing assessment



Maintain scene and personal safety
Support airway, breathing, circulation
› Consider need for BLS/ALS airway.
 Oropharyngeal (OPA), nasopharygeal (NPA)
 Endotracheal intubation

Ensure adequate ventilation.
› BVM ventilation if needed
› Oxygen 2-4 lpm/NC or 15 lpm/NRB
› Monitor oxygen saturation with pulse oximetry
keeping Spo2 >92%
 Continuous
 Cardiac
stroke.
Cardiac Monitoring/12 lead ECG
dysrhythmia and AMI can occur with

IV Access x 2 of NS/LR (This should not delay transport)
› Administer fluids, if patient is hypotensive.
 Note: Over administration of IV fluids can create or
worsen existing cerebral edema.

Blood Glucose Level
› Correct hypoglycemia with glucose administration.
› DO NOT administer glucose if hypoglycemia is not
identified.


Monitor V/S every 5 minutes.
Keep patient warm.

Elevate head, if no hypotension.
› If high BP SYS >200 or DIAS >110 treat with LABETALOL
10 mg IV over 1–2 min may repeat q 10 min to max
300mg
› Nitroglycerin may be used (Check with your Protocol)

EMS Treatment Guidelines
› Follow the CBRAC 2010 Stroke Algorithm

Place patient in position of comfort.
› Protect paralyzed extremities since the patient cannot
move the extremity, ensure that it is protected from
injury.


Reassure patient.
Rapid transport to an Accredited Stroke Center
EMS Treatment
Guidelines:
CBRAC 2010
Stroke Algorithm
CBRAC STROKE ALGORITHM
These are guidelines; they do not supersede the Medical Directors order set.
Critical EMS Assessment and Actions
Support ABCs
Oxygen 2-3 L NP or 15L NRB keep spo2 >92%
Perform Prehospital Stroke Assessment
Early Notification to Stroke Center
Establish SYMPTOM ONSET
< 4.0 hours
RAPID TRANSPORT TO THE APPROPRIATE FACILITY
ACTIVATE/Transport closest Accredited Stroke Center if <30 minutes by ground
or air transport; CALL STROKE ALERT
CHRISTUS Spohn Shoreline 1.361.881.3811 CCMC Bay Area 1.361.761.3637
CCMC Doctor’s Regional 1.361.761.1467
ACTIVATE/Transport closest facility capable of treating stroke with t-PA if >30 minutes
HALO Flight (Corpus Christi) 1.800.776.4256 AirLIFE (San Antonio) 1.210.233.5800
PHI (Victoria) 1.877.435.9744 Valley Air (Harlingen) 1.800.679.0911
In Transit:
Continuous Cardiac Monitoring
Blood Glucose Level
IV Access x2 (Should not delay transport)
CINCINNATI PREHOSPITAL STROKE SCALE
Facial Droop/Smile Normal Abnormal
Arm Drift Normal Abnormal
Speech
Say “you can’t teach an old dog new tricks”
Normal
Abnormal
TX for H-BP for SYS >200 or DIAS >110
LABETALOL 10 mg IV over 1–2 min
may repeat q 10 min to max 300mg
Time = Brain!
Transport to and Treatment at
an established Stroke Center
can make a difference in pt outcome!


Decision Criteria: The bypass protocol is intended
to ensure that patients with a witnessed acute
stroke be transported to an accredited stroke
center.
Exceptions to the bypass protocol requiring the
patient to be transported to the NEAREST facility
are:
› Inability to establish and/or maintain an airway or in
the event of a cardiac arrest.
› If transport time to the indicated accredited stroke
center exceeds 30 minutes; the patient should be
transported to the nearest facility capable of
treating stroke with Activase (t-PA) if indicated, then
transferred to an accredited stroke facility.
The activation of the Bypass Protocol for
the symptomatic acute stroke patient
should be initiated upon the recognition
of confirmed witnessed changes in patient
condition as to “Last Known Well” in less
than 4 hours.
 If “Last Known Well” temporarily unknown
due to patients inability to talk or the lack
of a witness, transport to an accredited
stroke center and activate a stroke alert.

Hand off of the acute stroke patient to advanced life
support “Mobile Intensive Care Unit” or Air Transport
will be initiated in the following circumstances:
 Basic life support unit is first responder only and/or
unable to leave service area
 If air transport/pick-up total time is less than ground
transport time.
HALO Flight (Corpus Christi) 1-800-776-4256
AirLIFE (San Antonio) 1-210-233-5800
PHI (Victoria) 1-877-435-9744
Valley Air (Harlingen) 1-800-679-0911
If >30 minutes by ground to an accredited
stroke center or no air medical then
transport to the closest facility capable of
treating stroke pts. with (t-PA)
Continue airway maintenance and
administration of supplemental
oxygen.
 Obtain IV access if not done
prehospital

› Central venous catheter
Blood glucose determination
 Cardiac monitoring, 12-Lead ECG
 Foley catheter


Lab studies
› Complete blood count (CBC) with
platelet count
› Coagulation profile
› Serum glucose
› Electrolytes, cardiac enzymes

NIH Stroke Scale

Imaging studies
› Noncontrast CT of the brain
 Differentiates between hemorrhagic and
ischemic stroke
› Chest X-Ray

Treatment for ischemic stroke may
include
› Anticoagulants
› Antiplatelet agents
› Fibrinolytics
 Recombinant tissue-type plasminogen
activator (rtPA)

Patients with ischemic stroke and
hypertension may receive
›
›
›
›
Labetalol
Enalaprilat
Nicardipine
Nitroglycerin

Treatment of intracerebral
hemorrhage
› Severe hypertension (MAP >130 mmHg)
may be treated.




Labetalol
Enalapril
Nicardipine
Nitroprusside
› Increased ICP treated with
 Hyperventilation
 Mannitol, furosemide
› Surgical intervention dependent on
patient neurological status plus size and
location of hemorrhage

Treatment of subarachnoid
hemorrhage
› Head elevated to 30 degrees
› Maintenance of blood pressure to
prehemorrhagic levels
› Seizure prophylaxis
› Ventriculostomy
› Surgical clipping of ruptured aneurysm




Door to Triage by Doctor – 10 minutes
Door to CT Scan – 25 minutes
Door to CT Read/Lab Results – 45 minutes
Door to (t-PA) – 60 minutes

Inclusion criteria
› Older than 18 years
› Clinical diagnosis of ischemic stroke
› Time of onset well established to be less
than four hours

Exclusion criteria
› Past medical history of
 Intracranial hemorrhage, aneurysm, or
arteriovenous malformation
 Internal bleeding within preceding 21 days
 Head trauma, intracranial surgery, CVA
within past three months
› Warnings:
 Major surgery within past 14 days
 Recent myocardial infarction
 Lumbar puncture within past seven days
 Recent arterial puncture

Exclusion criteria
› Known bleeding disorder
 Platelet count <100,000/mm3
 Current use of oral anticoagulants and/or
prothrombin time (PT) >15 seconds
 Heparin used in past 48 hours and/or
elevated partial thromboplastin time (PTT)
› Evidence of intracranial hemorrhage on
noncontrast CT scan
› High clinical suspicion of SAH even with
normal CT scan
(If all exclusion criteria “NO” the patient is a
potential candidate for IV-tPA)
“Hey you …..
Some exclusion criteria are
“warnings”
Any EXCLUSION will be done by the
NEUROLOGIST”







All post t-PA patients should be sent by Critical Care
Transport (MICU)
Document vital signs prior to transport and verify
that SBP <180, DBP <100. If BP above limits, sending
hospital should stabilize prior to transport
Obtain contact method for family or caregiver
(preferably cell phone) to allow contact during
transport or upon patient arrival
Obtain and record Vitals Signs and Neurological
checks (CPSS) every 15 minutes
Perform and record baseline GCS
Continuous cardiac monitoring/12 Leads
Strict NPO – this includes all PO medications
Verify total dose and time of IV t-PA bolus (if t-PA is
completed prior to transfer)
 If IV t-PA dose administration will continue en route:
 Verify estimated time of completion.
 Verify with the sending hospital that the excess
t- PA has been withdrawn and discarded (for
example, if the total dose of t-PA to be given is
70mg, then verify the remaining 30cc has been
wasted since a 100mg bottle of t-PA contains 100cc
of fluid)

If SBP >180 or DBP >100, and if antihypertensive medication
started at sending facility, then adjust as follows:

If Labetalol IV drip started at the sending hospital,
increase by 2mg/min every 10 minutes (to a maximum
of 5mg/min) until SBP <180 and DBP <100; If SBP <150 or
DBP <80 or HR <60, turn off drip and call receiving
hospital for further instructions.

If Nicardipine IV drip was started at the sending hospital,
may increase dose by 2.5mg/hr every 5 minutes. To a
maximum of 15mg/hr until SBP <180 and DBP <100; If SBP
<150 or DBP <80 or HR <60, turn off drip and call
receiving hospital for further instructions.
For any acute worsening of neurologic condition, or
if patient develops severe headache, acute
hypertension or vomiting (suggestive of
intracerebral hemorrhage) or profuse bleeding
not controlled by pressure:
1. Discontinue t-PA infusion (if still being administered)
2. Call receiving facility for further instructions including
decision to adjust blood pressure medication and/or divert
to nearest hospital.
3. Continue to monitor vitals and neuro checks every 5 mins.
Rapid Assessment, Management and Transport
by EMS to an Accredited Stroke Center
can help reduce mortality and morbidity,
and produce maximal potential for
rehabilitation and recovery.







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