Stroke Management for the
EMS Provider
Alameda County Educational Module
Brenda Krokoski RN (Alta Bates/Summit Stroke Center)
Douglas Van Houten RN (Washington Hospital Stroke Center)
Stroke Management for the
EMS Provider
At the completion of this module, the EMS
Provider will be able to:
Describe
the various types of stroke and their etiology.
Discuss
the imperatives for best practice in regard to EMS stroke
management.
List
5 or more risk factors for acute stroke.
Define
“penumbra” and how this concept is important in stroke.
Generally
Discuss
Identify
describe the major vessels involved in acute ischemic stroke.
the “therapeutic window” for thrombolytic therapy in stroke.
interventions that individual EMS providers can make to
improve outcomes in stroke.
Stroke Management for the EMS
Provider

Instructions:


Page through the module to learn the content.
Complete the post test.
Is STROKE a health problem in the US today?

700,000 strokes every year
• Stroke is the 3rd leading cause of death
• One person dies of stroke every 3 minutes
• Stroke is the leading cause of serious, long
term disability
• 5 million stroke survivors, but with
substantial morbidity:
• 18% unable to return to work
• 4% require total custodial care
Is STROKE a health problem in the US today?

Only 50-70% of stroke survivors regain
functional independence
• 20% are institutionalized within 3 months
• 22% of men & 25% of women die
within 1 year of their first stroke
• Locally, African-Americans have 50%
more strokes than Caucasians, and
twice as many as Asians and Hispanics
(Statistics from the American Stroke Association)
African Americans & Stroke

Incidence is nearly double that of white Americans

Suffer more extensive physical impairments

Twice as likely to die from stroke

High incidence of risk factors for stroke
•hypertension
•diabetes
•obesity
•smoking
•sickle cell anemia
(National Stroke Association)
Women & Stroke

Stroke kills more than twice as many American
women every year as breast cancer

More women than men die from stroke

Women over age 30 who smoke and take highestrogen oral contraceptives have a stroke risk
22 times higher than average
(National Stroke Association)
How Bad is a Major Stroke?
Elders at Risk for Stroke (1183, TTO), --Samsa et al, Am Heart J 1998
P
e
r
c
e
n
t
50
45
40
35
30
25
20
15
10
5
0
Worse than death
Equivalent to being well
Equivalent to death
Is STROKE a health problem in the
US today?



YES, stroke is a major health problem in
the US today.
EMS Providers are closely involved with this patient
population and are a vital component of the “Stroke
Chain of Survival”.
Increased knowledge and personal motivation on the
part of EMS providers can:



Greatly reduce death and disability due to stroke.
Improve stroke centers’ ability to provide thrombolytic therapy.
Make a positive impact on communities’ strides to reduce costs
for healthcare and improve outcomes.
Goals for EMS Provider Care of
Stroke Patients
1.
2.
3.
4.
5.
Improve knowledge of identification of stroke
signs and symptoms.
Develop a rapid assessment process.
Facilitate transfer of stroke victims to Primary
Stroke Centers in the quickest and safest
manner.
Pre-notify the Stroke Center, “Possible acute
stroke in route.”
Encourage family members familiar with the
patient care to either ride with the transfer
vehicle or drive to the stroke center ASAP to
provide more patient information.
Goals for EMS Provider Care of
Stroke Patients
6.
7.
8.
9.
10.
Obtain reliable list of meds taken or bring bag of all
medications taken.
Obtain a set of vital signs and finger stick blood sugar
at the site.
Reliably identify family’s best estimation of when the
patient was “last seen normal”.
Administer the Cincinnati Pre-hospital Stroke Scale.
Provide the receiving facility with a quick, complete
verbal report that incorporates the information
obtained since arrival on scene.
Review: Anatomy & Physiology of
Acute Ischemic Stroke






What is acute ischemic stroke?
What is the major vasculature involved?
When circulation is suddenly reduced, how
quickly is brain tissue affected?
What is “penumbra”?
What are the types and etiologies of stroke?
What about different stroke symptoms?
What Is Stroke ?
A stroke occurs when blood flow
to the brain is interrupted by
a blocked or burst blood vessel.
What is Stroke?
 No oxygen, nerve cells die in minutes
 In first three hours, some cells
can be saved (up to 35% recovery)
 Thrombolytics (‘clot-busting’) drugs
dissolve clots; prevent more strokes:



Administered via IV pump
Heparin (mixed results)
t-PA, “Activase”
Activase” (good results)
Copyright 2004 MEDRAD, Inc. All rights reserved.
One quarter of cardiac
output goes to the 5-6
pound organ—the brain.
The brain needs a
constant supply of:
•Oxygen
•Glucose
•Other nutrients
Circulation is supplied
via 2 pairs of arteries:
•Internal carotids
•Vertebrals
The Major Circulation to the Brain
PENUMBRA
(That tissue surrounding the infarct that is salvageable, but at risk.)
Rapid transfer to the stroke center will allow for protection of penumbra
through emergency interventions and medical management.
Cerebrovascular Disease:
Pathogenesis
Hemorrhagic Stroke (17%)
Intracerebral
Hemorrhage (59%)
Ischemic Stroke (83%)
Atherothrombotic
Cerebrovascular
Disease (20%)
Cryptogenic (30%)
Subarachnoid Hemorrhage (41%)
Lacunar (25%)
Small vessel disease
Albers GW, et al. Chest. 1998;114:683S-698S.
Rosamond WD, et al. Stroke. 1999;30:736-743.
Embolism (20%)
Acute Ischemic Stroke

Deficits:








(What do you see?)
Unilateral (though not always) weakness
Unilateral sensory deficit
Visual deficits (blindness, gaze palsy, double)
Speech (slurred – a motor dysfunction)
Language (aphasia – damage to the brain’s
speech center)
Ataxia (lack of coordinated movement)
Cognitive impairment
Like real estate—Location, Location, Location
What Parts of
the Brain Are
Affected by Stroke?
What Are the Effects
of Stroke?

Left Brain
What Are the Effects
of Stroke?

Right Brain
Stroke Assessment Scale
(Cincinnati Pre-hospital Stroke Scale)
“The sky is blue in Cincinnati.”
Any abnormality means an
abnormal Cincinnati scale
for stroke.
Probably accurately detects
stroke 80% of the time.
Stroke Assessment in the Field



Administer Cincinnati Scale.
If abnormal, facilitate a rapid transfer to
the primary stroke center. (Alta Bates in
North Alameda County—Washington
Hospital in South Alameda County.
Pre-notify the receiving stroke center—
”possible acute stroke in route”.
Identify Time “Last Seen Normal”


A 75 year old man with HTN and diabetes finishes dinner with a friend
at 8pm. He drives himself the short distance home that night, and a
daughter stops by the next morning to find him still in bed and with
right side weakness and severe aphasia. When do we assume the stoke
occurred? (Answer: “last seen normal at 8pm)
A 35 year old hypertensive man who is known to be non-compliant with
meds is found slumped over in his car in a job site parking area at 3pm.
In the ED he was found to have a massive left hemispheric ischemic
stroke. His wife said he left for work at 7am that morning as normal,
and she had a clear and normal cell phone conversation with him at
12:30pm. At 1pm a co-worker stated the man said he wasn’t feeling
well and was going to his car to rest. At the time the co-worker noticed
his speech was slurred. What time can we use as the time “last seen
normal”? (Answer: 12:30pm)
Types of Acute Ischemic Strokes



Middle Cerebral Artery Stroke
Vertebral—Basilar Artery Strokes
Lacunar Strokes
Types of Strokes
(Middle Cerebral Artery – MCA)
CT Scan of Acute Ischemic Stroke
(Left MCA territory stroke)
Types of Strokes


(Middle Cerebral Artery – MCA)
The most common artery occluded in AIS—
can be proximal or from carotid circulation.
Features:

Motor/Sensory Deficit: face, arm, leg
Speech deficit – dysarthria (slurred speech)
Language deficit – if in dominant hemisphere
Gaze palsy – eyes directed towards side of AIS

Blindness – visual field cut



(homonymous hemianopsia)
Types of Strokes

(Vertebral—Basilar Artery)
Features:







Cranial nerve involvement – hearing, visual,
facial, swallowing
Can have bilateral weakness
Cerebellar signs – ataxia
Sensory deficits
Vertigo – often nystagmus
Nausea and vomiting
Common to have waxing and waning symptoms
Lacunar Strokes

These strokes are
ischemic in nature.



Mainly caused by HTN.
Occurs in the small
penetrating arteries of
the brain.
Presentation – affects
the arm, leg, and face,
sometimes silent.
Deficits are equal to all
areas.
Conditions That Mimic AIS





Bell’s Palsy
Todd’s Paralysis
Hemorrhagic Stroke
Subdural Hematoma
Other conditions
Conditions That Mimic AIS

Bell’s Palsy
Bell’s Palsy is a viral infection of the facial nerve which causes stroke-like
symptoms: unilateral facial droop, sensory deficit, dysarthria, etc.
Conditions That Mimic AIS

Differential dx:





Hx: women, pregnancy,
viral illness
Can’t close eye completely
or raise forehead
May have facial pain
No other stroke symptoms
May have no risk factors for
stroke
Conditions That Mimic AIS

Todd’s Paralysis: unilateral weakness that
occurs after a seizure.




Can involve speech, language, visual and
sensory
May be due to hyperpolarization in the area of
the seizure
Resolves within 48 hours
Key concern in regard to thrombolytic therapy
Conditions That Mimic AIS





Hypoglycemia
Metabolic conditions – fever, hyponatremia,
drugs, etc.
Psychogenic
Complex migraines
Hypertensive crisis
What are the risks factors for
Ischemic Stroke?

Modifiable Risks










HTN
CAD/Carotid Disease/PVD
Atrial Fibrillation
Diabetes
Weight
High Cholesterol/Diet
Lack of exercise
ETOH/Drug abuse
Coagulopathy- Cancer,
Sickle Cell Anemia
PFO- Patent Foramen Ovale

Non-Modifiable Risks





Age->55
Race- African Americans
have 2x the risk of death
and disability. Asians have
1.4x the risk of death and
disability.
Sex- 9% greater chance in
men. (61% of stroke
deaths occur in women)
Previous Stroke or TIA
Family History of Stroke
Goals for Treatment in the ED







EMS rapid identification & pre-notification of the
Emergency Dept.
Quick evaluation in ED.
Last seen normal < 3 hr.
Door-to-CT scan
< 25 minutes
CT-to-Radiologist Reading
< 20 minutes
IV TPA administration
< 15 minutes
(Door-to-needle within 60 minutes.)
What can be done for an acute
ischemic stroke?




These patients may be appropriate for “clot
busting” drugs. Tissue Plasminogen Activator
(TPA).
Requires a rapid, coordinated response.
IV TPA can only be given within the first 3
hours of symptom onset.
Expected response: “60 minutes from door to
needle.”
Tissue Plasminogen Activator



Natural body substance. Recombinant TPA
converts Plasminogen to plasmin, which in turn
breaks down fibrin and fibrinogen, thereby
dissolving the clot.
Dose for Stroke: 0.9mg/kg up to a dose not to
exceed 90mg. 10% of dose as an IV bolus; the
rest over one hour by IV drip.
IV window of opportunity is < 3 hours of known
symptom onset.
Early Rx was better in the NINDS tPA Trial
Odds Ratio For Favorable Outcome at 3 Months
8
7
6
5
4
3
2
1
0
60
70
80
90
100 110 120 130 140 150 160 170 180
Minutes From Stroke Onset To Start of Treatment
Marler JR, et al. Early stroke treatment associated with better outcome. The NINDS rt-PA Stroke Study.
Neurology 2000;55:1649-1655.
Transition
Hemorrhagic Stroke
Hemorrhagic Stroke
(Intracranial Hemorrhage—ICH & Subarachnoid Hemorrhage—SAH)

Intracranial Hemorrhage (Hypertensive):





> twice as common as SAH
more likely to result in death or severe disability
37,000 Americans/year
35-52% dead within 1 month (half of deaths in
the first 2 days)
Only 10% living independently in 1 month;
improves to only 20% within 6 months
Hemorrhagic Stroke
(Intracranial Hemorrhage—ICH & Subarachnoid Hemorrhage—SAH)

Risk factors:






Hypertension
Advancing age
Coagulation disorders & therapy
ETOH abuse
Drug use (meth, cocaine, crack, etc.)
Ischemic stroke—hemorrhagic transformation
Hemorrhagic Stroke
(Intracranial Hemorrhage—ICH & Subarachnoid Hemorrhage—SAH)

Presenting signs:






Sudden—signs over minutes to hours
Headache
Nausea and vomiting
Decreasing LOC
Extremely elevated blood pressure
(All of these are signs of increased ICP)
Hemorrhagic Stroke
(Intracranial Hemorrhage—ICH & Subarachnoid Hemorrhage—SAH)

Differential Diagnosis:
AIS—often high BP
AIS—rare decreased LOC
AIS—rare or vague H.A.
AIS—rare nausea & vomiting
AIS—often wake up with the
symptoms
• Final
ICH—usually very high BP
ICH—50% of the time ↓ LOC
ICH—40% of the time H.A.
ICH—50% of time vomiting
ICH—rarely wake up with
symptoms (15%)
diagnosis is by CT scan.
Weakened blood vessels in a
Hypertensive Bleed
Autopsy of Intracerebral Hemorrhage
Small hemorrhagic stroke
Large hemorrhagic stroke
ICH: Goals for Early Management

Airway management



Assure adequate oxygenation & reduce
hypercapnea (Remember: ↑CO2 = ↑ ICP)
Prevent aspiration (Remember: 50% of ICH
patients vomit and have ALOC)
Prevent seizures


Acute mgt: Fosphenytoin 500-1000 PE
(phenytoin equivalents over 3-6 minutes)
Prevention: Phenytoin 500-1000 mg/20-30 min
ICH: Goals for Early Management

Blood Pressure Management:



Very poor outcomes if BP is allowed to stay very
high—more bleeding
Very poor outcomes if BP is allowed to drop
precipitously—removes the brain’s attempt to
perfuse a “tight” brain
Guidelines:


In general, keep BP about 160/90 or MAP <130
In the first 48 hours: no BP drop > 15-25% of
presenting value
Hemorrhagic Stroke



(Subarachnoid Hemorrhage)
Acute bleeding around the outside of the
brain and into the subarachnoid space.
Usually from an aneurysm or arteriovenous malformation.
Statistics:




50% are fatal
1--15% die before reaching the hospital
Those who survive are often impaired
1-7% of all strokes
Hemorrhagic Stroke
(Subarachnoid Hemorrhage)

Diagnosis:



“Thunderclap” headache. “It is the worst
headache of my life!”
Xanthochromic lumbar puncture (blood in the
CSF not due to traumatic tap)
“Star pattern” on CT scan
Aneurysmal bleed
Classic “Star Pattern” of Subarachnoid Hemorrhage
Magnified view
of cerebral
aneurysm.
Subdural Hematoma
(Not a true stroke
but symptoms can
mimic stroke.)
Subdural Hematoma

Symptoms:





Unilateral weakness, sensory deficit
Facial weakness
Dysarthria
Altered level of consciousness
Onset:


Can be rapid
Can take months to show symptoms
Subdural Hematoma
Causes





Anticoagulation (Heparin, Coumadin)
Antithrombotics (Aspirin, Plavix)
ETOH abuse
Trauma (could be recent or months ago)
Advanced age (most common cause)
Subdural Hematoma
Small bridging veins from the dura mater to the brain are stretched
and can rupture releasing blood into the subdural space and causing
pressure on that part of the brain. This leads to the deficits seen.
Subdural Hematoma on CT Scan
Subdural Hematoma
Treatment Options

Medical Management:



Correct Coags
Monitor neuro signs
Surgical Management:



Correct Coags
Burr hole drainage
Craniotomy for removal of solid clot
Summing Up


The best stroke care is a coordinated approach
and developed in a stroke center system of care.
Requires everyone to be on board:





Patients/Families
EMS
ED
Stroke Unit
Stroke Rehabilitation
Summing Up



How well a patient does; whether a
patient has a life-long serious disability;
whether he/she lives or dies; may depend
on you and how you respond.
A few minutes delay may make a very big
difference.
What you do really matters!
Emergent Stroke Care and the
Chain of Survival
Patient
Calling
Knowledge 911
EMS
System
ED
Staff
Stroke
Team
Stroke
Unit
Module is Completed
Proceed to Post Test
Post Test
1.
Which of the following are types of ischemic strokes?
a.
b.
c.
d.
2.
3.
Middle cerebral artery occlusion
Vertebral-basilar occlusion
Lacunar stroke
All of the above
A vertebral-basilar stroke might have bilateral
weakness as a symptom. (True or False)
This quick stroke assessment scale accurately identifies
stroke 80% of the time. ________________
Post Test
4.
5.
6.
7.
8.
The family states the patient woke up at 6:30am and
exhibited signs of acute stroke. We should assume
that the stroke started at 6:30am. (True or False)
List 4 things the EMS Provider should be able to tell
the Stroke Receiving Center ED about the possible
stroke patient who just arrived.
The IV TPA window of opportunity for treatment is
how long from symptom onset?
The most common type of hemorrhagic stroke is
caused by a cerebral aneurysm. (True or False)
List 5 conditions that can mimic acute ischemic stroke.
Post Test
Which of the following is not a true hemorrhagic
stroke?
9.
a.
b.
c.
10.
Subarachnoid Hemorrhage
Subdural Hematoma
Intracerebral Hemorrhage (Hypertensive Bleed)
The Stroke Receiving Center Emergency Room is the
stroke system of care. (True or False)
Post Test (Answers)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
d. –all of the above
True
Cincinnati Pre-hospital Stroke Scale
False –it is the time “last seen normal”
VS; FSBS; time last seen normal; stroke symptoms; meds the
patient takes
3 hours
False –Intracerebral Hemorrhage (HTN bleed)
Bell’s Palsy; Todd’s Paralysis; Subdural hematoma; hemorrhagic
stroke; Psychogenic; HTN; Complex Migraine; Hypoglycemia; etc.
Subdural Hematoma
False –all entities are equally important links in the stroke chain of
survival.