Transcript Stroke Management for the EMS Provider

Stroke: Understanding
Management for EMS
Silver Cross EMS System
Adapted from and thanks to Alameda EMS System
Additional material from Erika Ball, RN, BSN
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 describe the major vessels involved in acute ischemic stroke.
Discuss the “therapeutic window” for thrombolytic therapy in stroke.
Identify interventions that individual EMS providers can make to improve
outcomes in stroke.
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)
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)
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
• 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
(What do you see?)
• Deficits:
– 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.
• Code 38 of the SMO’s: Suspected Stroke
• If abnormal, facilitate a rapid transfer to the
primary stroke center.
• 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
known 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 known 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. There are some out-of FDA
parameter administrations.
– 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.
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 arterio-venous
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
Cardiac Connection
• A Fib and A Flutter. What is the connection?
– Coagulation in the right atrium
• Cardiac medications common with stroke
patients:
– Coumadin [warfarin] and Cardizem [diltiazem] are
common in A Fib patients
– Be aware of medications for hypertension
Medication of the month
Aspirin
•
Salicylate drug, andfirst came to use in 1897.
•
Aspirin also has an antiplatelet effect by inhibiting the production of thromboxane,
which under normal circumstances binds platelet molecules together to create a
patch over damaged walls of blood vessels. Because the platelet patch can become
too large and also block blood flow, locally and downstream, aspirin is also used
long-term, at low doses, to help prevent heart attacks, strokes, and blood
clot formation in people at high risk of developing blood clots.
•
It has also been established that low doses of aspirin may be given immediately
after a heart attack to reduce the risk of another heart attack or of the death of
cardiac tissue. Aspirin may be effective at preventing certain types of cancer,
particularly colorectal cancer.
Wikipedia_ Aspirin 2013.
ASA: Contraindicated in Suspected
Stroke!
• Contraindications of ASA include:
– Allergy
– Suspected stroke (why?)
– GI bleeding history
– Pediatrics
– Used with caution in alcoholics
A Fib
• Irregular R to R
• No P wave
Skill: Cincinatti Stroke Scale
• F Face: Symmetry, drooping, inability to have muscle
control. Do not necessarily worry about differentiating from
Bell’ pre-hospital. Better be safe than sorry!
• A Arm drift: have patient hold arms out, palms up [supinated]
and close eyes. If patients’ arm drifts off to the side or down, this
is drift.
• S Speech: Slurring, garbled, aphasia (receptive or expressive)
• T Time of Last known normal.
• Ask family or bystanders
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!
Reminder…
• As always, Silver Cross EMS System is open to
new ideas and your feedback. Please do not
hesitate to contact Erika Ball, educator for the
CME.
• Erika Ball, RN
– [email protected]
– Mobile 815-325-3049
References
•
Alameda EMS Stroke PowerPoint
•
Aehlert, B. (2011). Paramedic Practice Today.
•
Aspirin (2013) National Library of Medicine http://www.ncbi.nlm.nih.gov/pubmedhealth/PMHT0000168