Transcript Understanding and Managing Acute Stroke in the Pre

BRAIN ATTACK
Understanding and Managing
Acute Stroke
in the
Pre-hospital Setting
EMS Education – Stroke
Carolyn Walker RN, BN
January 2011
What’s New in Prehospital care of Acute Stroke?
Change is
Everywhere!
• New approach to EMS delivery in Alberta
• New EMS Provincial Medical Control Protocols
New Approach to EMS delivery in Alberta
• EMS services prior to April 2009
•Private, Municipal, Hospital based/Regional
• EMS services since April 2009
•Governance and Policy – Alberta Health and Wellness
•Operations and Support – Alberta Health Services
•>550 ambulances in system across Alberta
•300 are AHS
•250 are owned and operated by approx. 50 contracted services
New EMS Provincial Medical Control Protocols
• Implemented Dec 1, 2010 for both ground and air
• Developed by a provincial committee
• Ensure evidence based practices
• Ensure consistent standards of care throughout Alberta
• Clearly defined clinical treatment pathways
STROKE MANAGEMENT PROTOCOL
Introduction
EMS = Prehospital care
Neurological emergencies
• Acute Stroke Syndromes
• Acute Ischemic Stroke
Used with permission by Genetech
Objectives
• Define stroke
• Describe acute ischemic stroke
• Discuss EMS assessment and management of the suspected
stroke patient
• Describe provincial stroke management protocol
• Identify requirements for direct transport to the nearest Primary
or Comprehensive Stroke Centre
• Explain the importance of rapid reperfusion
• Describe how reperfusion is achieved
Case Study
• 65 year old female
• Collapsed
• Unable to move right
side
• Unable to speak
Define Stroke
Stroke Syndrome – sudden vascular event
leading to focal neurological dysfunction
Hemorrhagic -15% (ICH & SAH )
Ischemic- 85% (Thrombotic & Embolic)
Ischemic Stroke – 65%
Transient Ischemic Attack – 20%
- symptoms resolve
- no brain cell death
- 20-40% of strokes are proceeded by TIA
Used with permission by National Stroke Association
• “… proficient … recognize, assess, manage, treat, triage, and transport stroke
patients” NAEMSP
Cerebral Perfusion and Acute Ischemic Stroke
Mechanisms of ischemic stroke
 Multi-factorial
Risk Factors
 Recent prior TIA/ stroke
 Diabetes
 Atrial fibrillation
 Smoking
 HTN - 70% of all strokes
Cerebral Blood Flow
32 000 brain cells/ second
“Time is Brain”
Used with permission by National Stroke Association
EMS Assessment

Primary Assessment
o
Sudden onset of:
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Weakness or numbness on one side
of the body and/or face
Difficulty with speech or understanding
•
Double vision or loss of vision
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o
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Vital signs
BGL
Medical history
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o
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Focused neurological assessment
Last seen normal
Co-morbid diseases – cardiac disease,
diabetes, HTN, dyslipidemia
Risk factors – smoking, obesity, alcohol
Hemorrhage risk – recent trauma, surgery
or bleeding problems
Neuro history – TIA, Stroke, TBI
ECG – Atrial Fibrillation
Used with permission by The City of Calgary EMS
Stroke Management Protocol
When was patient last seen normal?
EMS Stroke Screen Form
Stroke Screen Form
EMS Assessment - Neurological
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Level of Consciousness
o A – alert
o V – verbal
o P – painful
o U – unconscious
Speech impairment - Aphasia
and dysarthia
Facial symetry - facial droop?
Arm weakness
o Limb drift
o Hemiplegia vs. hemiparesis
Leg weakness
o Limb drift
Vision abnormalities
Hand Grip Strength - non-specific
Used with permission by AHS EMS
Stroke Screen Form
Positive Stroke Screen Criteria:
Stroke screen criteria are positive when the following
3 criteria are met:
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Blood glucose > 3.0 mmol/L
•
Interval from “last seen normal” to arrival at nearest PSC
or CSC is < 4.5 hours
(Calgary only- awoke with symptoms OR last seen normal to arrival < 6 hours)
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One or more disabling findings are present
Case Study Assessment
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Aphasic
Hemiparesis - right arm
• Weakness - right leg
• Facial weakness
• Medical History
o
o
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Childhood Rheumatic fever
Mitral valve replacement
Medications
o
o
Previous coumadin
ASA
Used with permission by AHS EMS
EMS Treatment
Airway management - ETI
Oxygen – SPO2 > 95%
Positioning – supine to 30 degrees
IV – minimum1 large bore N/S at 100mL/hr
-no dextrose IV solutions
NO CT Scan
= No Thrombolytics
= No ASA
= No Anti-hypertensives
Used with permission The City of Calgary EMS
Access to Tertiary care
• Minimize total ischemic time
• Treatment window for t-PA
<4.5 hours
• Scene time < 10 mins
• Rapid transport
(with family/ witness if able or
phone # to contact)
Used with permission by Calgary EMS
• Early Notification
• Prehospital recognition
=
Time to reperfusion
“Time is Brain”
Communication and Transport Decision:
Hyperacute - Metro
- EMS Crew identifies hyperacute stroke,
reviews stroke screen form, contacts ADCC
(Ambulance Destination Co-ordination Centre)
- ADCC advises on location and sets up
information patch to ED
- Awaiting ED notified by crew, clinical details,
lytic screen
- ED will contact stroke team to prepare for CT
Bypass Decision:
Rural/Suburban
- Bypass protocol in place, determines
closest PSC location
- Contacts ADCC if coming into
Edmonton for direction to CSC
- Transport to local PSC or to CSC with
pre-notification
- Consultation with Stroke
team/Telestroke
Partners in Acute Ischemic Stroke
Primary Stroke Centre (PSC) criteria:
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CT scan availability
Door to CT time less than 20 minutes with a pre-alert
Stroke expertise on-site or available by Telestroke link
r-tPA treatment availability
May not be available 24/7 due to CT/physician availability
Serves surrounding communities in which it is the nearest PSC
Comprehensive Stroke Centre (CSC) criteria:
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CT scan availability
Door to CT time less than 20 minutes with a pre-alert
Stroke team on-site
Neurological expertise on-site
Neurointerventional expertise on-site
Central hub of stroke Neurologist expertise in a telestroke network
Be aware of PSC and CSC in your area
Alberta Stroke Centre Locations
2 Comprehensive Stroke Centres
Calgary - Foothills Medical Centre
Edmonton - University of Alberta Hosp
*Grey Nuns Hosp in Edmonton
14 Primary Stroke Centers
Reperfusion: t-PA (Activase), Mechanical Devices
TIME IS BRAIN!!
Alteplase binds to fibrin in a thrombus:
- converts plasminogen to plasmin
- initiates local fibrinolysis with minimal
systemic effects.
Mechanical Thrombectomy Devices:
- MERCI device: Mechanical Embolus Removal in Cerebral Ischemia
- Penumbra device
National and Provincial Stroke Statistics
Prevalence in Canada
3rd leading cause of death
14,000 deaths/ year
50,000 strokes per year or 1 every 10 minutes
300,000 Canadians live with a disability due to stroke
Leading cause of adult disability
Alberta Provincial Stroke Strategy : 2003-2008
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20% decline in stroke occurrence from 2003/4 -2007/8
4500 stroke patients admitted to Alberta hospitals
4000 stroke patients ED visits
EMS is involved in majority of TIAs / Strokes
EMS in Stroke Management
“… proficient … recognize, assess, manage, treat, triage, and transport
stroke patients”
NAEMSP
"EMS providers are critical to the management of the acute
stroke patient. Early recognition of stroke in-the-field ,
stabilization and transport to a Primary or Comprehensive Stroke
Centre as rapidly as possible are mandatory for acute stroke
treatment and good outcomes.“
Dr. Michael Hill, Stroke Neurologist, APSS
Thank you
Alberta Provincial Stroke Strategy
AHS Emergency Medical Services – Calgary Zone
Greg Vogelaar
Calgary Stroke Program:
Dr. Michael Hill
Darren Knapp
Paramedic/Quality Assurance Strategist
AHS Emergency Medical Services - Edmonton Zone
References
1. 2005 American Heart Association guidelines for cardiopulmonary resuscitation and emergency
cardiovascular care. Part 9: Adult stroke. Circulation. 2005;112:111-120.
2. Canadian Stroke Network and the Heart and Stroke Foundation of Canada: Canadian Stroke Strategy.
Canadian Best Practice Recommendations for Stroke Care: 2006. Ottawa, 2006.
3. Canadian best practice recommendations for stroke care (updated 2010) Patrice Lindsay, BScN
PhD, Mark Bayley, MD, Chelsea Hellings, BScH, Michael Hill, MSc MD, Elizabeth Woodbury, BCom
MHA, Stephen Phillips, MBBS (Canadian Stroke Strategy Best Practices and Standards Writing Group
on behalf of the Canadian Stroke Strategy, a joint initiative of the Canadian Stroke Network and the Heart
and Stroke Foundation of Canada*). FINAL v.25 October 21, 2010
4. EMS MANAGEMENT OF ACUTE STROKE– PREHOSPITAL TRIAGE (RESOURCE DOCUMENT TO
NAEMSP POSITION STATEMENT)
5. T. J. Crocco, J. C. Grotta, E. C. Jauch, S. E. Kasner, R. U. Kothari, B. R. Larmon, J. L. Saver,M. R.
Sayre, S. M. Davis. ABSTRACT. PREHOSPITAL EMERGENCY CARE 2007;11:313–317
6. Demchuk AM., Calgary Stroke Program – Thrombolysis Update 2008 mostly a 3 to 4.5 hours post stroke
story. December 2007 – Lecture presentation
7. Kidwell CS, Alger J, Saver JL. Beyond mismatch: Evolving paradigms in imaging the ischemic
penumbra with multimodal magnetic resonance imaging. Stroke. 2003; 34: 2729–2735
8. Saver JL. Time is brain--quantified Stroke. 2006 Jan;37(1):263-6. Epub 2005 Dec 8
9. Koeing KL Benefits of Pre-hospital Notification for Stroke Patients. Journal Watch Emergency
Medicine Nov 7, 2008
10. Alberta Provincial Stroke Strategy: Pre-Hospital Care February 2009
11. Government of Alberta Health and Wellness: Alberta Health Services: Emergency Medical
Services: Provincial Medical Control Protocols: Adult and Pediatric, December 1, 2010.