STROKE

Presence Regional EMS System

September 2013
 Grandpa had a stroke
Not too long ago this statement meant death or
disastrous disability for patients and families.

In the 21st century medical

science has progressed in
the understanding of STROKE,
prevention and treatment
 How
big is the problem of
STROKE?
 Magnitude of the Problem
795,000 Americans annually suffer a
STROKE
25% die
#3 killer of Americans
25% of women have strokes
before age 65
#1 cause of long term disability
 Stroke in the US
One case of stroke every 45 seconds
Results in devastating disability
16% institutionalized in nursing homes
31% assistance with Activities of Daily Living
(bathing, dressing eating)
20% assistance with walking
30% depressed
Annual cost of $68 billion
 New Advancements
The FDA has approved the same clot busting
drugs (tPA thrombolytic) used in heart attacks to
be used in brain attacks stroke.

For a variety of reasons, only 2% of stroke

victims are treated with thrombolytic medication

Aggressive treatment begins with assessment

and intervention at point of patient contact
 Before STROKE can be
managed
Learn more about what strokes are and
how they happen.
 A very selfish organ
The brain requires
20 % of
the total blood
pumped
by the heart.
No storage
in the brain for
either fuel or oxygen
Requires constant
supply of oxygen and glucose.
 Blood Supply to the Brain
Carotid arteries anterior neck
Large
Frequently congested
with plaque
Can be cleaned out surgically
Vertebral arteries
Pass through cervical vertebrae
Well protected
Not accessible for
surgical cleaning
 Circle of Willis
Both blood supplies (carotid and vertebral) join
on the under surface of the brain.
Fail-safe mechanism
in case of a blockage
somewhere in
circulation
BUT some hard corners in
circle where debris can get
caught and site of most
cerebral aneurysms
 What can go wrong???
Disruption of blood flow to the brain
Plaque build up of cholesterol in interior of
blood vessel
Foreign debris
blood clot
bubble of fluid
air
Broken vessel
 Ischemic STROKE
Blockage of blood flow to brain
Progressive Thrombus -- growing
Plaque deposit similar to process in heart with
coronary artery disease
Cerebral Emboli --Clot from somewhere else --
floating debris
Blood clot
Air bubble
Bubble of amniotic fluid
Bone marrow from
a fracture
 Hemorrhagic STROKE
Aneurysm weakened area in artery
Congenital
Younger population younger than 40 years
Complain of worst headache in my life

Spontaneous Hypertensive Bleed

Due to BP > 200/100
Malformed Artery
50% younger than 30 years
 Transient Ischemic Attack
One Free Spin
Looks like a stroke but,symptoms improve in
1-24 hours
Temporary disruption of blood flow to the
brain Like Unstable Angina of the brain
Warning sign (15% of strokes have TIA first)
Mimicked by low blood sugar (> blood sugar
signs and symptoms go away)
1 in 20 patients will have a true stroke in 3
months
Can STROKES be prevented?
Modifiable risk factors
High BP
Cigarette smoking
Alcohol intake
Uncontrolled Heart disease
Atrial fibrillation
(creates mini clots)
Uncontrolled Diabetes
Carotid congestion
 High blood cholesterol
Sedentary lifestyle
Obesity
Seasons spring and fall
Stress
 Risk Factors Unable to Control
Age
Gender
more women than men
Race
African American high risk
Prior strokes
Heredity
Sickle Cell Disease
Causes clot formation and
strokes even in children
 Signs and Symptoms of
STROKE
Hemorrhagic
Sudden and dramatic
Violent explosive headache
worst headache of my life
Visual disturbance
Flashing lights, aura
Nausea and vomiting
Neck and back pain
Due to blood in sub-arachnoid space
Sensitivity to light
Weakness on one side
Can present like a migraine headache
 Signs and Symptoms of
STROKE
Ischemic Stroke
Harder to detect
Weakness in one side
Facial drooping
Numbness and tingling
Language disturbance
Visual disturbance
 Left Brain Stroke
Right side paralysis
Speech and language disturbance
Behavioral changes
Swallowing problems
 Right Brain Damage
Left side paralysis
Spatial perception
Where your limbs
are in relation to the room
Coordination problems
Perception
Recognition of familiar

objects
 Primary Stroke Care
180 minute window of time
Time is tissue
The longer the brain is without
oxygen and glucose the more
brain cells die

Goal is to restore blood flow as

soon as possible

Treatment is a system beginning with early

recognition and continuing through rehabilitation
Goals of Primary STROKE Care
Rapid Recognition of STROKE Symptoms
Rapid access in to the medical system
Assessment
Treatment
 Seven Ds of STROKE Care
Detection of STROKE symptoms
Dispatch of EMS/ MET Team
Delivery to a facility prepared to manage STROKE
Door to treatment rapid diagnosis and decision
making
Data CT Scan
Decision Ischemic or Hemorrhagic, does the patient
meet the criteria to receive thrombolytic drugs
Drug thrombolytics when appropriate
 EMS Has a Critical Role
Educate your community
At first signs of a possible STROKE call
EMS
Many families wait to see if the patient gets
better
Take patient to the hospital by car

Dont guess call EMS!!

 Use a FAST STROKE
Assessment
Modification of Cincinnati Pre-Hospital
Stroke Screen
Face
Arm
Speech
Time of onset
 FACE
Look for Facial Droop
Have the patient smile or show his/her teeth
NORMAL Both sides of the
face move equally
ABNORMAL One side of
the patients face droops
or does not move
 ARMS
Motor Weakness: Look for arm drift by asking
the patient to close eyes and lift arms
NORMAL- arms remain
extended equally or drift
downward equally
ABNORMAL One arm
drifts down compared
to the other
 Problem with gripping hands
Many elderly have arthritis in hands
Hurts to grip hands
May mimic weakness
 SPEECH
Ask the patient to say You cant teach an
old dog new tricks
Lots of ts, ks and cs
NORMAL Phrase repeated clearly and
plainly
ABNORMAL Words slurred, abnormal or
unable to speak
 Abnormal Speech
Slurring of speech
Unable to think of words
Inappropriate words
Expressive aphasia unable to speak words
Area of brain where words are created is damaged
Receptive aphasia unable to understand
words
Area where words are interpreted is damaged
 TIME OF ONSET
The window of opportunity to effectively
treat STROKE is 3 hours (180 minutes)
May be extended to 4 hours in some cases
Need to know last known well.
Difficult when
Patient lives alone
Woke up with symptoms
 180 minutes
Dont think of as 3 hours, but 180 minutes
Time gets eaten up fast
Short scene time
Take transport time into consideration
 Assessing the Stroke Patient

Initial Assessment
General Impression
Airway Airway Airway!!
High-flow O2
Circulation
HIGH PRIORITY TRANSPORT
 Focused history and physical exam
Perform thorough neurologic exam.
FAST Stroke Screen
History of
Seizures
Headache
Nausea/vomiting
Neck pain

Obtain baseline set of vitals

Recheck Vital Signs frequently
 Priorities of care
Conduct general assessment
Trauma recent or within last month
Recent seizure
Could be a subdural hematoma
Cardiovascular on heart medications
Does the patient have atrial fibrillation
Does the patient take blood thinners
Pulse oximetry > 94%
Blood sugar treat if able
Low blood sugars mimic a stroke
Pupils
 Position
Protect potentially paralyzed parts
 STROKE Check List
Securing A B Cs
Stroke identification
Use of FAST Screen
EKG monitoring if able
Oxygen saturation of > 94%
Management of blood glucose
IV access (ILS/ALS)
Blood specimens obtained (ILS/ALS)
Head of Bed elevated 15 degrees
Early communication with Physician
Urgent transport to CT Scan
Non Contrast CT of Head
Want a normal CT
Acute Hemorrhagic Stroke
Blood shows up white
 Sub Arachnoid Bleed
Blood in meninges due to
aneurysm
 Could this be anything other
than a STROKE?

Transient Ischemic Attack

Hypoglycemia
Race Against Time
 Goals of STROKE Care 2013
Standardized assessments, vocabulary,
protocols and goals
Door to treatment (with thrombolytics)
goal is 60 minutes
Early identification of candidates
Direct transport to CT scan
NINDS** Recommended Goals
Door to doctor 10 minutes
Door to CT completion 25 minutes
Door to CT read 45 minutes
Door to treatment 60 minutes
Access to neurological expertise* 15 minutes
Access to neuro-surgical expertise* 120 minutes
Admit to monitored bed 180 minutes

* by phone or in person
** National Institute of Neurological Diseases and Stroke
 Case Study 1: 6:30 pm
You are called by a family member to
assess a patient who is not acting right.

What could be the problem?

Keep an eye on the time

you have 180 minutes
 What could be the problem?
Seizure
Code
Myocardial infarction
Diabetic reaction
Medication reaction
Anxiety attack
STROKE
 6:35 pm
Upon arrival, you find the patient, Mrs.
Short, sitting in bed. She is confused, but
responds to verbal stimuli.

What assessments do you need?

 ABC/FAST
Airway and ventilations are adequate
Regular pulse and good perfusion
Speech is garbled
Unable to move her right arm and leg
Denies chest pain.
BP 195/105, pulse 90, respirations 18
 The patients daughter reports that her mother
felt fine a few minutes ago when suddenly her
arm felt funny. She did not lose consciousness
and did not have a seizure.

The woman did not complain of a headache,

and has no history of seizures, diabetes, chest
pain or palpitations.
 6:43 pm
This patient, Mrs. Short, is 65 years old.
She has left sided facial drooping and right
arm and leg weakness. She can move the
right arm and leg slightly, but with great
difficulty. Her speech is slurred. All of
these signs and symptoms are new in the
last 10 minutes.
 FAST
How does Mrs. Short fare on the FAST
Screen?
Face
Arm
Speech
Time
 Case 1 cont

Face -- left sided facial drooping

Arm right arm and leg weakness
Speech speech is slurred
Time last known well within 20 minutes
 HIGH PRIORITY
Determine precise time of onset of signs
and symptoms.
If thrombolytic therapy is to be considered,
its infusion must begin within 3 hours of
the onset of symptoms.
 Does Mrs. Short meet the criteria so far to
be on the Primary STROKE Care track to
receive thrombolytics (tPA)?

YES, Proceed with Stroke protocol

 Case Study 2: 0635 Hours
70 year-old woman, Mrs. Black
Awake with slight weakness and tingling
in her left side.
Speech is hesitant and slightly slurred
No facial drooping
Good eye contact
 Case 2 cont.
Symptoms began 0615 per patient
Speech was fine before that
Blood sugar 50 mg/dl
No emesis or seizure
BP 150/90, Pulse 80, Respirations 16
O2 sat 92%
 FAST
How does Mrs. Black fare
on the FAST Screen?
Face
Arm
Speech
Time
 Case 2 cont

Face -- no drooping
Arm slight weakness and tingling
Speech -- Speech is hesitant and slightly
slurred
Time known well -- 20 minutes ago
 Case 2
BUT blood sugar is low!
Treat the blood sugar and reassess the
need for additional treatment
High priority transport to
a CT for acute STROKE
 Case Study 3
Ambulance call at 1400 hours
80 year-old man, Mr. Schmidt
Daughter found him 15 minutes ago
Unknown down time
Awake
Drooping left side of face
No movement of right arm and leg
Speech too slurred to understand
 Case 3 cont.
Blood sugar 200 mg/dl
No evidence of seizure or emesis
BP 180/100, pulse 72, respirations 15
 FAST
How does Mr. Schmidt fare
on the FAST Screen?
Face
Arm
Speech
Time
 Case 3 cont

Face --Drooping left side of face

Arm No movement of right arm and leg
Speech Speech too slurred to
understand
Time known well unknown, daughter
found him 15 minutes ago, but she had not
had contact with him since yesterday
 Case 3
Time window has closed. Not a candidate
for thrombolytic treatment. Transport to
ED for acute care.
 Quiz
What are the 2 general types of stroke?
1.
2.

What condition is equivalent to angina of the

brain?
3.
What are 3 risk factors for stroke that can be
modified?
4.
5.
6.
 What are 2 risk factors for stroke that cannot be
modified?
7.
8.
What are you measuring in a FAST Stroke
Screen?
9.
10.
11.
12.
 In the 21st century, some patients suffering
from STROKE can be treated using what
type of medication?
13.
What is the time deadline that must be met
in order to use the aggressive medication
in the question above?
14.
 Answers
1. Hemorrhagic stroke
2. Ischemic stroke
3. TIA (transient ischemic attack)
4. 6. High BP
Cigarette smoking High blood cholesterol
Sedentary lifestyle Carotid Congestion
Obesity Uncontrolled diabetes
Seasons Atrial fibrillation
Stress Uncontrolled heart disease
Alcohol intake
 7-8
Age prior strokes
Gender heredity
Race Sickle cell disease

9. Face
10. Arm
11. Speech
12. Last known well
 13. Clot busting drugs, thrombolytics, tPA
14. 3 hours (180 minutes)