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MDPH/OEMS Stroke Point of Entry. Created by: Central Mass EMS Corp. www.cmemsc.org Edited by: Lee H. Schwamm, MD, FAHA Associate Director, Acute Stroke Services, MGH www.stopstroke.org and Jonathan L. Burstein, MD, FACEP Medical Director, Office of Emergency Medical Services. Purpose.

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Mdph oems stroke point of entry l.jpg

MDPH/OEMSStroke Point of Entry

Created by:

Central Mass EMS Corp.

www.cmemsc.org

Edited by:

Lee H. Schwamm, MD, FAHA

Associate Director, Acute Stroke Services, MGH www.stopstroke.org

and

Jonathan L. Burstein, MD, FACEP

Medical Director, Office of Emergency Medical Services


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Purpose

To provide EMTs with the fundamental knowledge needed to recognize and manage potential stroke in the pre-hospital setting and make appropriate transport and hospital notification decisions based on the Stroke POE Plan.

Courtesy of UMass Memorial LifeFlight & Mark Ide


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Objectives

  • Identify the two major categories of stroke

  • List common signs & symptoms of stroke

  • Provide several risk factors for stroke

  • Explain the importance of rapid stroke therapy

  • Describe pre-hospital assessment and care, including the MASS and thrombolytic checklist

  • Describe the MA and Regional Stroke POE plan

  • Discuss appropriate treatment and transport modalities

  • Describe detailed stroke documentation


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Background

  • Third leading cause of death in the U.S.

  • Approx. 700,000 people suffer strokes each year

  • Incidence increases with age

  • Mortality from stroke increases with age

  • Frequent cause of disability

  • Pre-hospital care has been primarily supportive


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Stroke: What is it?

  • Injury or death of brain tissue due to oxygen deprivation; usually due to an interruption of blood flow

  • Also referred to as “Brain Attack” or “Cerebrovascular Accident” (CVA)

  • A true emergency!


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Etiology Overview

Atheromatous

Atheromatous

Source: Brady CD, Paramedic Care: Principles & Practice Vol.3 ©2001


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Ischemic Stroke

  • About 80% of all strokes

  • Occurs when a cerebral artery is blocked by a clot or other foreign matter

  • Causes ischemia (inadequate blood supply to tissue)

  • Progresses to infarction (death of tissues)

  • Classified as:

    • Embolic Stroke

    • Thrombotic Stroke


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Ischemic Stroke

  • Embolic

    • The occlusion is caused by an embolus (solid, liquid, or gaseous mass) carried to a blood vessel from another area

    • Most common emboli are blood clots

    • Risk factors for blood clots include Atrial Fibrillation and diseased or damaged carotid or vertebral arteries

    • Rare causes of emboli include air, tumor tissue, and fat

    • Occurs suddenly & may rarely be accompanied by headache


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Embolic Stroke

Source: http://www.irishhealth.com/?level=4&con=8


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Ischemic Strokes

  • Thrombotic

    • The occlusion is caused by a cerebral thrombus; a blood clot which develops gradually in a previously diseased artery and obstructs it

    • Caused by atherosclerosis:

      • atheromatous plaque deposits form on the inner walls of arteries, resulting in narrowing and reduction of blood flow

      • platelets adhere to the roughened surface of the plaque deposit and a blood clot is created


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Ischemic Strokes

  • Thrombotic, continued:

    • Signs & symptoms may develop more gradually

    • Often occurs at night with patient awakening from sleep with symptoms


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Thrombotic Stroke

Source: http://www.strokecenter.org/pat/ais.htm


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Hemorrhagic Strokes

  • About 20% of all strokes

  • Onset usually sudden with severe headache

  • Classified as:

    • Intracerebral hemorrhage (within the brain)

    • Subarachnoid hemorrhage (in the fluid filled spaces around the blood vessels outside the brain)


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Hemorrhagic Strokes

  • Intracerebral hemorrhage

    • Most occur in the hypertensive patient when a small vessel within the brain tissue ruptures

    • Hemorrhage inside the brain often tears and separates brain tissue


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Intracerebral Hemorrhage

Often caused by a ruptured blood vessel within the brain tissue of the hypertensive patient.


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Hemorrhagic Strokes

  • Subarachnoid hemorrhage

    • Most often result from congenital blood vessel abnormalities (e.g., aneurysm) or head trauma


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Subarachnoid Hemorrhage

Often result from congenital abnormalities (e.g., aneurysms) or from head trauma

Source: http://medic.med.uth.tmc.edu/edprog/Path/NeuroIIb.htm


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Cerebral Aneurysm

  • dilation, bulging or ballooning out of part of the wall of a vein or artery in the brain.


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Hemorrhagic Strokes

  • Subarachnoid hemorrhage

    • Blood in the subarachnoid space may impair drainage of cerebrospinal fluid and cause a rise in intracranial pressure

    • Herniation of brain tissue may occur


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Herniation

Protrusion of brain tissue through the base of skull (shown as “e”) from pressure due to mass lesion

Source: http://www.uth.tmc.edu/radiology/test/er_primer/skull_brain/skull.html


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What can be done?

  • Rapid recognition and prompt transport to a Primary Stroke Service (PSS) provider

  • A Primary Stroke service provider is a MDPH designated facility that offers emergency diagnostic and therapeutic services provided by a multidisciplinary team and available 24 hours per day, 7 days per week to patients presenting with symptoms of acute stroke.


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Stroke: What can be done?

Tissue plasminogen activator (tPA) and other thrombolytic (clot dissolving) agents used for heart attack, are also effective against certain ISCHEMIC strokes


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Stroke: What can be done?

A multi-center, randomized clinical trial conducted by The National Institute of Neurological Disorders and Stroke (NINDS) found that selected stroke patients who received t-PA within three hours of the onset of stroke symptoms were at least 30 percent more likely than placebo patients to recover from their stroke with little or no disability after three months.


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Time Sensitive Treatment

  • Must receive treatment within three (3) hours of onset of symptoms

  • EMS must determine the exact time of onset as accurately as possible and also note the time the patient was last seen well

  • Transport to PSC within 2 hours of symptom onset if possible

  • Time = Brain Tissue


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Team Approach

  • Detection

    • Importance of early recognition by lay public

  • Dispatch (9-1-1)

    • Obtains pertinent info; identifies urgency

  • Delivery (EMS)

    • Evaluates, obtains symptom onset, minimizes on scene time; immediate transport and pre-notification to PSS as soon as possible!


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Team Approach

  • Door (Primary Stroke Service)

    • Alerts stroke team, performs patient exam & assessment, rapid CT scan

  • Data

    • Reviews all pertinent patient information

  • Decision

    • determines if thrombolytic therapy candidate

  • Drug

    • administers treatment <60 min of arrival


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Therapies & New Developments

  • Thrombolytic Agents

  • Cytoprotective Agents

  • Platelet Inhibitor Drugs

  • Neuroradiological Intervention

  • Ultrasound-aided Therapy

  • In vitro diagnostic tests

    • may allow rapid detection of ischemic stroke in the field, at the bedside or in the ED!


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Stroke Risk Factors

  • High blood pressure

  • Atrial fibrillation, CHF

  • High cholesterol

  • Diabetes (twice the risk)

  • Smoking (50% higher risk)

  • Alcohol or Drug Abuse

  • Inactivity or Obesity

  • Clotting problems (OCP, Sickle Cell)


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Stroke Risk Factors, continued

  • Prior Stroke History

  • Heredity

  • Age (risk increases with age)

  • Gender

    • more common in men

    • more women die from stroke

  • Race (greater risk among African Americans)


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Stroke: Signs & Symptoms

  • Paralysis on one side

  • Facial Droop

  • Limb Weakness

  • Paresthesias/Sensory loss

    (numbness or tingling)

  • Ataxia

    • Gait Disturbance

    • Uncoordinated fine motor movements


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Signs & Symptoms, continued

  • Speech Disturbance

  • Vision Problems

  • Headache

  • Confusion/Agitation

  • Dizziness/Vertigo


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Speech Disturbance

  • Aphasia

    • Inability to speak

  • Dysphasia

    • Difficulty speaking

  • Dysarthria

    • Impairment of the tongue muscles essential to speech


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Vision Problems

  • Nystagmus

    • Involuntary jerking of the eyes

  • Diplopia

    • Double vision

  • Monocular blindness

    • Blindness in one eye


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Transient Ischemic Attacks (TIAs)

  • Temporary interruption of blood supply to brain

  • Carotid artery disease a common cause

  • Stroke-like neurological deficit symptoms

    • abrupt onset

    • Symptoms resolve in less than 24 hours, usually within minutes.

    • No long-term effects, but high stroke risk


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TIAs, continued

  • One third of TIA patients will suffer an acute stroke

  • Evaluate through history taking:

    • History of HTN, prior stroke, or TIA

    • Symptoms and their progression

  • Impossible (at this time) in pre-hospital setting to determine if a neurological event is due to TIA or stroke


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Conditions that mimic Stroke

  • Hypoglycemia

  • Electrolyte imbalances (esp. Sodium)

  • Epidural or subdural hematoma

  • Brain abscess or tumor

  • Post-seizure

  • Migraine


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Pre-hospital Care

  • Scene safety & BSI

  • Maintain airway & assist ventilations as indicated (do not hyperventilate)

  • Provide 2 lpm O2 NC unless in resp. distress

  • Provide C-Spine immobilization if indicated

  • Obtain Vital Signs & SAMPLE history

  • Collect or document ALL medications


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Pre-hospital Care, continued

  • Record onset time and phone access to witness

  • Do not allow patient to exert themselves

  • Do not administer aspirin unless evidence of acute coronary syndrome

  • Complete and then document results of Massachusetts Stroke Scale (MASS)

    • (Refer to Protocols Appendix Q)

    • ONE positive finding is strongly predictive of stroke


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Massachusetts Stroke Scale (MASS)

  • FACIAL DROOP

    • Patient shows teeth or smiles

      NORMAL ABNORMAL


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MASS Scale

  • ARM DRIFT

    • Patient closes eyes & extends arms for 10 seconds

      NORMAL ABNORMAL


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MASS Scale

  • SPEECH

    • Patient repeats “The sky is blue in Boston”

      Normal:

      States correctly without slurring on first attempt

      Abnormal:

      Slurs words, says the wrong words or is unable to speak on first attempt (mute)


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Pre-hospital Care, continued

  • Determine blood glucose level if allowed; get medical control permission to administer glucose even if glucose level is low

  • If unconscious or seizing, transport on left side

  • If BP drops below 100 systolic, treat for shock

  • Initiate transport by ground to nearby PSS using BLS or ALS; activate ALS in patients with respiratory or hemodynamic compromise


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Pre-hospital Care, continued

  • Notify receiving facility ASAP

  • Monitor/record VS every 5 minutes if unstable, or every 15 minutes if stable

  • Position the patient, protecting paralyzed extremities

  • Secure patient to stretcher and transport rapidly without excessive movement or noise

  • Use Thrombolytic Checklist en-route & include information in documentation


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Pre-hospital Care: ALS

  • Contact medical control prior to administration of D50 or D5W

  • IV access & 12 lead should not delay transport


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Stroke POE Plan

  • EMS Operational Definition of Acute Stroke

    • Onset of symptoms < 2hr duration (or since last seen at baseline) according to the MASS scale OR other concerning neurologic signs consistent with stroke, such as:

      • Eye movement abnormalities

      • Weakness affecting the leg

      • Double vision

      • Sudden onset dizziness AND unable to walk


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Stroke POE Plan

  • Following the Mass EMS Pre-hospital Treatment Protocols for Acute Stroke (3.11), determine possibility of stroke based on MASS scale (Protocols, Appendix Q) and assessment

  • Establish time of onset and last time seen at baseline


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Stroke POE Plan

  • If stroke symptoms present & time from

    onset of symptoms to hospital arrival will be

    < 2 hours, transport patient to nearest appropriate DPH designated provider of Primary Stroke Service (PSS)

  • Notify receiving facility ASAP


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Stroke POE Plan

  • GOAL: To transport patient to PSS within 2 hours of symptom onset.

  • Choose most appropriate mode of transport (ground, air) and destination to achieve this.


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Stroke POE Plan

  • It may be more appropriate to transport to the nearest hospital for acute stabilization if:

    • Compromised airway

    • Hemodynamically unstable

    • Depressed level of consciousness

    • Documented or suspected severe hypoglycemia (diaphoretic & known diabetic)


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Stroke POE Plan

  • If CT Scan capability is unavailable at the nearest PSS (e.g., “Cautionary Status”), the patient should be transported to the next nearest appropriate PSS

  • If the patient will arrive at the PSS more than 2 hours after symptom onset, transport to the nearest hospital.

  • These time guidelines may be revised as new therapies extend the stroke treatment time frame


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Stroke: Documentation

  • SAMPLE

  • Age, Sex, Race/Ethnicity

  • Onset time and last seen at baseline

  • Assessment and care provided (BLS/ALS)

  • Receiving Primary Stroke Service (PSS)

  • Trip times (dispatch, patient contact, hospital notified, hospital arrival)

  • Thrombolytic Checklist (include all information)


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Documentation

  • Remember to leave a copy of the Patient Care Report at the hospital per:

    105 CMR 170.345 (C)(2)

    The EMS patient care report is a CRITICAL part of the patient’s medical record and contains vital information pertinent to continuing care at the hospital and to providing follow-up information to EMS.


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Summary

  • Two major categories of stroke

  • Common signs & symptoms of stroke

  • Risk factors for stroke

  • The importance of rapid stroke therapy

  • Pre-hospital assessment and care, the (MASS) and thrombolytic checklist

  • Stroke POE plan

  • Stroke documentation


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Scenario 1

  • 67 year old female at home

  • Chief complaint dizziness

  • History of NIDDM


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Scenario 1 examined

  • There are many causes of dizziness that are not stroke-related. Review these together.

  • Older patients and those with Diabetes are at increased risk of ischemic stroke.

  • Discuss the other findings that might make you think this patient is experiencing a stroke.


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Scenario 2

  • 54 year old male at minor MVA

  • Chief complaint sudden onset headache

  • History of hypertension


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Scenario 2 examined

  • The MVA may have caused the headache, but maybe the headache caused the MVA. Remember to consider all the possibilities.

  • Patients with hypertension are at increased risk of ischemic stroke and intracerebral hemorrhage.

  • Headache is unusual in ischemic stroke, but is the hallmark of hemorrhagic stroke.


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Scenario 3

  • 72 year old male at fast food restaurant

  • Wife reports patient “acting funny” and slurring words

  • History of TIA


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Scenario 3 examined

  • Older patients and those with prior cerebrovascular disease are at increased risk of ischemic stroke.

  • “Acting funny” may indicate impaired language or cognitive function. Slurred speech may be aphasia or dysarthria.

  • Discuss what to do next to determine if this patient meets the POE criteria.


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Questions?

  • Ask your training coordinator

  • Consult your Affiliate Hospital Medical Director (ALS) or service Medical Director

  • Call your Regional office or visit their website

  • Contact OEMS at (617)753-7300 or visit www.mass.gov/dph/oems


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References

  • Bledsoe, B., Porter, R., Cherry, R. (2003). Neurology. In Brady, Essentials of Paramedic Care (pp. 1356-1361, 1827-1828). Upper Saddle River, NJ: Pearson Education, Inc.

  • Dambinova, S. (2004). Diagnostic Potential of New Brain Markers for TIA/Stroke Assessment. Business Briefing:Medical Device Manufacturing & Technology, 1-4.

  • (2010). Acute Stroke. In EMS Pre-hospital Treatment Protocols (V. 8.01, Protocol 3.11). MDPH/OEMS.


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Internet References

  • www.ninds.nih.gov

  • www.strokeassociation.org

  • www.stopstroke.org


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