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Start Show. Notes. The following presentation is taken from the American Heart Association’s Advanced Cardiac Life Support : Principles and Practice, Chapter 18, Acute Stroke: Current Treatments and Paradigms Please use this publication as a reference. ASA Operation Stroke EMS Committee

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Start Show

Notes


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The following presentation is taken from the American Heart Association’s Advanced Cardiac Life Support : Principles and Practice, Chapter 18, Acute Stroke: Current Treatments and Paradigms

Please use this publication as a reference.


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ASA Operation Stroke

EMS Committee

Volunteers including:

Bruce Barnhart, Chair

Amy Boise, Vice Chair

Nancy Parks, RN

Charlann Staab, RN

Linda Meiner, RN

Mike Baros, RN

Terry Mason, RN

Don Baird, RN

Sandy Nygard, CEP

AEMS, Inc.

Robert Londeree, M.D.

Phoenix Fire Department

John Gallagher, M.D.

Air-Evac Services, Inc.

Professional Medical Transport (PMT)

Cigna Healthcare

Halle Heart Center

Dave Heath

Special Thanks To:


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Stroke

An Educational Program

for

Pre-Hospital Personnel

Developed by:

EMS Committee

Operation Stroke – American Stroke Association

Phoenix, Arizona

July 2003


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Stroke Overview

Introduction, Definition, Types and Risks


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How Serious Is Stroke in the US?

  • About 700,000 strokes occur each

    year.

  • Over 167,000 deaths each year.

  • #3 killer.

  • A leading cause of serious long-term

    disability in adults.

  • 4.7 million stroke survivors.


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Introduction

New emerging therapies offer hope, however the following MUST occur:

  • Education of at-risk patients.

  • Early recognition of stroke signs.

  • Prompt transport to the hospital.

  • Rapid hospital triage and evaluation.


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Introduction

With rapid, aggressive prehospital stroke care, at-risk patients can be appropriately managed and quickly assessed for fibrinolytic therapy that may significantly improve their outcome.


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Definition of Stroke

A stroke is a neurological impairment caused by a disruption in blood supply to a region of the brain.


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Classification of Stroke

Two major categories:

  • Ischemic strokes, caused when a blood vessel supplying the brain is occluded by a clot. Responsible for 75% of all strokes.

  • Hemorrhagic strokes, caused when a cerebral artery ruptures.

    Both forms are life threatening.


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Hemorrhagic Stroke

  • Hypertension is the most common cause of intracerebral hemorrhage.

  • Other causes:

    Aneurysms and

    Arteriovenous malformations.


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Risk Factors for Stroke

Although some strokes occur without warning, most stroke victims have prior risk factors.

Major strokes can be prevented in many cases, but only if early signs and symptoms are heeded.


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Hypertension

Smoking

Diabetes

Asymptomatic Carotid Stenosis

Atrial Fibrillation

Hyperlipidemia

Sickle Cell Disease

Other cardiac diseases

Well-DocumentedModifiable Risk Factors

Goldstein et al. Circulation. 2001:103:163


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Obesity

Physical Inactivity

Poor Diet/Nutrition

Alcohol Abuse

Drug Abuse

Hypercoagulability

Hormone Replacement Therapy

Oral Contraceptive Use

Inflammatory Process

Less Well DocumentedPotentially Modifiable Risk Factors

Goldstein et al. Circulation. 2001:103:163


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Non-modifiable Risk Factors

  • Age

  • Sex

  • Race/Ethnicity

  • Family History


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Stroke Diagnosis

Signs and Symptoms of Stroke


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Signs and Symptoms of Stroke

Consider in anyone

who has:

  • Sudden numbness or weakness of face, arm, or leg, especially on one side of the body

  • Sudden confusion, trouble speaking or understanding


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Signs and Symptoms of Stroke

  • Sudden trouble seeing in one or both eyes

  • Sudden trouble walking, dizziness, loss of balance or coordination

  • Sudden severe headache with no known cause


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Signs and Symptoms of Stroke

THIS IS A LIFE THREATENING EMERGENCY!

Emergency healthcare providers must:

  • Recognize the importance of these symptoms.

  • Respond quickly with medical and / or surgical

    interventions.


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Stroke Signs and Symptoms: Hemorrhagic Stroke

May present similar to Ischemic stroke.

Distinguishing Features:

  • Appear more seriously ill

  • Deteriorate more rapidly

  • Severe headache

  • Alteration in consciousness

  • Nausea and/or vomiting

  • Neck pain

  • Intolerance of noise or light


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Transient Ischemic Attack

“Temporary” or “mini” stroke.

  • The signs and symptoms of a TIA are similar to those of a completed stroke; however, they typically last only a few minutes to several hours before resolving.


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Transient Ischemic Attack

  • TIA is the most important forecaster of impending stroke.


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Stroke Patient Management

The Stroke Chain of Survival and Recovery


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Seven Step Stroke Chain of Survival and Recovery

Pre-arrival: Post-arrival:

  • Detection4. Door

  • Dispatch5. Data

  • Delivery6. Decision

    7. Drug


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1. Detection: Early Recognition

  • Early treatment of stroke depends on the victim, family members, or other bystanders detecting the event.

  • Mild signs or symptoms may go unnoticed or be denied by the patient or bystander.


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2. Dispatch: Early EMS Activation and Dispatch Instructions

  • Stroke victims and their families must be taught to activate the EMS system as soon as they detect stroke signs or symptoms.

  • EMS dispatchers must appropriately prioritize the call to ensure a rapid response within the EMS system.


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3. Delivery:Pre-hospital Transport and Management

The goals :

  • Rapid identification of the stroke

  • Support of vital functions

  • Rapid transport of the victim to the receiving facility

  • Pre-arrival notification of the receiving facility


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3. Delivery:Pre-hospital Transport and Management

The Cincinnati Pre-hospital Stroke Scale

  • Facial Droop (have patient show teeth or smile):

    Normal - Both sides of face move

    equally well.

    Abnormal - One side of face does not

    move as well as the other side.


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3. Delivery:Pre-hospital Transport and Management

The Cincinnati Pre-hospital Stroke Scale

2. Arm Drift (patient closes eyes and holds both arms out):

Normal - Both arms move the same or both

arms do not move at all (other findings,

such as pronator grip, may be helpful).

Abnormal - One arm does not move or one

arm drifts down compared with the other.


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3. Delivery:Pre-hospital Transport and Management

The Cincinnati Pre-hospital Stroke Scale

3. Speech (have the patient say "you can't teach an old dog new tricks"):

Normal - Patient uses correct words with

no slurring.

Abnormal - Patient slurs words, uses

inappropriate words, or is unable to speak.


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3. Delivery:Pre-hospital Transport and Management

  • The presence of acute stroke is an indication for "load and go“.

  • Establish the time of onset of stroke signs and symptoms!

  • This timing will have important implications for potential therapy. If the time of onset of symptoms is viewed as time "zero," all assessments and therapies can be related to that time.


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3. Delivery:Pre-hospital Transport and Management

Once stroke is diagnosed, pre-hospital treatment includes management of the ABCs of critical care (Airway, Breathing, and Circulation) and close monitoring of vital signs.


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3. Delivery:Pre-hospital Transport and Management

Airway:

  • Paralysis of the muscles of the throat, tongue, or mouth can lead to partial or complete upper-airway obstruction.

  • Saliva pools or vomit may be aspirated.


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3. Delivery:Pre-hospital Transport and Management

Breathing:

  • Breathing abnormalities are uncommon, except in patients with severe stroke, and rescue breathing is seldom needed.

  • Abnormal respirations, however, are prominent in comatose patients and portend serious brain injury.


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3. Delivery:Pre-hospital Transport and Management

Circulation:

  • Monitor both blood pressure and cardiac rhythm as part of the early assessment and treatment of a stroke patient.

  • Hypotension or shock is rarely due to stroke, so other causes should be sought.


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3. Delivery:Pre-hospital Transport and Management

Circulation:

  • Hypertension is often present in stroke patients, but it typically subsides and does not require treatment.

  • Treatment of hypertension in the field is not recommended!


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3. Delivery:Pre-hospital Transport and Management

Other Supportive Measures:

  • Intravenous access.

  • Management of seizures, and diagnosis and treatment of hypoglycemia, can be initiated en route to the hospital if necessary.

  • Isotonic fluids (Normal Saline or Lactated Ringer's solution) are used for intravenous therapy; hypotonic fluids are contraindicated.


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3. Delivery:Pre-hospital Transport and Management

Early Notification:

  • Early notification enables personnel to prepare for the imminent arrival of any seriously ill or injured patient.

  • In many hospitals this notification shortens the time to evaluation of, and critical interventions for, stroke patients.


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4. Door:Emergency Department Triage

Even if a potential stroke victim arrives in the emergency department in a timely fashion, too often hours may elapse before appropriate neurological consultation and diagnostic studies are performed.


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5. Data:Emergency Evaluation and Management

ABCs should be reassessed and rechecked frequently.


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5. Data:Emergency Evaluation and Management

An emergency neurological stroke assessment should be done quickly focusing on four key issues:

  • Level of consciousness

  • Type of stroke (hemorrhagic versus nonhemorrhagic)

  • Location of stroke (carotid versus vertebrobasilar)

  • Severity of stroke


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5. Data:Emergency Evaluation and Management

  • Obtaining the exact time of stroke or onset of symptoms from family or people at the scene is critical.


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Emergency Diagnostic Studies

  • Currently, CT is the single most important diagnostic test.

  • Goal: CT scan obtained and read within 45 minutes of the stroke victim's arrival at the emergency department.


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Emergency Diagnostic Studies

  • Anticoagulants and fibrinolytic agents should be withheld until CT has ruled out a brain hemorrhage.

Hemorrhagic Stroke


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Differential Diagnosis:

  • Unrecognized seizures

  • Confusional states

  • Syncope

  • Toxic or metabolic disorders

  • Hypoglycemia

  • Brain tumors

  • Subdural hematoma

Adams et al. Stroke. 2003;34:1056


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6. Decision:Specific Stroke Therapies

General care includes, but is not limited to:

  • Prevention of aspiration

  • Management of hypertension

  • Management of hyper/hypo-glycemia

  • Management of seizures

  • Management of intra-cranial pressure (ICP)

Acute Stroke, 2003 American Heart Association


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7. Drugs:Fibrinolytic Therapy for Ischemic Stroke

  • Intravenous tPA represents the first FDA-approved therapy for acute ischemic stroke.

  • In the NINDS trial, patients treated with tPA within 3 hours of onset of symptoms were at least 30% more likely to have minimal or no disability at 3 months compared with those treated with placebo.


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7. Drugs:Fibrinolytic Therapy for Ischemic Stroke

  • However, there were 10-fold increases in the risk of fatal intracranial hemorrhage in the treated group (3% vs 0.3%) and the frequency of all symptomatic hemorrhage (6.4% vs. 0.6%).

  • This increase in symptomatic hemorrhage did not lead to an overall increase in mortality in the treated group.


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7. Drugs:Fibrinolytic Therapy for Ischemic Stroke

Careful patient selection and strict adherence to the treatment protocol are essential!


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7. Drugs:Fibrinolytic Therapy for Ischemic Stroke

Because of the time criteria and risk associated with fibrinolytic therapy, it is important for hospitals to develop specific strategies and protocols that will achieve rapid initiation of therapy.


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NINDS-Recommended Stroke Evaluation Targets for Potential Fibrinolytic Candidates*

Time Target

*Target times will not be achieved in all cases, but they represent a reasonable goal.†CT indicates computed tomography.‡By phone or in person.


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Management of Hemorrhagic Stroke Fibrinolytic Candidates*

Optimal management:

  • Prevention of continued bleeding.

  • Appropriate management of ICP.

  • Timely neurosurgical decompression when warranted.

    Large intracerebral or cerebellar hematomas often require surgical intervention.


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Summary: Fibrinolytic Candidates*Pre-hospital Critical Actions and Management

This is what should happen:

  • Recognize the signs of stroke and TIA

  • Rapid neuro exam (Cincinnati Stroke Scale or similar).

  • Determine time of symptom onset (if possible).

  • Provide rapid transport to an ED capable of caring for acute stroke (pre-notify).

  • Perform finger-stick to assess serum glucose levels.


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Summary: Fibrinolytic Candidates*Pre-hospital UNACCEPTABLE Actions

  • Failure to recognize signs and symptoms of stroke/TIA

  • Failure to attempt to determine symptom onset.

    • Delay in transport.

    • Transporting a potential stroke patient to an ED not capable of treating acute ischemic stroke with fibrinolytic therapy.


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Summary: Fibrinolytic Candidates*Pre-hospital UNACCEPTABLE Actions

  • Attempts to treat hypertension in the field.

  • Failure to notify receiving ED.


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Conclusion: Fibrinolytic Candidates*

Now, fibrinolytic and other emerging therapies offer practitioners the opportunity to limit neurological insult and improve outcome in stroke patients.


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Conclusion: Fibrinolytic Candidates*

The challenge with these therapies is that they require administration within hours of stroke onset, making the following measures imperative:

  • Education of at-risk patients

  • Early recognition of stroke signs

  • Prompt transport to the hospital

  • Rapid hospital triage and evaluation


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