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Stroke Continuing Education EMS Region 7 May 2010. MENINGES. Dura Mater Arachnoid Pia Mater. Dura Mater creates Potential Space * Epidural space * Subdural space. Epidural Hemorrhage. Subdural Hemorrhage. CEREBRAL CORTEX. FRONTAL LOBE. Personality Behavior

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Stroke continuing education ems region 7 may 2010

Stroke

Continuing Education

EMS Region 7

May 2010


Meninges
MENINGES

  • Dura Mater

  • Arachnoid

  • Pia Mater


Dura Mater creates Potential Space

* Epidural space

* Subdural space

Epidural Hemorrhage

Subdural Hemorrhage



Frontal lobe
FRONTAL LOBE

  • Personality

  • Behavior

  • Voluntary motor function

  • Motor speech (Broca’s),

    Left side dominent

  • Intellectual functions, problem solving

  • Judgment; good/bad, right/wrong

Called the “MOM” portion of the Brain


Parietal lobe
PARIETAL LOBE

  • Primary sensory lobe; pain, pressure,

    vibration, touch

  • Localization of stimuli

  • Object recognition

  • Position sense

  • Sensory association


Temporal lobe
TEMPORAL LOBE

  • Primary auditory lobe

  • Long term memory

  • Emotions

  • Cognitive speech

    (Wernicke’s); organize language,

    understand and respond to verbal input

  • Uncus discriminates smells


Occipital lobe
OCCIPITAL LOBE

  • Processing visual input


Intracranial dynamics
INTRACRANIAL DYNAMICS

  • Three substances in the cranial vault

    • Brain 80%

    • Blood 12%

    • CSF 8%

MONRO-KELLIE DOCTRINE

If one of these substances increase, then one or

both of the other must therefore decrease to

maintain normal pressure within the cranial vault


Blood supply

The Brain:

Needs constant supply of O2 and glucose

Receives 15% of cardiac output

Consumes 20% of inspired O2

Perfused by the Circle of Willis

BLOOD SUPPLY


Not that Willis…..

THE CIRCLE OF WILLIS !


The circle of willis

The brain’s own arterial circulatory system

Connected to the aorta by the carotid arteries

THE CIRCLE OF WILLIS



Stroke defined
STROKE DEFINED

  • Sudden, catastrophic event causing focal neuro impairment due to interruption of cerebral blood flow

    • Most often caused by an occlusion or rupture of an artery that supplies a specific part of the brain


Brain attack ischemic stroke

Caused by anything that decreases blood flow to the brain

Thrombus /embolus (A-fib, hypercoagulable state, etc)

Carotid artery plaques

Vasospasm

Hypotension with carotid artery stenosis

BRAIN ATTACK / ISCHEMIC STROKE


Ischemia
Ischemia

  • Can result from:

    • Vascular injuries

    • Secondary vascular spasm

    • Increased intracranial pressure

    • Focal or more global infarcts can result


Internal carotid artery occlusion
Internal Carotid Artery occlusion

No characteristic clinical picture

May range from a TIA to infarction of a major portion of the ipsilateral (on the same side) hemisphere

If adequate intracranial collateral circulation is present, may see no signs or symptoms

Neurological symptoms may include:

monoparesis to hemiparesis with or without a defect in vision

impairment of speech or language

transient monocular blindness


Middle cerebral artery occlusion
Middle Cerebral Artery occlusion

Most occlusions in the first portion of this artery are due to emboli and typically produce a neurological deficit

Opportunity for collateral circulation is restricted

Neurological symptoms:

hemiplegia (paralysis of one side of the body)

hemisensory deficit

hemianopsia (blindness in 1/2 of the visual field)

aphasia (if infarct is in the dominant hemisphere)


Anterior cerebral artery occlusion
Anterior Cerebral Artery occlusion

Neurological symptoms may include:

weakness of the opposite leg with or without sensory involvement

apraxia (particularly of gait)

possible cognitive impairment


Vertebrobasilar system
Vertebrobasilar system

Neurological symptoms may include:

severe vertigo, nausea, vomiting, dysphagia, ipsilateral cerebellar

ataxia

decreased pain and temperature loss of 2 point discrimination

diplopia, visual field loss, gaze palsies


Posterior cerebral artery occulusion
Posterior Cerebral Artery Occulusion

Neurological symptoms may include:

Alterations in LOC, delerium and coma

possible

hemisensory disturbances

visual disturbances with possible blindness

Visual agnosia-lack of recognition or understanding of visual objects or loss of color

Amenesia

Loss of motor function possible


Stroke statistics
STROKE STATISTICS

  • Stroke occurs every 40 seconds

  • 3rd leading cause of mortality

    • 143,00 deaths annually

    • Death due to stroke every 3-4 minutes

  • 4.8 million stroke survivors

    • Leading cause of serious long tern disability

    • Life time cost of an ischemic stroke is $140,000

  • Strides in prevention are off set by aging population

  • 80% of strokes are preventable!!!


Tia statistics
TIA STATISTICS

  • 200,000-500,000 Per Year

    • Prevalence increases with age

    • Half of those with TIA’s fail to report it

  • 15% of strokes are preceded by a TIA

  • Following TIA

    • 12% of patients experience a stroke within the next 30 days

    • 3-17% have a stroke within 90 days

    • 25% die with in 1 year


Stroke awareness survey
STROKE AWARENESS:SURVEY

  • 38% aware of 5 stroke signs and would call 911

  • Stroke pts:

    • 55% able to identify 1 stroke warning sign!

    • 60% able to identify 1 stroke risk factor!

  • Huge public education need


Effect of stroke on brain cells
EFFECT OF STROKE ON BRAIN CELLS

Interrupted supply O2 and glucose causing anaerobic metabolism and increasing cellular waste (toxins) causing cell membrane dysfunction causing cellular swelling and pressure on the cells which causes cellular ischemia and death


Stroke risk factors non modifiable
STROKE RISK FACTORS: NON MODIFIABLE

  • Age

    • >55 risk doubles every decade

  • Gender

    • Male more common

    • Female higher death rate

  • Heredity

    • Relative with stroke increased risk

  • Prior stroke/TIA

    • 25-40% chance of stroke in 5 years

  • Prior MI

  • Race

    • Increased in Hispanic/Asian/Pacific Islander

    • African American 2x higher rate than whites


Stroke risk factors modifiable
STROKE RISK FACTORS: MODIFIABLE

  • HTN

    • >140/90

    • Most important risk factor

    • Most common cause of stroke

    • Increased risk 4-6 times

    • Improved treatment may be responsible for decreased stroke deaths

  • High Cholesterol

    • Clogs arteries

    • 107 million in US


Stroke risk factors modifiable1
STROKE RISK FACTORS: MODIFIABLE

  • Atrial Fibrillation

    • Pooling blood promotes clots

    • Increases risk by 6 times

    • 15% stroke patients have A-Fib

  • Diabetes

    • Most have other risk factors as well

    • 2/3 die from stroke or heart disease

    • Increases risk 2-4 times


Stroke risk factors modifiable2
STROKE RISK FACTORS: MODIFIABLE

  • Tobacco

    • Damages vessel walls

    • Accelerates arterial stenosis

    • Increases CV workload

    • Increases BP

    • Increasing clotting factors

    • Doubles risk

  • Alcohol

    • Heavy use related to stroke

    • >2/day may increase risk by 50%

    • Leads to HTN


Stroke risk factors modifiable3
STROKE RISK FACTORS: MODIFIABLE

  • Obesity

    • Strains entire cardiovascular system

    • Likely to have DM, HTN and high cholesterol


Neuro assessement
NEURO ASSESSEMENT

BASELINE ASSESSMENT IS OF GREAT IMPORTANCE TO DETERMINE THE HISTORY OF THE PRESENT ILLNESS AND TO ACT AS A GUIDE FOR FURTHER SERIAL ASSESSMENTS


Assessment symptoms chief complaint
ASSESSMENT: SYMPTOMS/CHIEF COMPLAINT

  • Headache of unknown cause

  • AMS/Sudden confusion

  • Photophobia, visual deficits

  • Stiff neck

  • Weakness/paralysis

  • Sensory loss face, arm or leg

  • Vertigo, dizziness,syncope,ataxia

  • Trouble speaking or understanding

  • Seizure


Assessment cincinnati stroke scale
ASSESSMENT: CINCINNATI STROKE SCALE

  • 3 Components

    • Facial (Smile)

    • Arm drift-Unilateral weakness

    • Speech- abnormal speech pattern

  • Takes less than 1 minute

  • Reliability

    • 1 finding= 72%

    • 3 findings = 85%

  • However, patients can be having a stroke despite a normal CSS

  • Correct documentation


Css arm drift
CSS: ARM DRIFT

  • Weakness

  • Clumsiness

  • Heaviness

  • Documentation – in narrative or use built-in Zoll categories

    • Normal

    • Drift

    • Can’t resist gravity

    • No effort

    • No movement


Css speech
CSS: SPEECH

  • Speech

    • Ask the patient to repeat a simple sentence

      • The sky is blue

      • You can’t teach an old dog new tricks

  • Assess

    • Ability to form words

    • Abnormal pattern

    • Articulation

    • Hoarseness

    • Phonation

    • Rate


Ccs smile
CCS: SMILE

  • Facial Symmetry

    • Smile/Grimace

    • Show teeth

  • Does he have a deficit?


Bell s palsy vs stroke
BELL’S PALSY vs. STROKE

  • Bell’s Palsy

    • Total hemiparesis of face

  • Stroke

    • Can wrinkle both sides of forehead but has lower facial weakness


Stroke abnormal presentations
STROKE: ABNORMAL PRESENTATIONS

  • Weakness

    • Quick neuro exam

    • Negative suspect ACS obtain a 12 lead

    • Positive Consider Stroke

  • Syncope

    • Hx of seizures

    • Exam

      • GCS

      • ECG

      • Trauma


Stroke abnormal presentations1
STROKE: ABNORMAL PRESENTATIONS

  • AMS

    • Scene size up

    • Differential diagnosis

      • AEIOUTIPS

  • Other

    • Visual disturbances

    • Hoarseness

    • “Heavy” sensation

    • Cranial nerve S/S


Stroke abnormal presentations2
STROKE: ABNORMAL PRESENTATIONS

  • Strong trend for misdiagnosis <35

    • 50% of those were diagnosed as inner ear disorder

  • Women

    • AMS (most common)

    • Meaning confusion

    • Disorientation

    • Loss of consciousness

    • Delays in triage, exam and imaging


It s neuro time
IT’S NEURO TIME!!

  • Lessons learned in Trauma and Cardiac care can be applied to Stroke care:

    • Patients need definitive treatment in the hospital

    • Outcomes greatly improved with early access to emergency care


Stroke chain of survival
STROKE CHAIN OF SURVIVAL

  • Goal

    • Minimize brain injury and maximize recovery

  • Rapid

    • Recognition and reaction

    • EMS Dispatch

    • EMS transport and pre arrival notification

    • Diagnosis and treatment


7 d s of stroke care potential points of delay
7 D’s OF STROKE CAREPOTENTIAL POINTS OF DELAY

  • Detection

  • Dispatch

  • Delivery with advance notification

  • Door

  • Data

  • Decision

  • Drug/Monitoring


Ems prehospital stroke care
EMS PREHOSPITAL STROKE CARE

  • ID stroke symptoms

  • Transport to a Stroke Center

  • Medical Center pre arrival notification

  • Safest most efficient method of transport

  • Manage the life threats

  • Perform targeted neuro assessment

  • ID/treat other causes of symptoms

  • Establish time of symptom onset


Overview stroke care
OVERVIEW STROKE CARE

  • Prehospital

    • Identify signs

    • CSS/assessment

    • Time of onset

    • Check glucose

    • Support ABC’s

    • Oxygen

    • Monitor

    • Transport

    • Alert hospital


Minimize scene time but ensure

Glucose check

Limit IV attempts to 2

Neuro Exam (GCS, Stroke Scale, Pupils)

Note TIME OF ONSET OF SYMPTOMS!

Protect patient from injury/aspiration

Be attuned to subtle changes/ongoing assessment

MINIMIZE SCENE TIME, BUT ENSURE …


Overview stroke care1
OVERVIEW STROKE CARE

  • What does the ED do?

    • ABC’s

    • O2

    • IV access

    • 12 lead

    • Labs

    • Detailed neuro exam

    • CT, MRI

    • Stroke Team


Treatments for ischemic stroke
TREATMENTS FOR ISCHEMIC STROKE

  • Clot removal device

  • MERCI

  • Clot busters

  • tPA


Overview stroke care2
OVERVIEW STROKE CARE

  • IV tPA

  • Time: 3 hrs (5/09: up to 4.5 hr)

  • Administered in ED

  • Class I for qualified pts

  • Good outcomes only if given in window

  • ICU admit w/ close monitoring

  • Intra-arterial tPA

  • Med directly to thrombus

  • Class I up to 6 hrs k

  • Qualified interventionalist at specialty center

  • Beneficial up to 6+ hr of onset


  • Interventional Therapy

  • • "MERCI" procedure

  • Mechanical Embolus Removal in Cerebral Intervention

  • Removes thrombus from vessel

  • Useful when tPA contraindicated


Transport considerations

Time is Brain!

TRANSPORT CONSIDERATIONS

Stroke Centers?

Aero medical?



Ems plays integral role in stroke care

Early access to hospital care is crucial to optimizing patient outcome

EMS PLAYS INTEGRAL ROLE IN STROKE CARE!

Taking care of stroke victims

Worrying about becoming stroke victims


Assessment and evaluation
Assessment and Evaluation patient outcome

  • Prehospital management of the head-injured patient is determined by:

    • Mechanism and severity of injury

    • Patient's level of consciousness

    • Associated injuries

  • Airway and ventilation

  • Circulation

  • Neurological examination

  • Fluid therapy

  • Drug therapy


Avoid tunnel vision

Form a list of differential patient outcomediagnoses for EACH patient.

What are some reasons why people have alterations in their mental status?

Psychiatric causes should always be the last explanation, even if the patient has a previous history of psychological illness.

AVOID TUNNEL VISION!



Code 38 it!

SUSPECTED STROKE

INITIAL MEDICAL CARE

Perform Cincinnati Pre-Hospital Stroke Scale*

Identify patients last “known normal”

If Stroke scale positive and “last known normal” < 3 hours,

transport to the nearest most appropriate facility.

Do not delay scene time. Initiate rapid transport.

Blood Glucose

GO TO CODE 32

< 60 or > 400

12 Lead EKG

Other SMO CODE’s as indicated:

Coma of Unknown Origin

Seizures

  • *Cincinnati Prehospital Stroke Scale

  • Facial Droop (Have the 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

  • Arm Drift (Patient closes eyes and holds both arms straight out for 10 seconds)

    • 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

  • 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

Effective 05/01/10

ALS


Questions

QUESTIONS it!

Thank You for Your Attention


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