IDPH EMS Region Five

Stroke Education

Time is Brain!!!!!

Time is Brain !!!!

Stroke refers to any spontaneous damage to the brain

caused by an abnormality of the blood supply by

means of a clot or bleed.

Strokes should be treated emergently.

During a stroke, up to 2 million brain cells die every

minute. For every hour a stroke continues, up to 200

million nerve cells die and the brain ages 4 years.

Intravenous tPA (Activase / alteplase) should be given

within 180 minutes of the onset of ischemic stroke, so

do not delay transport and minimize scene time. It is

recommended to limit scene time to 10 minutes.

TIME IS BRAIN!

Cerebrovascular Accident (CVA)

Pathophysiology

Thrombosis (brain itself)

Embolus (head, neck or heart)

Hemorrhage (within brain)

Ischemia (systemic blood flow)

Predisposing Factors: Modifiable

Hypertension

Cigarette smoking

Diabetes Mellitus

Heart disease

Hyperlipidemia

Cardiovascular

disease

Chronic atrial

fibrillation

Sickle cell disease

Polycythemia

Hypercoagulability

Birth control pill use

Cocaine use

Predisposing Factors: Unmodifiable

Age

Gender

Race

Prior stroke

Heredity

CVA Mechanisms

Thrombus

Embolus

Aneurysm

Arrhythmia

Hypovolemia

CVA Origin

Ischemic Stroke

Blood vessel occlusion

Thrombosis

Embolism

Plaque fragments from carotids

Chronic atrial fibrillation

Fat particles

IV substance abuse particulates

Systemic hypoperfusion

Pump failure

Hypovolemia

Ischemic Stroke Syndromes

Transient Ischemic Attack (TIA)

Neurological deficits that resolve in 24

hours or less (most in 30 minutes)

Commonly result from carotid artery

disease

Same symptoms as CVA

Often warning sign of impeding CVA

5% risk of stroke per year

Ischemic Stroke Syndromes

Dominant Hemisphere Infarction

Contralateral weakness, numbness

Contralateral blurring of vision of half the

visual field in both eyes

Difficulty pronouncing words (dysarthria)

Difficulty speaking or understanding speech

(dysphasia or aphasia)

Ischemic Stroke Syndromes

Nondominant Hemisphere Infarction

Contralateral weakness, numbness

Contralateral visual field cut

Neglect of contralateral extremities

Dysarthria

Usually NOT dysphasic or aphasic

Hemorrhagic Stroke

Hemorrhagic Stroke Syndromes

Intracerebral Hemorrhage

Headache, nausea, vomiting precede

deficits

Patients commonly have decreased LOC

with extreme hypertension

Contralateral hemiplegia, hemianesthesia

Possible aphasia, extremity neglect

depending on hemisphere involved

Hemorrhagic Stroke Syndromes

Subarachnoid Hemorrhage Grade I Asymptomatic or mild headache and mild

nuchal rigidity

Grade II Moderate to severe headache, nuchal

rigidity, cranial nerve dysfunction but no

other deficits

Grade III Drowsiness, confusion, mild focal deficits

Grade IV Stupor, moderate to severe hemiparesis,

possibly early decerebrate rigidity,

vegetative response

Grade V Deep coma, decerebrate rigidity,

moribund appearance

CVA Presentation Brain can show injury in only three ways:

Decreased LOC

Seizures

Localizing signs

Hemiparesis or hemiplegia

Dysphasia (Receptive or expressive)

Visual disturbances

Gait disturbances

Inappropriate affect

Bizarre behavior

Incontinence

Cincinnati Stroke Scale

To facilitate accuracy in diagnosing stroke and

to expedite transport, a rapid neurological

examination tool is recommended.

The most common prehospital exam used is

the Cincinnati Stroke Scale (CSS).

One new onset positive sign on the CSS

indicates a 72% probability of stroke. Three

new onset positive signs on the CSS indicates

a greater than 85% probability of stroke.

Cincinnati Stroke Scale:

Facial Droop (ask the patient to show their

teeth or smile)

Normal – Both sides of the face move

equally/symmetrically.

Abnormal – One side of the face does

not move as well as the other.

Cincinnati Stroke Scale:

Arm Drift (ask the patient to close their

eyes and hold both arms out straight with

palms up for 10 seconds).

Normal – Both arms move the same.

Abnormal –One arm turns over, drifts

down compared to the other arm, or is

flaccid.

Cincinnati Stroke Scale:

Speech (ask the patient to say, “You can’t

teach an old dog new tricks”)

Normal – The patient says the phrase

correctly with no slurring/slowing of

words.

Abnormal – The patient slurs words,

uses the wrong words or is unable to

speak.

Cincinnati Stroke Scale:

Time (ask the patient/witness when the

symptoms started)

Time of Onset: the time symptoms

actually begin.

Last Known Well Time: the last time

the patient was known to be without

symptoms (asymptomatic).

CRITICAL THINKING ELEMENTS:

CRITICAL THINKING ELEMENTS:

EMS personnel should ask family members or bystanders the stroke

symptom onset time if the patient is unable to provide that

information. Consider transporting a witness or obtaining witness’

contact information.

Maintain the head/neck in neutral alignment. Elevate the head of the

cot 30 degrees if the systolic BP is >100mmHg (this will facilitate

venous drainage and help reduce ICP).

Be alert for airway problems (swallowing difficulty,

vomiting/aspiration)

Bradycardia may be present in a suspected stroke patient due to

increased ICP. DO NOT give Atropine if the patient’s BP is normal or

elevated.

Spinal immobilization should be provided if the patient sustained a fall

or other trauma. Monitor and maintain the patient’s airway.

87% of strokes are ischemic and should be considered for tPA, while

13% of strokes are hemorrhagic.

Assessment Signs & Symptoms

Ischemic S&S usually of slower onset

Hemiparesis or hemiplegia

Numbness or decreased sensation of face or

unilateral

Altered LOC or coma

Convulsions

Visual disturbances

Slurred or inappropriate speech

Headache or dizziness

Assessment

Signs & Symptoms

Cerebral Embolus with rapid onset

Emboli from valvular HD or Afib

rapid onset

Often with an identifiable cause (e.g. Afib,

Valvular heart disease, recent long bone

fracture)

Assessment

Signs & Symptoms

Cerebral hemorrhage associated with rapid

onset

high mortality rate

Often with severe HA (“Worst headache ever”)

N/V

Rapid decrease in LOC or seizure

Coma, Cushing’s and Herniation

Assessment

Past Medical History

Associated Altered LOC or Seizure?

Onset/Precipitating factors?

Initial symptoms and progression? Dizziness, Severe HA, N/V

Previous CVA or TIA?

Previous neurological deficits?

Concomitant illnesses?

Sickle Cell Disease

Atrial fibrillation

Risk factors for stroke & thrombus formation?

BCP, Smoking

HTN, CVD

Assessment Physical Exam

Mental Status & Behavior

Extremity Motor & Sensory

Gait

Pupils & Vision

Cincinnati Prehospital Stroke Scale

Evidence of Cushing’s Syndrome (Reflex)or

Herniation

Blood glucose level

CVA Management

Basic Objective

Improve cerebral blood flow and

oxygenation

CVA Management Airway

If no gag reflex, intubate

Otherwise, position to ensure drainage of

secretions

Suction as needed

Breathing

Oxygen via NRB

Ventilate with BVM and O2 if rate or tidal

volume inadequate

CVA Management Circulation

Check blood glucose level

Hypoglycemia may mimic CVA

Treat hypoglycemia with D50W

Establish IV Access

Draw blood samples

TKO

avoid solutions with glucose (Hypertonic)

Monitor ECG

10% of CVAs are associated with cardiac event

12 Lead ECG if suspected ischemia

CVA Management

Do not assume patient cannot

understand because they cannot talk

Position appropriately:

If hypertensive, semireclined (head slightly

elevated)

If normotensive, on affected side

If hypotensive, supine

CVA Management

Increased Blood pressure treated ONLY

if strongly suggestive of ischemic stroke

If systolic >220 or diastolic >120 consider

gradual blood pressure reduction

Labetalol

Nitropaste

Nitroprusside

Controlled reduction

Return to pre-CVA levels, NOT to “normal”

CVA Management

Thrombolytic agents

Consider for all patients with ischemic CVA

presenting within 3 hours of onset

Early recognition of ischemic stroke and

administration of thrombolytics can

prevent/limit loss of neurologic function

Requires CT scan!!!

CVA Management Think like AMI of the Brain

Time is Muscle….. Time is Brain

Therapy Mainstays

Oxygenation/Ventilation

IV Access

Rapid assessment & differential

Treat associated conditions (hypoglycemia,

hypoxia, hypotension)

Rapid Transport to appropriate facility CT Scan & Thrombolytics vs. CT Scan & Neurosurgery

Definitions

Primary Stroke Center (PSC) – a hospital that is currently

certified by The Joint Commission (TJC) or Healthcare

Facilities Accreditation Program (HFAP) as a Primary

Stroke Center.

Definitions

Emergent Stroke Ready Hospital (ESRH) – a hospital which

provides emergency care with a commitment to Stroke with

recognition by Illinois Department of Public Health that has

the following capabilities:

CT availability with in-house technician availability

24/7/365

Lab availability 24/7/365

Ability to rapidly evaluate an acute stroke patient to

identify patients who would benefit from thrombolytic

administration

Ability and willingness to administer thrombolytic

agents to eligible acute Stroke patients

Accepts all patients regardless of bed availability

Definitions

Non-Stroke Hospital – No recognized organized

treatment for acute stroke.

INTERHOSPITAL TRANSPORT

GUIDELINES FOR CONFIRMED STROKE

PATIENTS

TPA (Activase / alteplase) Transfers

Patients with a tPA infusion in progress must be accompanied by

a Registered Nurse.

Patients that have completed a tPA infusion must be transported

by an ILS/ALS ambulance.

It is preferred to complete tPA before transferring patient.

Hemorrhagic Transfers

Keep head of cot elevated at least 30 degrees (if stable) and

head positioned midline.

Vital Signs and Neuro checks every 15 minutes

Notify Medical Control immediately of

SBP > 180 mmHg

DBP > 105 mmHg

Deterioration in level of consciousness

Bleeding at any location

Severe headache

Time is Brain !!!!!!!