EMS in Stroke Care: A Critical Partnership Spokane County EMS Objectives Identify the types and time limitations for acute ischemic stroke treatment options Identify the importance of early identification of stroke Name three pre-hospital stroke scales available for field use List three critical tasks for EMS pre-hospital stroke care Stroke Facts Effects > 690,000 adults yearly 1 Currently is the 5 th leading cause of death in the United States Is the leading cause of disability in the United States An estimated 6.6 million Americans 20 years of age have had a stroke 2 Of all strokes, 85% are ischemic, and 15% are hemorrhages (ICH or SAH) 2 1
The Golden Hour of Stroke Intravenous tpa remains the only medication approved for treatment of acute stroke. Must be given within 3 hours (with extended window to 4.5 hours) Greatest improvement when given in less than 90 minutes from symptom onset Time window demands critical cooperation between EMS and hospital system Beyond the Golden Hour. Intra-arterial clot retrieval device Efficacy strongly supported by recent clinical trials (ESCAPE, Extend I-A, Mr. Clean, SWIFT Prime) Requires presence of large artery occlusion Treatment time windows: 0-6 hours for anterior cerebral circulation 0-12 hours for posterior cerebral circulation Acute Stroke Assessment 2
Anterior Cerebral Circulation Anterior Cerebral Circulation Symptoms: Paralysis of opposite side (lower face, arm, hand, leg) Sensory loss on opposite side Upper and/or lower vision loss on opposite side Partial or total loss of ability to communicate through language (speaking and/or understanding) Neglect (unaware) of affected side Most common arteries affected: Internal Carotid Artery Middle Cerebral Artery Posterior Cerebral Circulation 3
Posterior Cerebral Circulation Most common arteries affected: Vertebral Artery Posterior Cerebellar Artery Basilar Artery Symptoms: Vision loss Dizziness Slurred speech Nausea and vomiting Headache Uncoordinated movements Nystagmus Intra Cerebral Hemorrhage Within the main parts of the brain Often spontaneous Often related to hypertension Hemorrhages Sub Arachnoid Hemorrhage Causes: Vascular: Aneurysm rupture Trauma Complicating Factors in Acute Stroke Care The Public Denial / Fear Absence of pain Lack of knowledge The Healthcare Team Lack of knowledge Slow triage processes Reluctance to treat 4
EMS: A Critical Link in the Chain Activation of 911 Determine last known normal Priority dispatch Use of pre-hospital stroke assessment tool Pre-hospital management Limited scene time (<15 minutes) Rapid transport to nearest appropriate hospital Cincinnati Pre-Hospital Stroke Scale Pre-Hospital Stroke Assessment Tools Facial Droop Normal: Both sides of face move equally Abnormal: One side of face does not move at all Arm Drift Normal: Both arms move equally or not at all Abnormal: One arm drifts compared to the other Speech Normal: Patient uses correct words with no slurring Abnormal: Slurred or inappropriate words or mute Pre-Hospital Stroke Assessment Tools Los Angeles Prehospital Stroke Screen (LAPSS) Added elements Age History of seizures New onset of neuro symptoms in last 24 hours Ambulatory at baseline Blood glucose between 60 and 400 Exam Facial smile / grimace Grip Arm weakness Assesses for unilateral weakness If above positive : Code Stroke 5
Pre-Hospital Stroke Assessment Tools MEND* Exam Prehospital Checklist (*Miami Emergency Neurologic Deficit) Further added elements Monitoring scene time History of severe headache Head trauma at onset LOC, neck stiffness Mental status Cranial nerves Limb strength, sensory loss Medications, allergies, recent surgery, trauma, MI Management reminders Guidelines for Stroke Specific Report to the emergency department Pre-Hospital Evaluation Determine time of symptom onset (Last Known Well) Obtain family contact and cell phone information Obtain list of medications, especially note if on blood thinners Obtain allergies Obtain recent medical history: Bleeding, recent surgery, procedure or trauma, seizure at onset Note any history of metal or implants in body (possible MRI) Pre-Hospital Management ABC s Cardiac Monitoring, Vitals, Airway management Supplemental O2 to maintain O2 saturation > 94% Establish IV access per local protocol; draw lab tubes (18 gauge w/leur lock, above wrist) Check blood glucose (treat if < 50) Do not treat hypertension Rapid Transport to nearest appropriate stroke hospital *** Limit scene time to less than 15 minutes *** Pre-notify hospital of arrival (10 minutes) 6
EMS Response:Time Really IS Brain With large vessel occlusion, 1.9 million neurons die every minute Stroke is a neurological emergency! Cooperative treatment efforts between EMS systems and hospital stroke teams are impacting stroke outcomes References 1. Retrieved 2/21/2015 from: http://www.cdc.gov/stroke/facts.htm 2. Circulation. 2015;131:e29-e322. DOI: 10.1161/CIR.0000000000000152. Downloaded February 20, 2015 from http://circ.ahajournals.org/ 3. Stroke.2006; 37: 263-266DOI: 10.1161/01.STR.0000196957.55928.ab Retrieved 2/21/2015 from: http://stroke.ahajournals.org/content/37/1/263.full.pdf+html 4. Retrieved 2/21/2015 from: http://www.americannursetoday.com/identify-the-vessel-recognize-thestroke/ 5. Retrieved 2/21/2015 from: BMJ 2014;348:g3175 6. Retrieved 2/21/2015 from: https://www.uic.edu/com/ferne/pdf/posterior0501.pdf 7. Retrieved 2/21/2015 from: http://www.google.com/imgres?imgurl=https://classconnection.s3.amazonaws.com/542/fl ashcards/1331542/jpg/anterior_spinal_artery1333048345127.jpg&imgrefurl=https://www.studyblue.com/notes/note/n/neuro-ophth-vascularanatomy/deck/2473592&h=2585&w=2544&tbnid=wmpffl9wq7oqhm:&zoom=1&docid =b-2bjzdhqjbium&ei=urdovm7vazlgoath74g4cw&tbm=isch&ved=0ceiqmyg6mdo4za POST-TEST 1. IV tpa has a time window of 6 Hours? 2. Strokes in the anterior circulation will have different signs and symptoms as strokes in the posterior circulation. 3. High blood pressure should be treated pre-hospital. 4. Low blood sugar can produce symptoms that mimic stroke. 5. Intra-arterial clot retrieval has shown strong efficacy in recent clinical trials. 7
SECRET QUESTION What are three critical items to assess when at the scene of a new stroke patient? Special thanks to Sheila Crow Stitchin Dreams Embroidery wcsocrow@yahoo.com For providing our Secret Question prize Questions? Contact: Samantha Roberts 509-242-4264 1-866-630-4033 robertss@inhs.org Fax: 509-232-8344 8
Updates Please EMS Live@Nite presentation, all certificates will be printed by participants or their agency. The certificate template will be available through the health training website at the same location as all presentation downloads. It will be posted the day after each monthly presentation. 9