Acute Stroke - the role of EMS Diane Handler, RN, MSN, MeD, ANVP Stroke Coordinator Mercy Medical Center, Cedar Rapids. Iowa [email protected]
Dec 21, 2015
Acute Stroke - the role of EMS
Diane Handler, RN, MSN, MeD, ANVP Stroke CoordinatorMercy Medical Center, Cedar Rapids. [email protected]
Stroke is an emergency Stroke is treatable Stroke occurs at all ages! 1.9 million brain cells die/minute
The Facts
1. Understand symptoms of stroke. 2. Know the difference between ischemic
stroke and hemorrhagic stroke and treatment guidelines.
3. Review stroke syndromes to better understand stroke presentations.
4. Know times to treat goals for stroke. 5. Review triage considerations and when to
divert.
Objectives
780,000 strokes/ year Community role- education s/s and call 911 Dispatch role
Stroke high priority (like AMI) Screen for stroke symptoms 60 second turn around
More Facts
9 minutes to scene 15 minute on scene time Cincinnati stroke scale (arm, speech,
droop) Time of onset Check blood glucose Family/witness to ED/ cell phone # OVER TRIAGE -30%
EMS Role
Arm drift slurred speech facial droop
If one is positive = consider stroke
Cincinnati Stroke Scale
History – and why Time of onset Meds- on coumadin? Past medical Hx- HTN, diabetes, past stroke or
TIA A Fib, A Fib, A Fib, A Fib, A Fib…
Your Role
Acute Stroke Treatment
What is tPA? (tissue plasminogen activator) Approved for stroke in 1996 Enzyme that activates the clot busting system
in the body
Treatment
IV tPA Symptom onset 4.5 hrs IV tPA Symptom onset 3 hours
80 years old History of both previous stroke and diabetes
Stroke symptoms within 8 hrs- consider Intra-arterial tPA
Deadlines
Too late to ED On Coumadin and INR >1.7 Symptoms rapidly resolving Recent trauma, MI or stroke
Why no tPA
NINDS tPA Trial 30% more likely to have minimal or no
disability at 3 months. 6% risk of symptomatic bleeding with tPA 17% mortality with tPA and 21% with placebo
group
Outcomes
ED goals for time to treat
From Arrival to ED
Door to Doctor- 10 minutes
Door to neurological expertise – 15 minutes (by phone)
Door to CT taken – 25 minutes *
Door to CT interpretation – 45 minutes
Door to treatment with tPA – 60 minutes
Your Role
History EMS straight to CT
Why CT fast and first
What does a typical stroke look like?
Typical Stroke
Weakness on Left or Right side and may have facial droop
Visual gaze deviation Inability to speak and or confused
Typical Stroke…
Left Hemisphere Stroke
R side weakness R facial droop Speech affected- receptive or expressive
Left hemisphere stroke
L side weakness L facial droop Impaired decision making
Right hemisphere stroke
77 yo w, female Triage 1018 L facial droop, L hemiparesis, Last time seen normal 0828 Did not want to come to hospital Time to treat with tPA 49 minutes
Right hemisphere “Typical Stroke”
Small vessel disease Hypertension High cholesterol Diabetes Smoking Sedentary life style
Why did I have a stroke?Another typical stroke type
Cerebellum Loss of balance
Brain Stem Loss of consciousness
Occipital Lobes Visual changes
“Zebra” Strokes
38 yo female from Micronesia Symptom onset 0445 headache and dizziness,
LOB Posterior circulation Cerebellum stroke
Cause of stroke? Associated problems- heart disease, anemia
Less typical Stroke
43 yo male, unresponsive Hx not feeling well and vomiting Last normal night before Triage at 0814 L vertebral artery and basilar artery occulsion,
prob dissection (locked in)
Atypical Stroke
Nausea and vomiting Gaze palsy Swallow difficulty, slurred speech Hemiparesis or quadriplegia and sensory
loss Decreased level of consciousness
Brainstem Stroke
Cranial Nerves
82 yo male Sensory loss on left Visual field cut Weakness on the left
R Occipital Lobe Stroke
Less typical Stroke
36 yo female- headache migraine
47 yo female- weak R arm + leg, headache, chest pain Conversion reaction syndrome
65 yo female- slurred speech, decreased LOC hypogylcemia
85 yo male- in restaurant, became unresponsive Hypo-perfusion of brain due to low BP
Stroke Mimics
Seizures with todds paresis Tumor
*Call Stroke Alert in any case- over triage by 30% is expected
Other mimics
EMS Acute Stroke Report
March 2010, time ED arrival 2230 ,Patient 62 yo, M
Symptoms R side weakness, R facial droop, slurred speech (dysarthria), symptoms fluctuated. Time of symptom onset2159 Time to CT taken 25 minute
Treated with t-PA?yes Time to needle 61 minutes Disposition of patient- Intensive Care Center for 24 hours then Cardiac Stroke Center for 24 hours. Then home.
Comments- Good in transit time for EMS service. Symptoms fluctuated but tPA was given as symptoms could have stabilized to a major stroke. Patient made a good recovery with no rehab issues.
EMS Acute Stroke Report
Triage time- 1104, Sept 2010, 1104, 79 yo F Symptoms- R arm weakness, R facial droop,
dysarthria, symptom onset “Last normal” 0915 Taken dTo CT directly Treated with t-PA? yes Time to needle 43 minutes
Disposition of patient -To ICC then Cardiac Stroke Center
Comments: Patient has made a good recovery. Patient has a history of A Fib but was not treated with Coumadin as she was a fall risk in previous living situation. On MRI, multiple areas of stroke were noted in left frontal and temporal lobe – likely due to cardio-embolism from the A Fib. Started on Coumadin and will watch in new living area to prevent falls.
EMS Acute Stroke Report
Aug 2010, Triage 1723 66 yo, W, M SymptomsWeakness R side, leg greater
than arm. Time of symptom onset1300 Time to CT scan takenOn arrival Treated with t-PA?No, Arrived > 3 hours so could not give tPA
Disposition of patient To Cardiac Stroke Center, Acute, inpatient rehab and eventually home.
Comments: Had patient arrived within time IV tPA could have been given. For patients < 80 years old and with no prior history of stroke and diabetes, IV tPA can be given up to 4 ½ hours of symptom onset. Patients who are > 80 years old and who have both past stroke and diabetes need to be treated within 3 hours of symptom onset. * Education of patient to call 911 right away.
EMS Acute Stroke Report
Nov. 2010 56 yo, W, F, Symptoms -R Facial droop, R side
weakness. Time of symptom onset- 2130, Time to CT scan immediately, Treated with t-PA? yes Time to needle - 44 minutes
Disposition of patient - Intensive Care Center, then Stroke Center and home soon.
Comments: Good times to treat. Patient did very well post tPA. Had a small left “subcorticol” stroke (under the cerebral hemispheres). Complete work up done to find the cause in 56 yo female with no known risk factors.
Questions
How many brain cells die per minute?
What is the goal for response time?
What is the goal for on scene time?
Why not give tPA past 4.5 hours?