Assessment and Treatment of the Stroke Patient

Assessment and Treatment of the Stroke Patient

Clinical Guidelines and Routing Criteria for EMS in Iowa

November 2012

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Stroke

Fourth leading cause of death in the U.S.Leading cause of disability in the U.S., affecting over 700,0004.4 million stroke survivors85% ischemic

Less than 25% of eligible thrombolytic candidates are receiving therapy

Why we are here today…

Stroke system of care in Iowa can workWe have laid the groundwork and gave CDC noticeThey believed us…Funding for 3 years through the Paul Coverdell National Acute Stroke Program

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Why we are here today…

Studies are unequivocal – EMS / Hospital articulation is one of the most important factors in achieving time to treat.EMS cannot teach/ be taught in standalone mode any longer. We are an integral part of the healthcare system

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Stroke - Goals

Understand our shortfallsReview the disease processApply stroke screening processDiscuss current treatment practices

Treatment windowsPrimary stroke center destination

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Stroke identification

How easy is it to identify a stroke?90 % in tertiary care hospitals (stroke centers, teaching institutions)78% in community hospitals

6Cerebrovasc Dis 1999;9:224-230 (DOI: 10.1159/000015960)

Stroke identification

Study of 1045 patients transported by EMS; 440 with diagnosis of stroke

Paramedics correctly diagnosed 193 (49%)Paramedics missed 247 (56%)

7Journal of Emergency Medicine 2007;11:092

Stroke identification

Study of 1247 patients; 441 diagnosed with stroke

Paramedic PPV 47%Paramedic NPV 58%

8Stroke 2007;38:501

Stroke Identification

Paramedics demonstrated 61 – 66% sensitivity for identifying stroke after traditional training methodsSensitivity increased to 86 – 97% after receiving training in using a stroke assessment tool, such as the CPSS or LAPSS

2010 CPR & ECC Guidelines; Circulation, October 18, 2010

What causes a stroke?

77% – 94% ischemicThromboembolicCardioembolic

6%-23% hemorrhagicIntracerebral bleedSub-arachnoid hemorrhage

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Anterior Circulation

Internal Carotid (ICA) Ascends through base of skull to give rise to the anterior and middle cerebral arteries, and connect with the posterior half of circle of Willis via posterior communicating artery

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Anterior Cerebral Artery

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Anterior Cerebral Artery

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Middle Cerebral Artery – M 1, 2, & 3 Segments

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Middle Cerebral Artery

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Cerebral Anatomy

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Posterior Circulation Vertebral-Basilar

Vertebral ascends from the subclavian arteries, through the transverse foramen of the cervical vertebrae to enter the cranial cavity via the foramen magnum. Gives branch to basilar which terminates into the posterior cerebral arteries

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Posterior Circulation

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Cerebral Anatomy

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Stroke Symptoms

Right Hemisphere Left sided paralysis Spatial/perception

problems. Distance, size

position Judgment of own

abilities Impulsive behavior Left sided neglect Left visual field cut

Left Hemisphere Right sided paralysis Speech / language

problems Expressive Receptive

Slow, cautious behavior

Good judgment about ability / disability

Right visual cut25

Visual Field Deficits

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Current Treatments(FDA Approved)

Thrombolytics (t-PA)3 hoursRisk factors

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Current Treatments

ECASS 3Extends time window to 4.5 hours for IV t-PA

Published Sept. 2008 in New England Journal of MedicineNot yet FDA approvedAll primary stroke centers in Iowa use this 4.5 hour standard

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Current Treatments(Not FDA Approved)

Intra-arterial t-PA6 hoursRisk factors

Mechanical Clot Removal8 hoursRisk factors

Other StudiesDesmotoplaseNeuroprotective agents

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So Now What?!

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Evidence Based Approach

Higher Prehospital Priority Level of Stroke Improves Thrombolysis Frequency andTime to Stroke Unit: The Hyper Acute STroke Alarm (HASTA) Study. Stroke. 2012 Oct;43(10):2666-2670. Epub 2012 Aug 9.

Barriers to the utilization of thrombolysis for acute ischaemic stroke. J Clin Pharm Ther. 2012 Aug;37(4):399-409. doi: 10.1111/j.1365-2710.2011.01329.x. Epub 2012 Mar 4.

Prehospital diagnosis and management of patients with acute stroke. Emerg Med Clin North Am. 2012 Aug;30(3):617-35. doi: 10.1016/j.emc.2012.05.003. Pre- and in-hospital intersection of stroke care. Ann N Y Acad Sci. 2012 Sep;1268(1):145-51. doi: 10.1111/j.1749-6632.2012.06664.x.Overview of key factors in improving access to acute stroke care. Neurology. 2012 Sep 25;79(13 Suppl 1):S26-34.

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Pre-Hospital Intervention

Good assessments Physical exams History taking

Stroke centers

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Reproducible Assessment

Accuracy of stroke recognition by emergency medical dispatchers and paramedics--San Diego experience.Prehosp Emerg Care. 2008 Jul-Sep;12(3):307-13.

EMD Dispatchers had higher sensitivity and PPV for recognition of stroke than paramedic at pt side

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Stroke Assessment

NIH stroke scale42 point scale to look at neurological deficitsGreat baseline – creates a uniform exam that can be reproduced

Good for transition of care Easier to track statistically

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Stroke Assessment – NIH Scale

Complete assessment is great tool for baselineTests all cranial nerves, peripheral nerves for sensation, movement, spatial perception, coordination…TOO LONG FOR PRE-HOSPITAL SCENES

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Cincinnati Prehospital Stroke Scale

Facial DroopArm DriftSpeech

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Stroke Assessment

Cincinatti Pre-Hospital Stroke Score (CPSS)Facial droopSpeechArm drift

Los Angelas Pre-Hospital Stroke Scale (LAPSS)Miami Emergency Neruologic Defecit Exam (MEND)

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Stroke Assessment

Differential DiagnosesSeizure / postictalHypoglycemiaBell’s PalsyMigraineTumor

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Treatment Goals

Oxygenate the brain – there still may be some left!

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Treatment Goals

BP management (?)CPP = MAP – ICP

If hypertensive crisis in conjunction with stroke, call medical control before lowering pressureAHA guidelines – drop systolic BP by increments – no more than 25% of initial value, or diastolic approaches 100

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Treatment Goals

OxygenBlood Glucose checkCardiac Monitor

A-fib common cause of emboliAMI another cause

IV access Elevate head – facilitate venous drainageAspirin?

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What about Stroke Centers?

Positive effects of stroke center are comparable to the effects of timely administration of tPA…Preferential routing to stroke centers

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Iowa EMS Protocol Utilize CPSS or other reproducible stroke assessmentIf stroke symptoms are present with an onset of less than 4.5 hours

Transport to primary stroke center if transport is 30 minutes or lessTransport to closest stroke capable hospital if greater than 30 minutes

Iowa Primary Stroke Centers

Iowa Healthcare Collaborativewww.ihconline.org

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Questions????

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