CVA

CVA/STROKE

Purpose:

This protocol is used for those patients exhibiting signs consistent with acute stroke/CVA/”Brain Attack” (altered mental status, slurred speech, loss of function of any body part, hemiplegia, loss of vision, weakness of facial muscles, loss of sensation, drooling, etc.). Other causes should be ruled out (hypoglycemia, drug overdose, hypoxia, etc.).

2.5.5 CVA/Stroke Adult Medical Protocol

BASIC LEVEL: EMT and PARAMEDIC

1. Initial Patient Assessment Protocol 2.1.1.

2. Airway Assessment/Management Protocol 2.1.2. Oxygen via nasal cannula @2 - 4 LPM to maintain pulse ox of > 94% (non-rebreather @15 LPM if SpO2 < 90%).

3. When CVA is suspected, transport to the hospital should not be delayed. Determine if patient has facial droop, abnormal speech, or arm drift.

4. If possible place in Semi-Fowler’s position with head of bed elevated 30 degrees for transport (if patient unable to tolerate, transport flat).

Procedure

5. Assess for and document Glasgow Coma Scale.

6. Attach cardiac monitor and pulse oximeter.

7. Keep patient NPO.

8. Determine time last seen normal. If onset of symptoms is within 6 hours notify hospital of a “stroke alert”.

9. Try to determine if patient had a seizure prior to onset of “stroke” symptoms as he/she may have a condition called Todd’s paralysis, which is NOT treated with thrombolytics. Relay this information to the hospital.

Procedure cont.

10. Cincinnati Pre-hospital Stroke Scale: (CPSS) a. Assess for the unilateral presence of at least one of the following: Item Description 1. Facial droop: Ask the patient to smile. Watch for weakness on one side of the face. 2. Arm drift: Ask the patient to hold both arms out with palms up and eyes closed for 10 seconds. Watch for a drift of one side. A positive result is present if there is weakness in one arm. Weakness in both arms or normal strength is a negative test result. 3. Slurred speech: Ask the patient to repeat a simple sentence such as “The sky is blue in Cincinnati.” Inability to repeat the words correctly and intelligibly is a positive result.

TRANSPORT: DESTINATION DETERMINATION

The RACE app can be downloaded to your phone for free!

If CPSS positive, proceed to Rapid Arterial Occlusion Evaluation: (RACE)

Any patient presenting with stroke symptoms of any kind, should, at minimum be transported to a designated stroke

center (either Primary or Comprehensive).

11. Rapid Arterial Occlusion Evaluation (RACE)The Rapid Arterial Occlusion Evaluation (R.A.C.E.) is based on an

abbreviated version of the National Institutes of Health Stroke Scale (NIHSS), the “gold standard” for evaluating stroke victims. The

maximum score is 9 (not 11) because the evaluation of the final two components is done based on the left or right side presentation, not

both simultaneously.

12. For any patient with a Rapid Arterial Occlusion Evaluation (RACE) score of 4 or above, every effort should be made to transport the patient to a Comprehensive Stroke Center, if available. (While transport destination is ultimately the decision of the patient and his/her family, crew members should provide the Protocol and Assessment based recommendations to the family so that they may make the most informed decision possible.)

Cincinnati Pre-Hospital Stroke Scale determines the presence of a stroke.

The RACE evaluation

determines the severity of the

stroke

1. Endotracheal intubation if patient does not have an intact gag reflex or for markedly decreased LOC, inability to maintain a patient airway, or for GCS <= 8.

2. Initiate IV lactated Ringer's or normal saline at 75cc/hr for patients 12 yrs. or older. Obtain two intravenous lines if possible. 3. Determine serum glucose level with Glucometer: a. If sugar 60 mg/dl - 80 mg/dl; give; 100 ml 10% Dextrose IV or Glucagon 1mg IM or Sublingual glucose paste, may repeat x 1 if after 15 minutes recheck, fingerstick glucose < 80 mg/dl. b. If Blood sugar < 60 mg/dl; 100 - 250 10% Dextrose IV (titrate to effect) or Glucagon 1 mg IM. c. If glucose > 80 mg/dl and < 200 mg/dl, provide supportive care, keep NPO. d. If glucose > 200 mg/dl, go to Hyperglycemia Protocol.4. If a stroke patient is found to be hypertensive, do not treat in the pre-hospital setting

unless ordered to do so by medical control. Hypertension could represent a compensatory response to the stroke to increase the cerebral perfusion pressure.5. Treat seizures with: a. Valium 5-10 mg IVP or Versed 5 mg IM or 1 – 2.5 mg IVP/IN (may repeat x 1). Monitor respiratory efforts and intervene as indicated.

ALS LEVEL 1: PARAMEDIC ONLY

1. Contact medical control if seizure did not respond to Valium.2. Contact medical control for treatment of agitation with: a. Valium 2-5 mg IVP. May repeat every 10 minutes to a maximum of 10 mg. Or b. Versed 2 mg IV. May repeat x 1 PRN. Maximum dose 4mg. 3. In the presence of acute stroke (CVA), hypertension may be lowered in special circumstances only with a physician order.

ALS LEVEL 2: MEDICAL CONTROL

Patient care: Takes care of most cases of ischemic (blood vessel blockage) types of stroke.

Minimally invasive catheter procedures: Not required.

Specialized ICU: No requirement for a separate intensive care for stroke patients.

Neurosurgery: Access to neurosurgery within 2 hours.

Patient transfers: Sends complex patients to a Comprehensive Stroke Center.

Primary Stroke Center

Patient care: Cares for all types of stroke patients, (blood vessel blockage) including bleeding (or hemorrhagic) strokes, such as those caused by brain aneurysms.

Minimally invasive catheter procedures: 24/7 access to minimally invasive catheter procedures to treat stroke.

Specialized ICU: Dedicated neuroscience intensive care unit for unit stroke patients.

Neurosurgery: On-site neurosurgical availability 24/7 with the ability to perform complex neurovascular procedures, such as brain aneurysm clipping, vascular malformation surgery and carotid endarterectomy.

Patient transfers: Receives patients from Primary Stroke Centers.

Comprehensive Stroke Center

Ischemic stroke (Clots) occurs as a result of an obstruction within a blood vessel supplying blood to the brain. It accounts for 87 percent of all stroke cases

Hemorrhagic stroke occurs when a weakened blood vessel ruptures. Two types of weakened blood vessels usually cause hemorrhagic stroke: aneurysms and arteriovenous malformations (AVMs). But the most common cause of hemorrhagic stroke is uncontrolled hypertension (high blood pressure)

TIA (transient ischemic attack) is caused by a temporary clot. Often called a “mini stroke”, these warning strokes should be taken very seriously.

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SAVE THE PENUMBRA!

Depending on which region of the brain the stroke occurs, the effects may be very different. The brain is divided into 3 main areas:

Cerebrum (consisting of the right and left sides or hemispheres)CerebellumBrainstemBrainstem

Hemorrhagic Stroke

There are two types of hemorrhagic strokes:

Intracerebral hemorrhage is the most common type of hemorrhagic stroke. It occurs when an artery in the brain bursts, flooding the surrounding tissue with blood.

Subarachnoid hemorrhage is a less common type of hemorrhagic stroke. It refers to bleeding in the area between the brain and the thin tissues that cover it.

There are two kinds of thrombosis that can lead to a stroke: large vessel thrombosis and small vessel disease, also called “lacunar infarction.” Thrombotic stroke is caused by an artery disease called atherosclerosis, which is followed by the formation of blood clots.

According to the National Stroke Association (NSA), large vessel thrombosis is the most common of the thrombotic strokes.

Types of Thrombotic Stroke

Small vessel disease, or “lacunar infarction,” is the other type of stroke-causing thrombosis. Small vessel disease develops from a blood clot in a small artery.According to the NSA, researchers are uncertain about the exact cause of lacunar infarction. But they do know that the condition is related to high blood pressure.Both types of thrombotic stroke have been linked to coronary artery disease, the NSA reports.

Lacunar Infarction

Depending on the area and side of the cerebrum affected by the stroke, any, or all, of these functions may be impaired:

Movement and sensation Speech and language Eating and swallowing Vision Cognitive (thinking, reasoning, judgment, and memory) ability Perception and orientation to surroundings Self-care ability Bowel and bladder control Emotional control Sexual ability

In addition to these general effects, some specific impairments may occur when a particular area of the cerebrum is damaged.

EFFECTS OF STROKE IN THE CEREBRUM:

Left-sided weakness or paralysis and sensory impairment. Denial of paralysis or impairment and reduced insight into

the problems created by the stroke (this is called “left neglect”).

Visual problems, including an inability to see the left visual field of each eye.

Spatial problems with depth perception or directions, such as up or down and front or back.

Inability to localize or recognize body parts. Inability to understand maps and find objects, such as

clothing or toiletry items. Memory problems. Behavioral changes, such as lack of concern about

situations, inappropriateness, and depression.

EFFECTS OF RIGHT HEMISPHERE STROKE IN CEREBRUM:

Right-sided weakness or paralysis and sensory impairment Problems with speech and understanding language

(aphasia) Visual problems, including the inability to see the right

visual field of each eye Impaired ability to do math or to organize, reason, and

analyze items Behavioral changes, such as depression, cautiousness, and

hesitancy Impaired ability to read, write, and learn new information Memory problems

EFFECTS OF LEFT HEMISPHERE STROKE IN CEREBRUM:

Less common in the cerebellum area, the effects can be SEVERE. Four common effects of strokes in the cerebellum include: Inability to walk and problems with coordination and

balance (ataxia) Dizziness Headache Nausea and vomiting

EFFECTS OF STROKE IN THE CEREBELLUM:

EFFECTS OF A STROKE IN THE BRAINSTEM: