St. Elizabeth HealthcareSt. Elizabeth HealthcarePre-hospital CarePre-hospital Care

Stroke AssessmentStroke Assessment

Update 2010

Debbie Szurlinski, EMT-P EMS Coordinator

PurposePurpose

To provide EMTs and Paramedics To provide EMTs and Paramedics with the fundamental knowledge with the fundamental knowledge needed to recognize and manage needed to recognize and manage potential stroke in the pre-hospital potential stroke in the pre-hospital setting and make appropriate setting and make appropriate transport and hospital notification transport and hospital notification decisions based on the Stroke POE decisions based on the Stroke POE Plan.Plan.

ObjectivesObjectives

Identify the different categories of strokesIdentify the different categories of strokes List common signs & symptoms of strokeList common signs & symptoms of stroke Provide several risk factors for strokeProvide several risk factors for stroke Explain the importance of rapid stroke Explain the importance of rapid stroke

therapytherapy Describe pre-hospital assessment and careDescribe pre-hospital assessment and care Describe the Regional Stroke POE planDescribe the Regional Stroke POE plan Discuss appropriate treatment and Discuss appropriate treatment and

transport modalitiestransport modalities Describe detailed stroke documentationDescribe detailed stroke documentation

Stroke BackgroundStroke Background

Third leading cause of death in the U.S.Third leading cause of death in the U.S. Approx. 700,000 people suffer strokes Approx. 700,000 people suffer strokes

each yeareach year Incidence increases with ageIncidence increases with age Mortality from stroke increases with ageMortality from stroke increases with age Frequent cause of disabilityFrequent cause of disability Pre-hospital care has been primarily Pre-hospital care has been primarily

supportivesupportive

Stroke in the Pre-Hospital SettingStroke in the Pre-Hospital Setting

Stroke must be suspected quickly by Stroke must be suspected quickly by EMT’s and Paramedics in the field.EMT’s and Paramedics in the field.

Extensive neurological neurological exams Extensive neurological neurological exams are impractical in the pre-hospital settingare impractical in the pre-hospital setting

After assessment, notify hospital,rapid After assessment, notify hospital,rapid transport without delay to closest certified transport without delay to closest certified stroke facilitystroke facility

Cincinnati Pre-hospital StrokeCincinnati Pre-hospital Stroke ScaleScale

Patients with 1 of these three finding- Patients with 1 of these three finding- (as a new event)-(as a new event)- have 72% have 72% probability of ischemic strokeprobability of ischemic stroke

If all (3) findings are present If all (3) findings are present probability of an acute stroke is more probability of an acute stroke is more than 85%than 85%

Immediately contact medical control Immediately contact medical control and destination ED and provide pre-and destination ED and provide pre-arrival notificationarrival notification

Stroke AssessmentStroke Assessment One of the most important aspects of your One of the most important aspects of your

patient assessment must be the time of patient assessment must be the time of onset of first symptomonset of first symptom

Document time the patient was last seen Document time the patient was last seen acting normalacting normal

The onset time has the most important The onset time has the most important implications for potential therapy.implications for potential therapy.

Early notification to STROKE facility is Early notification to STROKE facility is essentialessential

Careful assessment of a stroke is a must, Careful assessment of a stroke is a must, signs of stroke can be very subtlesigns of stroke can be very subtle

Conditions that mimic StrokeConditions that mimic Stroke

HypoglycemiaHypoglycemia Electrolyte imbalances (esp. Sodium)Electrolyte imbalances (esp. Sodium) Epidural or subdural hematomaEpidural or subdural hematoma Brain abscess or tumorBrain abscess or tumor Post-seizurePost-seizure MigraineMigraine

Etiology OverviewEtiology Overview

Source: Brady CD, Paramedic Care: Principles & Practice Vol.3 ©2001

Atheromatous

Atheromatous

Stroke Risk FactorsStroke Risk Factors

High blood pressureHigh blood pressure Atrial fibrillation, CHFAtrial fibrillation, CHF High cholesterolHigh cholesterol Diabetes (twice the risk)Diabetes (twice the risk) Smoking (50% higher risk)Smoking (50% higher risk) Alcohol or Drug AbuseAlcohol or Drug Abuse Inactivity or ObesityInactivity or Obesity Clotting problems (OCP, Sickle Cell)Clotting problems (OCP, Sickle Cell)

Stroke Risk Factors (con’t)Stroke Risk Factors (con’t)

Prior Stroke HistoryPrior Stroke History HeredityHeredity Age (risk increases with age)Age (risk increases with age) GenderGender

• more common in menmore common in men• more women die from strokemore women die from stroke

Race (greater risk among African Race (greater risk among African AmericansAmericans))

Temporary interruption of blood Temporary interruption of blood supply to brainsupply to brain

Carotid artery disease a common Carotid artery disease a common causecause

Stroke-like neurological deficit Stroke-like neurological deficit symptomssymptoms• abrupt onsetabrupt onset• Symptoms resolve in less than 24 hours, Symptoms resolve in less than 24 hours,

usually within minutes.usually within minutes.• No long-term effects, but high stroke riskNo long-term effects, but high stroke risk

Transient Ischemic AttacksTransient Ischemic Attacks (TIA’s)(TIA’s)

TIA’s, (con’t)TIA’s, (con’t)

One third of TIA patients will suffer an One third of TIA patients will suffer an acute strokeacute stroke

Evaluate through history taking:Evaluate through history taking:• History of HTN, prior stroke, or TIAHistory of HTN, prior stroke, or TIA• Symptoms and their progressionSymptoms and their progression

Impossible (at this time) in pre-Impossible (at this time) in pre-hospital setting to determine if a hospital setting to determine if a neurological event is due to TIA or neurological event is due to TIA or strokestroke

Ischemic StrokeIschemic Stroke

About 80% of all strokesAbout 80% of all strokes Occurs when a cerebral artery is blocked Occurs when a cerebral artery is blocked

by a clot or other foreign matterby a clot or other foreign matter Causes Causes ischemiaischemia (inadequate blood (inadequate blood

supply to tissue)supply to tissue) Progresses to Progresses to infarctioninfarction (death of tissues) (death of tissues) Classified as:Classified as:

• Embolic StrokeEmbolic Stroke• Thrombotic StrokeThrombotic Stroke

Ischemic StrokeIschemic Stroke

EmbolicEmbolic• The occlusion is caused by an The occlusion is caused by an embolusembolus (solid, (solid,

liquid, or gaseous mass) carried to a blood liquid, or gaseous mass) carried to a blood vessel from another areavessel from another area

• Most common emboli are blood clotsMost common emboli are blood clots• Risk factors for blood clots include Atrial Risk factors for blood clots include Atrial

Fibrillation and diseased or damaged carotid or Fibrillation and diseased or damaged carotid or vertebral arteriesvertebral arteries

• Rare causes of emboli include air, tumor tissue, Rare causes of emboli include air, tumor tissue, and fatand fat

• Occurs suddenly & may rarely be accompanied Occurs suddenly & may rarely be accompanied by headacheby headacheSource: http://www.irishhealth.com/?

level=4&con=8

Ischemic StrokesIschemic StrokesThromboticThrombotic

• The occlusion is caused by a The occlusion is caused by a cerebral cerebral thrombusthrombus; a blood clot which develops ; a blood clot which develops gradually in a previously diseased artery gradually in a previously diseased artery and obstructs itand obstructs it

• Caused by atherosclerosis:Caused by atherosclerosis: atheromatous plaque deposits form on the atheromatous plaque deposits form on the

inner walls of arteries, resulting in narrowing inner walls of arteries, resulting in narrowing and reduction of blood flowand reduction of blood flow

platelets adhere to the roughened surface of platelets adhere to the roughened surface of the plaque deposit and a blood clot is createdthe plaque deposit and a blood clot is created

Ischemic StrokesIschemic Strokes

ThromboticThrombotic (con’t) (con’t)• Signs & symptoms may develop more Signs & symptoms may develop more

graduallygradually• Often occurs at night with patient Often occurs at night with patient

awakening from sleep with symptomsawakening from sleep with symptoms

Source: http://www.strokecenter.org/pat/ais.htm

Hemorrhagic StrokesHemorrhagic Strokes

About 20% of all strokesAbout 20% of all strokes Onset usually sudden with severe headacheOnset usually sudden with severe headache Classified as:Classified as:

• Intracerebral hemorrhage (within the brain)Intracerebral hemorrhage (within the brain)• Subarachnoid hemorrhage (in the fluid filled Subarachnoid hemorrhage (in the fluid filled

spaces around the blood vessels outside the spaces around the blood vessels outside the brain)brain)Intracerebral hemorrhageIntracerebral hemorrhage

•Most occur in the hypertensive Most occur in the hypertensive patient when a small vessel within patient when a small vessel within the brain tissue rupturesthe brain tissue ruptures

•Hemorrhage inside the brain often Hemorrhage inside the brain often tears and separates brain tissuetears and separates brain tissue

Intracerebral HemorrhageIntracerebral Hemorrhage

Often caused by a ruptured blood vessel within Often caused by a ruptured blood vessel within the brain tissue of the hypertensive patient.the brain tissue of the hypertensive patient.

Hemorrhagic StrokesHemorrhagic Strokes

Subarachnoid hemorrhageSubarachnoid hemorrhage• Most often result from congenital blood vessel Most often result from congenital blood vessel

abnormalities (e.g., aneurysm) or head traumaabnormalities (e.g., aneurysm) or head trauma

Source: http://medic.med.uth.tmc.edu/edprog/Path/NeuroIIb.htm

•Herniation of brain tissue may occurHerniation of brain tissue may occur

•Blood in the subarachnoid space may Blood in the subarachnoid space may impair drainage of cerebrospinal fluid impair drainage of cerebrospinal fluid and cause a rise in intracranial pressure and cause a rise in intracranial pressure

What can be done?What can be done?

Rapid recognition and prompt transport to Rapid recognition and prompt transport to Hospital.Hospital.

A Primary Stroke service provider is a DPH A Primary Stroke service provider is a DPH designated facility that offers emergency designated facility that offers emergency diagnostic and therapeutic services provided by a diagnostic and therapeutic services provided by a multidisciplinary team and available 24 hours per multidisciplinary team and available 24 hours per day, 7 days per week to patients presenting with day, 7 days per week to patients presenting with symptoms of acute strokesymptoms of acute stroke..

GCNKSS and Massachusetts DPH.

Stroke Chain of SurvivalStroke Chain of Survival

The Stroke Chain of SurvivalThe Stroke Chain of Survival

All links will be strong...All links will be strong...

Time-Sensitive TherapyTime-Sensitive Therapy

TransportTransport to PSC within 2 hours of to PSC within 2 hours of symptom onset if possiblesymptom onset if possible

EMS must determine the exact time EMS must determine the exact time of onset as accurately as possible of onset as accurately as possible and also note the time the patient and also note the time the patient was last seen acting normalwas last seen acting normal

Time = Brain TissueTime = Brain Tissue

Team ApproachTeam Approach DetectionDetection

• Importance of early recognition by lay Importance of early recognition by lay publicpublic

Dispatch (9-1-1)Dispatch (9-1-1)• Obtains pertinent info; identifies urgencyObtains pertinent info; identifies urgency

Delivery (EMS)Delivery (EMS)• Evaluates, obtains symptom onset, Evaluates, obtains symptom onset,

minimizes on scene time; immediate minimizes on scene time; immediate transport and transport and pre-notificationpre-notification to PSS to PSS as as ssoon as possibleoon as possible!!

Team ApproachTeam Approach

Door (Primary Stroke Service)Door (Primary Stroke Service)• Alerts stroke team, performs patient Alerts stroke team, performs patient

exam & assessment, rapid CT scanexam & assessment, rapid CT scan DataData

• Reviews all pertinent patient informationReviews all pertinent patient information DecisionDecision

• Determines appropriate therapyDetermines appropriate therapy DrugDrug

• Administers appropriate therapyAdministers appropriate therapy

StrokeStroke

Once the diagnosis of stroke is Once the diagnosis of stroke is suspected, suspected, time in the field must time in the field must be minimized.be minimized.

The presence of a patient with acute The presence of a patient with acute stroke is astroke is a “ “load and go”load and go”

A more extensive examination or A more extensive examination or initiation of supportive therapies initiation of supportive therapies should be accomplished en-route to should be accomplished en-route to the hospital.the hospital.

Paralysis on one side Facial Droop Limb Weakness Paresthesias/Sensory loss

(numbness or tingling) Ataxia

• Gait Disturbance• Uncoordinated fine motor movements

Stroke: Signs & SymptomsStroke: Signs & Symptoms

Signs & SymptomsSigns & Symptoms

Speech Disturbance Vision ProblemsVision Problems HeadacheHeadache Confusion/AgitationConfusion/Agitation Dizziness/VertigoDizziness/Vertigo

CINCINNATI STROKE SCALECINCINNATI STROKE SCALE

Identifies patients with strokes.Identifies patients with strokes. Evaluates three major physical Evaluates three major physical

findings.findings. Facial droopFacial droop Motor arm weaknessMotor arm weakness Speech abnormalitiesSpeech abnormalities

FACIAL DROPFACIAL DROP

FACIAL DROOPFACIAL DROOP• Patient shows teeth or smilesPatient shows teeth or smiles

NORMALNORMAL ABNORMALABNORMAL

Speech DisturbanceSpeech Disturbance

AphasiaAphasia• Inability to speakInability to speak

DysphasiaDysphasia• Difficulty speakingDifficulty speaking

DysarthriaDysarthria• Impairment of the tongue muscles Impairment of the tongue muscles

essential to speechessential to speech

Vision ProblemsVision Problems

NystagmusNystagmus• Involuntary jerking of the eyesInvoluntary jerking of the eyes

DiplopiaDiplopia• Double visionDouble vision

Monocular blindnessMonocular blindness• Blindness in one eyeBlindness in one eye

Arm DriftArm Drift

• Have the patient close his / her eyes and Have the patient close his / her eyes and hold both arms outhold both arms out

• Normal-both arms move the same way. Normal-both arms move the same way. or both arms do not move at allor both arms do not move at all

• Abnormal- one arm does not move or Abnormal- one arm does not move or one arm drifts down compared to the one arm drifts down compared to the other arm.other arm.

Other findings such as pronater grip may be Other findings such as pronater grip may be helful.helful.

Scene safety & BSIScene safety & BSI Maintain airway & assist ventilations Maintain airway & assist ventilations

as indicated (do not hyperventilate)as indicated (do not hyperventilate) Provide 2 lpm OProvide 2 lpm O22 NC unless in NC unless in

respiratory distressrespiratory distress Provide C-Spine immobilization if Provide C-Spine immobilization if

indicatedindicated Obtain Vital Signs & SAMPLE historyObtain Vital Signs & SAMPLE history Collect or document ALL Collect or document ALL

medicationsmedications

Pre-hospital Care Pre-hospital Care

Pre-hospital Care, continuedPre-hospital Care, continued

Record onset time and phone access to Record onset time and phone access to witnesswitness

Do not allow patient to exert themselvesDo not allow patient to exert themselves Follow appropriate ALS / BLS protocolsFollow appropriate ALS / BLS protocols Do not administer aspirin unless Do not administer aspirin unless

evidence of acute coronary syndromeevidence of acute coronary syndrome Complete and then document results ofComplete and then document results of

•Cincinnati Stroke ScaleCincinnati Stroke Scale

Pre-hospital CarePre-hospital Care

Notify receiving facility ASAPNotify receiving facility ASAP Monitor/record VS every 5 minutes if Monitor/record VS every 5 minutes if

unstable, or every 15 minutes if stableunstable, or every 15 minutes if stable Position the patient, protecting paralyzed Position the patient, protecting paralyzed

extremitiesextremities Secure patient to stretcher and transport Secure patient to stretcher and transport

rapidly without excessive movement or rapidly without excessive movement or noisenoise

Use treatment eligibility checklist en-route Use treatment eligibility checklist en-route & include information in documentation& include information in documentation

Stroke: DocumentationStroke: Documentation

SAMPLESAMPLE Age, Sex, Race/EthnicityAge, Sex, Race/Ethnicity Onset time and last seen at baselineOnset time and last seen at baseline Assessment and care provided (BLS/ALS)Assessment and care provided (BLS/ALS) Receiving Primary Stroke Service (PSS)Receiving Primary Stroke Service (PSS) Trip times (dispatch, patient contact, Trip times (dispatch, patient contact,

hospital notified, hospital arrival)hospital notified, hospital arrival) Eligibility checklist (include all information)Eligibility checklist (include all information)

Pre-hospital Care: ALSPre-hospital Care: ALS

Contact medical control prior to Contact medical control prior to administering any drugs.administering any drugs.

IV access & 12 lead should not delay IV access & 12 lead should not delay transporttransport

Scenario 1Scenario 1

67 year old female at home67 year old female at home Chief complaint dizzinessChief complaint dizziness History of NIDDMHistory of NIDDM

Scenario 1 examinedScenario 1 examined

There could be other causes of There could be other causes of dizziness, do not rule out stroke. dizziness, do not rule out stroke. Review other causes.Review other causes.

Older patients and those with Older patients and those with Diabetes are at increased risk of Diabetes are at increased risk of ischemic stroke.ischemic stroke.

Discuss the other findings that might Discuss the other findings that might make you think this patient is make you think this patient is experiencing a strokeexperiencing a stroke..

Scenario 2Scenario 2

54 year old male at minor MVA54 year old male at minor MVA Chief complaint sudden onset Chief complaint sudden onset

headacheheadache History of hypertensionHistory of hypertension

Scenario 2 examinedScenario 2 examined

The MVA may have caused the The MVA may have caused the headache, but maybe the headache headache, but maybe the headache caused the MVA. Remember to consider caused the MVA. Remember to consider all the possibilities.all the possibilities.

Patients with hypertension are at Patients with hypertension are at increased risk of ischemic stroke and increased risk of ischemic stroke and intracerebral hemorrhage.intracerebral hemorrhage.

Headache is unusual in ischemic stroke, Headache is unusual in ischemic stroke, but is the hallmark of hemorrhagic but is the hallmark of hemorrhagic stroke.stroke.

Stroke POE PlanStroke POE Plan

GOAL: Rapid transport to the closest GOAL: Rapid transport to the closest PSS facility within 2 hours of PSS facility within 2 hours of symptom onset.symptom onset.

Choose most appropriate mode of Choose most appropriate mode of transport (ground, air) and transport (ground, air) and destination to achieve thisdestination to achieve this..

DocumentationDocumentation Complete a Pre-hospital Stroke Complete a Pre-hospital Stroke

Assessment SheetAssessment Sheet Remember to leave a copy of the Patient Remember to leave a copy of the Patient

Care Report at the hospital Care Report at the hospital The EMS patient care report is a CRITICAL The EMS patient care report is a CRITICAL

part of the patient’s medical record and part of the patient’s medical record and contains vital information pertinent to contains vital information pertinent to continuing care at the hospital and to continuing care at the hospital and to providing follow-up information to EMSproviding follow-up information to EMS..

SummarySummary

Early detection of CVA / TIA in the pre-Early detection of CVA / TIA in the pre-hospital care setting can have a hospital care setting can have a

dramatic effect of the mortality and dramatic effect of the mortality and morbidity of patients. Using the morbidity of patients. Using the

Cincinnati Stroke Scale pre-hospital Cincinnati Stroke Scale pre-hospital personnel can quickly and accurately personnel can quickly and accurately

access the neurological status of a access the neurological status of a patient presenting with signs and patient presenting with signs and

symptoms of a CVA / TIAsymptoms of a CVA / TIA

ReferencesReferences Bledsoe, B., Porter, R., Cherry, R. (2003). Neurology. Bledsoe, B., Porter, R., Cherry, R. (2003). Neurology. In Brady, In Brady,

Essentials of Paramedic CareEssentials of Paramedic Care (pp. 1356-1361, (pp. 1356-1361, 1827-1828). Upper 1827-1828). Upper Saddle River, NJ: Pearson Saddle River, NJ: Pearson Education, Inc.Education, Inc.

Dambinova, S. (2004). Diagnostic Potential of New Dambinova, S. (2004). Diagnostic Potential of New Brain Brain Markers for TIA/Stroke Assessment. Markers for TIA/Stroke Assessment. Business Business Briefing:Medical Briefing:Medical Device Manufacturing & TechnologyDevice Manufacturing & Technology, 1-4., 1-4.

(2004). Acute Stroke. In (2004). Acute Stroke. In EMS Pre-hospital Treatment EMS Pre-hospital Treatment Protocols Protocols (V. 5.1, (V. 5.1, Protocol 3.11). MDPH/OEMSProtocol 3.11). MDPH/OEMS..

www.ninds.nih.gov www.strokeassociation.org www.stopstroke.org

Internet ReferencesInternet References

www.ninds.nih.gov www.strokeassociation.org www.stopstroke.org