ACUTE STROKE CARE ACUTE STROKE CARE FOR THE EMS FOR THE EMS PROVIDERPROVIDER

Julie Berdis-RN,BSN,CNRN,Julie Berdis-RN,BSN,CNRN,Stroke CoordinatorStroke CoordinatorProvidence Sacred Heart Medical CenterProvidence Sacred Heart Medical CenterSpokane, WashingtonSpokane, Washington

DisclosuresDisclosures

No financial disclosuresNo financial disclosures Will be discussing off-label usesWill be discussing off-label uses Always follow your local and Always follow your local and

regional protocolsregional protocols

ObjectivesObjectives

Review the impact of strokeReview the impact of stroke Recognize signs and symptoms of strokeRecognize signs and symptoms of stroke Define risk factors for strokeDefine risk factors for stroke Identify types of strokeIdentify types of stroke Learn Pre-hospital recommendations for Learn Pre-hospital recommendations for

DispatchDispatch Review stroke care in the field Review stroke care in the field Review medical management and treatment Review medical management and treatment

options for strokeoptions for stroke Review national/regional guidelines and Review national/regional guidelines and

recommendations for strokerecommendations for stroke

Key PointsKey Points

EMS play a EMS play a criticalcritical role in the Emergency care of role in the Emergency care of acute stroke patients.acute stroke patients.

Over 400,000 acute stroke patients are being Over 400,000 acute stroke patients are being transported annually by EMS providers.transported annually by EMS providers.

50% of all stroke patients use EMS, but this is the 50% of all stroke patients use EMS, but this is the majority of patients who present within the 3 hour majority of patients who present within the 3 hour treatment windowtreatment window

EMS use decreases time to hospital arrival and EMS use decreases time to hospital arrival and the ability to implement acute stroke intervention.the ability to implement acute stroke intervention.

The Impact of StrokeThe Impact of Stroke

795,000 strokes in 2009795,000 strokes in 2009 163,000 die from stroke every year in America 163,000 die from stroke every year in America Stroke is the third leading cause of deathStroke is the third leading cause of death Stroke is the Stroke is the leading cause of disabilityleading cause of disability in in

adultsadults 4.4 million survivors; only 50-75% of stroke 4.4 million survivors; only 50-75% of stroke

survivors regain functional independencesurvivors regain functional independence Estimated direct/indirect costs for 2007- $62.7 Estimated direct/indirect costs for 2007- $62.7

billion billion 14% of persons who survive a first stroke or 14% of persons who survive a first stroke or

TIA will have another within one yearTIA will have another within one year

Time is Brain!Time is Brain!

Every second 32,000 neurons dieEvery second 32,000 neurons die Every minute 1.9 million neurons dieEvery minute 1.9 million neurons die Every hour 120 million neurons dieEvery hour 120 million neurons die Completed stroke: Loss of 1.2 billion neuronsCompleted stroke: Loss of 1.2 billion neurons

Blockage of one blood vessel will cause ischemia within 5 minutesBlockage of one blood vessel will cause ischemia within 5 minutes

What is our goal?What is our goal?

Reduce stroke mortality Reduce stroke mortality Improve quality of life for stroke survivors Improve quality of life for stroke survivors

and their familiesand their families

Focus:Focus: Increasing public awarenessIncreasing public awareness Timely initiation of 911 systemTimely initiation of 911 system Deployment of informed EMS personnelDeployment of informed EMS personnel Delivery to a stroke centerDelivery to a stroke center

Did You Know?Did You Know?

The average time from symptom onset The average time from symptom onset to the ED is to the ED is 17-2217-22 hours. hours.

42% of people over 50 do not recognize 42% of people over 50 do not recognize signs and symptoms of strokesigns and symptoms of stroke

17% of people over 50 can’t name a 17% of people over 50 can’t name a single stroke symptomsingle stroke symptom

Only 38% call 9-1-1Only 38% call 9-1-1 Only 20-25% arrive within 3 hoursOnly 20-25% arrive within 3 hours

Signs and Symptoms of Signs and Symptoms of StrokeStroke

Sudden numbness/weakness Sudden numbness/weakness of the face,arm,or leg, of the face,arm,or leg, especially on one side of the especially on one side of the bodybody

Slurred speech/difficulty Slurred speech/difficulty speaking/understandingspeaking/understanding

Sudden change in vision Sudden change in vision (blurred or decreased vision) (blurred or decreased vision) in one or both eyesin one or both eyes

Dizziness, loss of balance or Dizziness, loss of balance or coordinationcoordination

Acute onset severe headacheAcute onset severe headache Nausea or vomiting with any Nausea or vomiting with any

of the above symptomsof the above symptoms Confusion or disorientation Confusion or disorientation

with above symptomswith above symptoms

Additional stroke Additional stroke symptomssymptoms Decrease level of consciousnessDecrease level of consciousness Difficulty with swallowing and Difficulty with swallowing and

secretionssecretions Respiratory distressRespiratory distress Pupil changesPupil changes ConvulsionsConvulsions

Modifiable Risk Modifiable Risk FactorsFactors HypertensionHypertension Elevated cholesterol (statins reduce risk by 30%)Elevated cholesterol (statins reduce risk by 30%) Diabetes mellitus-independent risk factorDiabetes mellitus-independent risk factor Coronary Artery diseaseCoronary Artery disease Heart disease-Valve disease/replacement, any Heart disease-Valve disease/replacement, any

factor that decreases ventricular contractionfactor that decreases ventricular contraction Atrial Fibrillation (3-4x risk)Atrial Fibrillation (3-4x risk) Previous strokePrevious stroke Obesity Obesity Excessive alcohol Excessive alcohol Smoking (2x risk ischemic; 4x risk hemorrhagic)Smoking (2x risk ischemic; 4x risk hemorrhagic) Oral Contraceptives/HRTOral Contraceptives/HRT

http://lh3.ggpht.com/_lpskxdt3lWE/SX1N3Z3szJI/AAAAAAAAASQ/ECBqTcZUVBg/s1600-h/beer%20squirrel%5B2%5D.png

Non-Modifiable Risk Non-Modifiable Risk FactorsFactors Age-Risk doubles per decade over 55 Age-Risk doubles per decade over 55 Gender-Men have greater risk, but women Gender-Men have greater risk, but women

live longer. live longer. More women die from stroke (60% of stroke More women die from stroke (60% of stroke

deaths)deaths) Race-African-American, Asian and Hispanic Race-African-American, Asian and Hispanic

have greater risk, possibly due to have greater risk, possibly due to hypertensionhypertension

Diabetes Mellitus- Exacerbated by Diabetes Mellitus- Exacerbated by hypertension or poor glucose control. Even hypertension or poor glucose control. Even diabetics with good control are at increased diabetics with good control are at increased risk.risk.

Family history of stroke or TIAFamily history of stroke or TIA

3 Regions of the Brain3 Regions of the Brain

CerebrumCerebrum

CerebelluCerebellumm

Brain Brain StemStem

CerebrumCerebrum

Conscious thoughtConscious thought MemoryMemory PersonalityPersonality SpeechSpeech Motor FunctionMotor Function VisionVision Touch (tactile)Touch (tactile)

CerebellumCerebellum

CoordinationCoordination BalanceBalance Fine motor controlFine motor control ReflexesReflexes

Symptoms: dizziness, nausea, Symptoms: dizziness, nausea, vomitingvomiting

Brain StemBrain Stem

Heart functionHeart function RespirationRespiration Autonomic nervous systemAutonomic nervous system DigestionDigestion

Symptoms: Involuntary life-support Symptoms: Involuntary life-support functions (breathing, heartbeat, blood functions (breathing, heartbeat, blood pressure), eye movement, hearing, pressure), eye movement, hearing, speech, swallow, mobility on one or speech, swallow, mobility on one or both sides of the bodyboth sides of the body

Cerebral Cerebral Circulation Circulation Anterior Circulation

– Carotid arteries– Anterior

cerebral arteries– Middle cerebral

arteries

Posterior Circulation– Vertebral

arteries– Basilar artery– Posterior

cerebral arteries

Cerebral CirculationCerebral Circulation

Stroke: What is it?Stroke: What is it? Sudden interruption Sudden interruption

of of blood supplyblood supply to to the brainthe brain

Lack of Lack of oxygenoxygen and and glucose to nerve glucose to nerve cells cells

IschemiaIschemia within 1 within 1 hourhour

Cytotoxic and Cytotoxic and vasogenic edemavasogenic edema

Cellular Cellular deathdeath

Ischemic PenumbraIschemic Penumbra

The ischemic penumbra is the viable but threatened brain The ischemic penumbra is the viable but threatened brain tissue between the normal tissue and the tissue of the tissue between the normal tissue and the tissue of the infarctinfarct

Acute stroke therapies focus on reversing orAcute stroke therapies focus on reversing or preventing ischemic damage. “Penumbral Salvage”preventing ischemic damage. “Penumbral Salvage”

Types of StrokeTypes of Stroke

Ischemic Stroke- 88%Ischemic Stroke- 88%Embolic (24%): Embolic (24%):

Blood clot formsBlood clot forms

somewhere in thesomewhere in the

body and travels to the brain body and travels to the brain

Thrombotic(61%):Thrombotic(61%):

Clot forms on blood vessel Clot forms on blood vessel deposits deposits

Hemorrhagic Stroke-12%Hemorrhagic Stroke-12%

Intracerebral Bleed (ICB)Intracerebral Bleed (ICB) Subarachnoid Subarachnoid

HemorrhageHemorrhage (SAH)(SAH)

Hemorrhagic StrokeHemorrhagic Stroke

Responsible for 30% of stroke deathsResponsible for 30% of stroke deaths Intracerebral-within the brain tissue. Intracerebral-within the brain tissue.

Most commonly from high blood Most commonly from high blood pressurepressure

Subarachnoid-around the brain’s Subarachnoid-around the brain’s surface and under its protective layer-surface and under its protective layer-Most commonly from aneurysm Most commonly from aneurysm rupturerupture

Risk factors: hypertension, alcohol, Risk factors: hypertension, alcohol, drug abuse, anti-clotting medication drug abuse, anti-clotting medication and blood clotting disordersand blood clotting disorders

The Problem With TIA’sThe Problem With TIA’s(Transient Ischemic Attack)(Transient Ischemic Attack)

A “TIA” has sudden onset and rapid resolutionA “TIA” has sudden onset and rapid resolutionRule of Thumb: The event should last 2-20 minutesRule of Thumb: The event should last 2-20 minutes

If the event lasts more than 1 hour it is probably a If the event lasts more than 1 hour it is probably a minor strokeminor stroke

The likelihood of stroke is greatest in the first 48 The likelihood of stroke is greatest in the first 48 hours after the eventhours after the event

More than 1/3 of all persons who experience TIA’s More than 1/3 of all persons who experience TIA’s will go on to have a strokewill go on to have a stroke

The Problem with TIA’sThe Problem with TIA’s

TIAs should not be ignoredTIAs should not be ignored Patients need to seek immediate Patients need to seek immediate

medical attention in order to medical attention in order to prevent a possible full blown prevent a possible full blown stroke stroke

MRI may be needed to determine MRI may be needed to determine TIA VS. StrokeTIA VS. Stroke

http://www.foundshit.com/foxhounds-jumping-barbwire-fence/

Stroke is a Time Critical Stroke is a Time Critical TransportTransport ACLS GuidelinesACLS Guidelines

IV Alteplase (tPA-tissue Plasminogen Activator) IV Alteplase (tPA-tissue Plasminogen Activator) improves neurologic outcome in patients when improves neurologic outcome in patients when administered within 3 hours of onsetadministered within 3 hours of onset

Stroke presenting within *3 hours should be triaged Stroke presenting within *3 hours should be triaged on an emergent basis with urgency similar to acute on an emergent basis with urgency similar to acute ST-elevation myocardial infarctionST-elevation myocardial infarction

Patients who may be candidates for fibrinolytic Patients who may be candidates for fibrinolytic therapy should be transported to hospitals identified therapy should be transported to hospitals identified as capable of providing acute stroke care, including as capable of providing acute stroke care, including 24-hour availability of CT scan and interpretation24-hour availability of CT scan and interpretation

Goals for EMS Response and Goals for EMS Response and Acute InterventionAcute Intervention

Rapid Recognition and Reaction Rapid Recognition and Reaction to Stroke warning signsto Stroke warning signs

Rapid EMS DispatchRapid EMS Dispatch Rapid EMS transport and hospital Rapid EMS transport and hospital

prenotificationprenotification Rapid diagnosis and treatmentRapid diagnosis and treatment

Emergency DispatchEmergency Dispatch

Use of 911 system is recommended for Use of 911 system is recommended for symptoms of strokesymptoms of stroke

Many callers do not use the word “stroke”Many callers do not use the word “stroke” Dispatchers should recognize the Dispatchers should recognize the

seriousness of stroke and be familiar with seriousness of stroke and be familiar with stroke symptoms.stroke symptoms.

Strokes should be dispatched as a high Strokes should be dispatched as a high priority call, send closest unit- similar to priority call, send closest unit- similar to acute MI or traumaacute MI or trauma

An EMD call-receiving algorithm is An EMD call-receiving algorithm is recommended to ask appropriate recommended to ask appropriate questions to callersquestions to callers

Emergency DispatchEmergency Dispatch

Dispatch should ask the caller when (what Dispatch should ask the caller when (what time) the patient was last seen normal (without time) the patient was last seen normal (without weakness, facial droop, loss of speech)?weakness, facial droop, loss of speech)?

Try to determine pertinent past medical historyTry to determine pertinent past medical history Relay information to ResponderRelay information to Responder Request feedback from Responder regarding Request feedback from Responder regarding

outcomeoutcome Dispatchers should receive education Dispatchers should receive education

recognizing stroke symptomsrecognizing stroke symptoms

EMS Stroke CareEMS Stroke Care

Rapid IdentificationRapid Identification of stroke as the of stroke as the cause of the patient’s findingscause of the patient’s findings

Elimination of conditions that could Elimination of conditions that could mimic strokemimic stroke

StabilizationStabilization Rapid transportationRapid transportation of the patient to of the patient to

the closest appropriate EDthe closest appropriate ED Pre notificationPre notification to the receiving to the receiving

hospital about impending arrival of a hospital about impending arrival of a patient with suspected strokepatient with suspected stroke

Suspected Stroke Prehospital Suspected Stroke Prehospital Protocol Guidelines Protocol Guidelines ((Washington State Emergency Stroke Care Washington State Emergency Stroke Care System)System)

Scene Size-Up/Initial Patient Scene Size-Up/Initial Patient Assessment Assessment (Sick or Not Sick)(Sick or Not Sick)

A.A. Support ABCsSupport ABCs

B.B. Check glucose, temperature, SpO2Check glucose, temperature, SpO2

C.C. Treat hypoglycemiaTreat hypoglycemia

D.D. NPONPO

Suspected Stroke Suspected Stroke Prehospital Prehospital Protocol Protocol Guidelines Guidelines (Washington State Emergency Stroke Care (Washington State Emergency Stroke Care System)System)

Focused History and Physical ExamFocused History and Physical ExamA.A. FAST Assessment FAST Assessment

((FFace/ace/AArms/rms/SSpeech/peech/TTime last normal)ime last normal)

If one component abnormal, high If one component abnormal, high probability of stroke. Refer to stroke probability of stroke. Refer to stroke destination triage tool. Time from last destination triage tool. Time from last normal will determine destination.normal will determine destination.

B.B. Limit scene time with goal of Limit scene time with goal of ≤≤ 15minutes15minutes

Time is Brain and Time is Brain and you must act FAST!you must act FAST!

F – A – S – T F – A – S – T FFace – smileace – smile

AArm raiserm raise

SSay a phraseay a phrase

TTime – Time Last ime – Time Last NormalNormal

Key Components of Key Components of Taking Patient History Taking Patient History (SAMPLE)(SAMPLE)S-Symptoms/ onset (When was the person last S-Symptoms/ onset (When was the person last

seen normal?)seen normal?)A-AllergiesA-AllergiesM-Medications-anticoagulants (M-Medications-anticoagulants (warfarinwarfarin), ),

antithrombotics, Insulin, antihypertensives, antithrombotics, Insulin, antihypertensives, antiepilepticsantiepileptics

P-Past Medical History-Hypertension, Diabetes P-Past Medical History-Hypertension, Diabetes (hypoglycemic patients may have symptoms (hypoglycemic patients may have symptoms that mimic stroke), seizures, prior stroke, that mimic stroke), seizures, prior stroke, aneurysmsaneurysms

L-Last oral intakeL-Last oral intakeE-Events Prior-stroke, MI, trauma, surgery, bleedingE-Events Prior-stroke, MI, trauma, surgery, bleeding

Suspected Stroke Suspected Stroke Prehospital Prehospital Protocol Protocol Guidelines Guidelines (Washington State Emergency Stroke Care (Washington State Emergency Stroke Care System)System)

TransportTransport

A.A. Early hospital notification-specify Early hospital notification-specify FAST findings (abnormal physical FAST findings (abnormal physical findings and time last normal)findings and time last normal)

B.B. If closest appropriate facility If closest appropriate facility greater than 30 minutes, consider greater than 30 minutes, consider air transport when appropriateair transport when appropriate

Suspected Stroke Suspected Stroke Prehospital Prehospital Protocol Protocol Guidelines Guidelines (Washington State Emergency Stroke Care (Washington State Emergency Stroke Care System)System) Management/Ongoing Assessment en routeManagement/Ongoing Assessment en route

A.A. Lay patient flat unless signs of airway compromise, Lay patient flat unless signs of airway compromise, in which case elevate no higher than 20 degrees.in which case elevate no higher than 20 degrees.

(Protocols vary! Follow your local protocol)(Protocols vary! Follow your local protocol)

A.A. IV access (as able)IV access (as able)1.1. Normal saline (avoid glucose-containing solutions)Normal saline (avoid glucose-containing solutions)

2.2. 16 or 18 ga IV in unaffected arm (affected arm is 16 or 18 ga IV in unaffected arm (affected arm is acceptable)acceptable)

3.3. Optional: Blood draw with IV startOptional: Blood draw with IV start

4.4. 22ndnd exam/neuro reassess exam/neuro reassess

5.5. Optional: Perform tPA checklistOptional: Perform tPA checklist

RecommendedRecommended

Manage ABCsManage ABCs Cardiac monitoringCardiac monitoring Intravenous access-18gauge w/leur-lok Intravenous access-18gauge w/leur-lok

preferredpreferred Oxygen (as required 02 saturation Oxygen (as required 02 saturation

<92%)<92%) Assess for hypoglycemiaAssess for hypoglycemia NPONPO Alert receiving EDAlert receiving ED Rapid transport to closest appropriate Rapid transport to closest appropriate

facility capable of treating acute strokefacility capable of treating acute stroke

Not RecommendedNot Recommended

Dextrose-containing fluids in Dextrose-containing fluids in nonhypoglycemic patientsnonhypoglycemic patients

Excessive blood pressure reduction Excessive blood pressure reduction (can cause hypotension, decrease (can cause hypotension, decrease cerebral perfusion and worsen stroke)cerebral perfusion and worsen stroke)

Excessive intravenous fluids (can Excessive intravenous fluids (can cause increased intracranial cause increased intracranial pressure)pressure)

In Addition:In Addition:

If local protocol allows, take a If local protocol allows, take a family member to the family member to the hospital/phone numberhospital/phone number

Minimize scene time; procedures Minimize scene time; procedures can be performed during transportcan be performed during transport

Transport patient to the nearest Transport patient to the nearest appropriateappropriate hospital per local hospital per local transport protocolstransport protocols

Notify receiving hospital en routeNotify receiving hospital en route

Recommendations fromRecommendations from NINDSNINDS((National Institute of Neurological National Institute of Neurological Disorder and Stroke)Disorder and Stroke)

1.1. Take the patient to the nearest hospital if Take the patient to the nearest hospital if there are no stroke centers nearbythere are no stroke centers nearby

2.2. Bypass hospitals unable to provide care Bypass hospitals unable to provide care if there are stroke centers close by. if there are stroke centers close by. Follow local destination protocolsFollow local destination protocols

3.3. If remote, consider air-evacuation if:If remote, consider air-evacuation if:– The closest center is > 1hour away, ORThe closest center is > 1hour away, OR– The closest center cannot provide stroke The closest center cannot provide stroke

care, ORcare, OR– If the patient can reach a center within the If the patient can reach a center within the

*3-hour time window or tPA treatment*3-hour time window or tPA treatment

Destination ProtocolsDestination Protocols

Coming soon!Coming soon!

Washington State destination Washington State destination protocols for strokeprotocols for stroke

Northwest Medstar Response Northwest Medstar Response TimesTimes

National Stroke Association National Stroke Association RecommendationsRecommendations

““EMS System Medical Directors EMS System Medical Directors should have a process to identify should have a process to identify and provide transport protocols to and provide transport protocols to authorize EMS to transport stroke authorize EMS to transport stroke patients to the nearest patients to the nearest appropriate hospitals, including appropriate hospitals, including recognized stroke centers”recognized stroke centers”

Evaluation of Current Evaluation of Current SystemsSystems

What is your general EMS environment in What is your general EMS environment in your state?your state?

What processes are in place that provide What processes are in place that provide rapid access to EMS for patients with acute rapid access to EMS for patients with acute stroke?stroke?

What are your EMS dispatch protocols?What are your EMS dispatch protocols? Where are suspected stroke patients Where are suspected stroke patients

transported?transported? What communications occur between local What communications occur between local

hospitals and EMS systems?hospitals and EMS systems?

Stroke is a time criticalStroke is a time critical

IV tPA (Alteplase)-Time from last normal to IV tPA (Alteplase)-Time from last normal to 3 hours. (Extended window 3-4.5 hours)3 hours. (Extended window 3-4.5 hours)

Dose is based on patient’s weight. 10% of Dose is based on patient’s weight. 10% of determined dose as an IV bolus, remaining determined dose as an IV bolus, remaining 90% over one hour90% over one hour

May cause intracranial bleeding but has May cause intracranial bleeding but has not been shown to increase mortalitynot been shown to increase mortality

CT ImagingCT Imaging

Large Ischemic stroke with midline Large Ischemic stroke with midline shiftshift

CT ImagingCT Imaging

CT Angiogram CT PerfusionCT Angiogram CT Perfusion

Acute Stroke Acute Stroke InterventionsInterventions

Intraarterial tPAIntraarterial tPA Time last normal to 6 hours.Time last normal to 6 hours.

Mechanical clot retrieval Mechanical clot retrieval 0-8 hours-anterior circulation0-8 hours-anterior circulation 0-12 hours (or longer)-posterior 0-12 hours (or longer)-posterior

circulationcirculation

MerciMerci™™--Mechanical Mechanical Clot Retrieval DeviceClot Retrieval Device

© Concentric Medical 2007

56

ACA/A1

ICA

ICA -T

MCA/M1

MCA/M2

MCA/M3ACA/A2

Anterior Circulation – AP View

APM0189/B/3073, 2007-12

© Concentric Medical 2007

57

Circle of Willis

PCA PCA

Basilar

VertVert

Posterior CirculationPosterior Circulation

APM0189/B/3073, 2007-12

© Concentric Medical 2007

58

Patient HistoryPatient History

47 year old male, history of excessive alcohol abuse47 year old male, history of excessive alcohol abuse Last seen normal at midnight, found at 4 am unable to Last seen normal at midnight, found at 4 am unable to

move his right side and unable to speakmove his right side and unable to speak Family called 911, transfer to stroke centerFamily called 911, transfer to stroke center Not a candidate for IV t-PA, symptom onset >3 hoursNot a candidate for IV t-PA, symptom onset >3 hours ER Physicians notified interventional team and arranged ER Physicians notified interventional team and arranged

for transferfor transfer Patient arrived to and was in the angiography suite by Patient arrived to and was in the angiography suite by

6:30 am6:30 am Clinical Neurologic exam: unable to move right arm and Clinical Neurologic exam: unable to move right arm and

leg, confused and unable to express language, NIHSS 18 leg, confused and unable to express language, NIHSS 18 (0 – 42)(0 – 42)

Patient not a candidate for IV t-PA as symptom onset >3 hours. He was

identified as a candidate for intervention.APM0189/B/3073, 2007-12

© Concentric Medical 2007

59

Pre-intervention Cerebral Angio 1Pre-intervention Cerebral Angio 1stst pass Merci Retriever pass Merci Retriever

Intervention with Merci Retriever

Clot completely blocking flow in the left middle cerebral artery

Merci Retriever positioned in the left middle cerebral artery

APM0189/B/3073, 2007-12

© Concentric Medical 2007

60

The cerebral artery is opened post The cerebral artery is opened post procedure. Patient had a dramatic clinical procedure. Patient had a dramatic clinical improvement.improvement.

Post InterventionPost Intervention Clinical Outcome Clinical OutcomeFirst division of the left middle

cerebral artery is open Neurologic Exam after interventional procedure:

• Alert and oriented, moving all extremities with subtle right sided weakness and mild language difficulties

• Following day NIHSS 3 decreased from 18

• Discharged to rehab• Awaiting home transfer with

24/7 supervision• Ambulates with quad cane

and has some persistent mixed aphasia

APM0189/B/3073, 2007-12

EMS Role in ResearchEMS Role in Research

Identification of an effective neuroprotective Identification of an effective neuroprotective therapy may further expand the role of EMS therapy may further expand the role of EMS in the treatment of acute stroke.in the treatment of acute stroke.

HypothermiaHypothermia-Reduces cytotoxic cascade, -Reduces cytotoxic cascade, Stabilizes blood-brain barrier, Reduces free-Stabilizes blood-brain barrier, Reduces free-radical formation, May prevent neurotoxicity radical formation, May prevent neurotoxicity of tPAof tPA

IV Magnesium-IV Magnesium-(FASTMAG Trial)(FASTMAG Trial)

IV Magnesium loading dose given in the field. IV Magnesium loading dose given in the field. Cytoprotective and vasodilating effects. Cytoprotective and vasodilating effects.

Public Education-Reducing Public Education-Reducing RiskRisk

Lifestyle ModificationLifestyle Modification Low fat diet/Controlling weight/ExerciseLow fat diet/Controlling weight/Exercise Treating Atrial FibrillationTreating Atrial Fibrillation Monitoring Alcohol consumption Monitoring Alcohol consumption Quit smokingQuit smokingMedical ManagementMedical Management Antihypertensive Medication-For blood pressure Antihypertensive Medication-For blood pressure

greater than 140/90. (Tighter control for diabetics)greater than 140/90. (Tighter control for diabetics) Cholesterol reducing medication for cholesterol > Cholesterol reducing medication for cholesterol >

200 mg/dl or LDL > 100 (statins)200 mg/dl or LDL > 100 (statins) Clot prevention medication(Anticoagulants) Clot prevention medication(Anticoagulants)

WarfarinWarfarin Antiplatelet drugs-Aspirin, Aggrenox, Plavix,TiclidAntiplatelet drugs-Aspirin, Aggrenox, Plavix,Ticlid

Questions?Questions?

Donald RumsfeldDonald Rumsfeld

There are known There are known knowns. These are knowns. These are things we know that we things we know that we know. There are known know. There are known unknowns. That is to unknowns. That is to say, there are things that say, there are things that we know we don't know. we know we don't know. But there are also But there are also unknown unknowns. unknown unknowns. There are things we There are things we don't know we don't don't know we don't know. know.

ReferencesReferences

American Stroke Association. Guidelines for the Early American Stroke Association. Guidelines for the Early Management of Adults With Ischemic Stroke. Management of Adults With Ischemic Stroke. StrokeStroke May May 2007. “Prehospital Management and Field Treatment”.2007. “Prehospital Management and Field Treatment”.

American Heart Association/ACLS Provider Manual. 2006American Heart Association/ACLS Provider Manual. 2006 National Institute of Neurological Disorders and Stroke National Institute of Neurological Disorders and Stroke

(NINDS)(NINDS) Concentric Medical-Merci Retrieval deviceConcentric Medical-Merci Retrieval device Genentec-AlteplaseGenentec-Alteplase National Stroke Association-EMS Provider informationNational Stroke Association-EMS Provider information Thanks to Michael Day-Trauma Services Coordinator Thanks to Michael Day-Trauma Services Coordinator

Sacred Heart Medical CenterSacred Heart Medical Center Northwest Regional Stroke Network-Destination Northwest Regional Stroke Network-Destination

protocols,protocols,EMS Online TrainingEMS Online Training

You are dispatched to a call of a 75-year-old female with sudden onset of trouble walking; she has become dizzy and very nauseated. She cannot walk without holding onto furniture. Her blood pressure is 160/90. Her blood sugar is normal. The cardiac monitor shows sinus rhythm. She has no c/o chest pain. She is a non-drinker/non-smoker, but takes medication for high blood pressure. She has no facial droop or arm weakness. You suspect this could be stroke. What area of the brain could give you these symptoms?

Super Secret Question

Questions?

Contact: Carolyn Contact: Carolyn StovallStovall

509-242-4263509-242-42631-866-630-40331-866-630-4033

stovalc@inhs.orgFax: 509-232-8168Fax: 509-232-8168