EMERGENCY EVALUATION OF THE

ACUTE STROKE PATIENT

Angel Rochester, MD Associate Director of Critical Care &

Trauma Associate Director of Chest Pain

Greenville County EMS

 800 Square Miles in Greenville County  Busiest EMS organization in South

Carolina  62,000 Annual Responses  Over 500 Stroke transports per year  Strong relationship with County Hospitals  Involvement in Hospital meetings

EMS Stroke Screening

 EMS Dispatchers perform a pre-arrival stroke screen over the phone

 EMS Providers conduct a Cincinnati Stroke Scale upon arrival

 NIH Stroke Scale  Pre-hospital Stroke Thrombolytic Check

List

Standing Orders EMSStroke/CVA/TIA Assessment:   1. Perform patient assessment.   2. Perform both Glasgow Coma Scale and Cincinnati Stroke Scale on

patients who present with signs / symptoms of Acute Stroke.   Determine blood glucose level, if hypoglycemic, follow

Hypoglycemia Standing Order. Interventions:   Follow Airway Management Standing Order.   Establish IV at KVO rate – follow

Intravenous Infusion Initiation Standing Order.   Monitor cardiac rhythm.   All patients with new signs and symptoms of a stroke regardless of time

onset are to be transported to a cardiac/stroke center (Greenville Memorial Medical Center or St. Francis Hospital Downtown). Notify the receiving facility as soon as possible of the STROKE ALERT.

  If Acute Stroke*, complete Prehospital Stroke Thrombolytic Check List and if time permits an NIH Stroke Scale

  If Major Stroke** and the patient meets the criteria, consider Rapid Sequence Intubation Standing Order.

Contact Medical Control:   Transport and continue BLS and ALS – follow Standard of Care guidelines.   Acute Stroke* = Involves onset of symptoms < 4 ½ hours   Major Stroke** = Involves patient with an altered level of consciousness

Cincinnati Stroke Scale

  Facial Droop  Normal: Both sides of face move equally  Abnormal: One side of face does not move at all

 Arm Drift  Normal: Both arms move equally or not at all  Abnormal: One arm drifts compared to the other

 Speech  Normal: Patient uses correct words with no

slurring  Abnormal: Slurred or inappropriate words or

mute

Stroke Distribution 8/1/2010- 8/1/2011

GHS Referral Line Transfers

 GHS Satellites have a dedicated onsite STEMI/Stroke stretcher and Activation Line

 GCEMS has an ambulance stationed at Hillcrest and Greer

 Mobile Care  Reach® Access to surrounding counties

Greenville MemorialEmergency Department

90,000 Adults/yr

20,000 pediatrics/yr

Acute Stroke Decision Pathway Greenville Memorial Emergency Department

Signs and Symptoms of Acute Stroke? • Sudden numbness or weakness of the face, arm or leg, especially on one side of the body • Sudden confusion, trouble speaking or understanding • Sudden trouble seeing in one or both eyes • Sudden trouble walking, dizziness, loss of balance or coordination

Yes Onset less than 4.5 hr

Triage in room • Print Form M10357, M10108, M10682 • Stroke Alert page to notify neurologist, CT & Lab

•  MD assesses patient, NIHSS (full initially) •  TPA criteria reviewed (M10357) •  Stroke orders started (M10357) •  LOD labs (CBC, PT/PTT, INR, BMP) •  LOD Head CT •  STAT EKG, continuous cardiac & O2 monitoring, CXR,

fingerstick glucose, urine pregnancy, NPO including meds •  Register patient in REACH cart (per neurologist request) •  Consult neurologist via REACH telemedicine

TPA candidate? YES • Neurologist to

o Discuss risks/benefits w/ pt/family o Make recommendations for tPA in person or via REACH & give order to ED RN

• RN to o Administer tPA, complete tPA orders M10682, transfer to GHS via Mobile Care or Med Trans o Complete Dysphagia Screening

NOT TPA candidate

•  ED MD to document reason in IBEX Doctor Notes, NIHSS

•  Neurologist recommendations in person or per REACH consult

•  ED MD calls PCP or neurologist for admission or transfer. (Follow normal admit procedure)

No Onset greater than 4.5 hr

Triage

• Stroke orders started •  Labs (CBC, PT/PTT,

INR, BMP, fingerstick glucose, Head CT, EKG and continuous monitoring, NPO

•  Assess using NIHSS (full initially, focused q 1 hr x 2 and then q2hr)

•  Complete Dysphagia Screen ED MD calls PCP or

Hospitalist for admission or transfer (Follow normal admit procedure)

• Nurse completes Dysphagia Screen before any PO Intake/Meds

Patient presents to triage

EMS calls with

possible stroke patient

ED Physician Goal: <10

min Stroke

Alert Page Goal: <15

min

Labs drawn & testing started - Goal: <15 min CT complete - Goal: <25 min

CT & labs resulted Goal:< 45 min

tPA initiated

Goal: <60 min

Stroke Alert

Process GMH

Accurate Weights

Acute Stroke Decision Pathway Greenville Memorial Emergency Department

Signs and Symptoms of Acute Stroke?

Sudden numbness or weakness of the face, arm or leg, especially on one side of the body Sudden confusion, trouble speaking or understanding Sudden trouble seeing in one or both eyes Sudden trouble walking, dizziness, loss of balance or coordination

Patient presents to triage

EMS possible stroke patient

Yes

Onset less than 4.5 hr

No

Onset greater than 4.5 hr

Triage in Critical Care Room

Print Form M10357, M10108, M10682 Stroke Alert page to notify neurologist, CT & Lab

ED Physician Eval

Goal: <10 min Triage

To Critical Care

Stroke Alert Page

Goal: <15 min

WEIGH THE PATIENT

CALL THE STROKE ALERT-3-3333

WEIGH THE PATIENT / STRETCHER

Labs drawn & testing started

Goal: <15 min

CT complete

Goal: <25 min

CT & labs reported/resulted

Goal: 45 min

• MD assesses patient • NIHSS (full initially) • TPA criteria reviewed (M10357) • Stroke orders started (M10357) • LOD labs (CBC, PT/PTT, INR, BMP) • LOD Head CT • STAT EKG, continuous cardiac & O2 monitoring, finger stick glucose, urine pregnancy, NPO including meds • Register patient in REACH cart (neurologist request) • NOTIFY CT REACH PATIENT

• Consult neurologist via REACH telemedicine

Code Stroke

Candidate for tPA

TPA candidate? YES • Neurologist to

o Discuss risks/benefits w/ pt/family o Make recommendations for tPA in person or via REACH & give order

• RN (2 signatures confirm dose ) o Administer tPA, infuse 50 ML BOLUS NS AT THE END OF TPA TO AT THE SAME RATE AS TPA. Complete tPA orders M10682,

o  Complete Dysphagia Screening o Vs q 15 minutes o NIHSS Q15, then Q30, then Qhr

tPA initiated Goal: <60 min

CALL 5-7455 (5-PILL) NOTIFY PHARMACIST OF LOCATION, PATIENT WEIGHT, SCAN

ORDER WHEN COMPLETED

Observation Unit Group Time Period Ischemic

stroke TIA SAH ICH Stroke NOS

No stroke related

diagnosis

Blank "Missing

diagnosis" Total

My Hospital

07/01/2010 - 06/30/2011

621 (69.1%)

116 (12.9%)

37 (4.1%)

124 (13.8%)

1 (0.1%)

0 (0%)

0 (0%) 899

All SC Hospitals

07/01/2010 - 06/30/2011

3414 (62.5%)

976 (17.9%)

243 (4.4%)

557 (10.2%)

85 (1.6%)

163 (3%)

26 (0.5%) 5464

JC PSC Hospitals

07/01/2010 - 06/30/2011

144816 (62%)

41588 (17.8%)

10198 (4.4%)

26200 (11.2%)

2947 (1.3%)

5159 (2.2%)

2770 (1.2%) 233678 Total CVA/TIA

Pts ALOS

7/2010 13 0.89 8/2010 6 1.21 9/2010 12 1.06 10/2010 8 1.53 11/2010 10 1.11 12/2010 6 1.33 1/2011 9 1.08 2/2011 14 1.06 3/2011 10 1.21 4/2011 11 1.02 5/2011 13 1.12 6/2011 23 1.22 Total 135

(53 – ICD9 435.9) 1.15

•  TIA/Stroke Workup as observation status • Labs, MRI/MRA, Echo, Carotid U/S • Risk factor identification/reduction • NP managed with ED physician

• Neurology consult

Observation Unit

•  TIA/Stroke Workup as observation status • Labs, MRI/MRA, Echo, Carotid U/S • Risk factor identification/reduction • Neurology Consult • NP managed with EM Physician • Work up completed in 24-48 hours, 365 days

Questions?

Thank You