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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. Stroke. Fourth leading cause of death in the U.S. Leading cause of disability in the U.S., affecting over 700,000 4.4 million stroke survivors 85% ischemic

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Assessment and Treatment of the Stroke Patient

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  1. Assessment and Treatment of the Stroke Patient Clinical Guidelines and Routing Criteria for EMS in Iowa November 2012

  2. Stroke • Fourth leading cause of death in the U.S. • Leading cause of disability in the U.S., affecting over 700,000 • 4.4 million stroke survivors • 85% ischemic • Less than 25% of eligible thrombolytic candidates are receiving therapy

  3. Why we are here today… • Stroke system of care in Iowa can work • We have laid the groundwork and gave CDC notice • They believed us… • Funding for 3 years through the Paul Coverdell National Acute Stroke Program

  4. 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

  5. Stroke - Goals • Understand our shortfalls • Review the disease process • Apply stroke screening process • Discuss current treatment practices • Treatment windows • Primary stroke center destination

  6. Stroke identification • How easy is it to identify a stroke? • 90 % in tertiary care hospitals (stroke centers, teaching institutions) • 78% in community hospitals Cerebrovasc Dis 1999;9:224-230 (DOI: 10.1159/000015960)

  7. Stroke identification • Study of 1045 patients transported by EMS; 440 with diagnosis of stroke • Paramedics correctly diagnosed 193 (49%) • Paramedics missed 247 (56%) Journal of Emergency Medicine 2007;11:092

  8. Stroke identification • Study of 1247 patients; 441 diagnosed with stroke • Paramedic PPV 47% • Paramedic NPV 58% Stroke 2007;38:501

  9. Stroke Identification • Paramedics demonstrated 61 – 66% sensitivity for identifying stroke after traditional training methods • Sensitivity 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

  10. What causes a stroke? • 77% – 94% ischemic • Thromboembolic • Cardioembolic • 6%-23% hemorrhagic • Intracerebral bleed • Sub-arachnoid hemorrhage

  11. 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

  12. Anterior Cerebral Artery

  13. Anterior Cerebral Artery

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

  15. Middle Cerebral Artery

  16. Cerebral Anatomy

  17. 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

  18. Posterior Circulation

  19. Cerebral Anatomy

  20. 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 cut

  21. Visual Field Deficits

  22. Current Treatments(FDA Approved) • Thrombolytics (t-PA) • 3 hours • Risk factors

  23. Current Treatments • ECASS 3 • Extends time window to 4.5 hours for IV t-PA • Published Sept. 2008 in New England Journal of Medicine • Not yet FDA approved • All primary stroke centers in Iowa use this 4.5 hour standard

  24. Current Treatments(Not FDA Approved) • Intra-arterial t-PA • 6 hours • Risk factors • Mechanical Clot Removal • 8 hours • Risk factors • Other Studies • Desmotoplase • Neuroprotective agents

  25. So Now What?!

  26. 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 ClinPharmTher. 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.

  27. Pre-Hospital Intervention • Good assessments • Physical exams • History taking • Stroke centers

  28. Reproducible Assessment • Accuracy of stroke recognition by emergency medical dispatchers and paramedics--San Diego experience. • PrehospEmerg Care. 2008 Jul-Sep;12(3):307-13. • EMD Dispatchers had higher sensitivity and PPV for recognition of stroke than paramedic at pt side

  29. Stroke Assessment • NIH stroke scale • 42 point scale to look at neurological deficits • Great baseline – creates a uniform exam that can be reproduced • Good for transition of care • Easier to track statistically

  30. Stroke Assessment – NIH Scale • Complete assessment is great tool for baseline • Tests all cranial nerves, peripheral nerves for sensation, movement, spatial perception, coordination… • TOO LONG FOR PRE-HOSPITAL SCENES

  31. Cincinnati Prehospital Stroke Scale • Facial Droop • Arm Drift • Speech

  32. Stroke Assessment • Cincinatti Pre-Hospital Stroke Score (CPSS) • Facial droop • Speech • Arm drift • Los Angelas Pre-Hospital Stroke Scale (LAPSS) • Miami Emergency Neruologic Defecit Exam (MEND)

  33. Stroke Assessment • Differential Diagnoses • Seizure / postictal • Hypoglycemia • Bell’s Palsy • Migraine • Tumor

  34. Treatment Goals • Oxygenate the brain – there still may be some left!

  35. Treatment Goals • BP management (?) • CPP = MAP – ICP • If hypertensive crisis in conjunction with stroke, call medical control before lowering pressure • AHA guidelines – drop systolic BP by increments – no more than 25% of initial value, or diastolic approaches 100

  36. Treatment Goals • Oxygen • Blood Glucose check • Cardiac Monitor • A-fib common cause of emboli • AMI another cause • IV access • Elevate head – facilitate venous drainage • Aspirin?

  37. What about Stroke Centers? • Positive effects of stroke center are comparable to the effects of timely administration of tPA… • Preferential routing to stroke centers

  38. Iowa EMS Protocol • Utilize CPSS or other reproducible stroke assessment • If stroke symptoms are present with an onset of less than 4.5 hours • Transport to primary stroke center if transport is 30 minutes or less • Transport to closest stroke capable hospital if greater than 30 minutes

  39. Iowa Primary Stroke Centers • Iowa Healthcare Collaborative • www.ihconline.org

  40. Questions????

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