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

Clinical Guidelines and Routing Criteria for EMS in Iowa

November 2012

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StrokeStroke

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% ischemicLess than 25% of eligible thrombolytic candidates are receiving therapy

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% ischemicLess than 25% of eligible thrombolytic candidates are receiving therapy

Why we are here today…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

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

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Why we are here today…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

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

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Stroke - GoalsStroke - Goals

Understand our shortfalls

Review the disease process

Apply stroke screening process

Discuss current treatment practices Treatment windows

Primary stroke center destination

Understand our shortfalls

Review the disease process

Apply stroke screening process

Discuss current treatment practices Treatment windows

Primary stroke center destination

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Stroke identificationStroke identification

How easy is it to identify a stroke?90 % in tertiary care hospitals (stroke centers, teaching institutions)

78% in community hospitals

How easy is it to identify a stroke?90 % in tertiary care hospitals (stroke centers, teaching institutions)

78% in community hospitals

6Cerebrovasc Dis 1999;9:224-230 (DOI: 10.1159/000015960)

Stroke identificationStroke identification

Study of 1045 patients transported by EMS; 440 with diagnosis of stroke

Paramedics correctly diagnosed 193 (49%)

Paramedics missed 247 (56%)

Study of 1045 patients transported by EMS; 440 with diagnosis of stroke

Paramedics correctly diagnosed 193 (49%)

Paramedics missed 247 (56%)

7Journal of Emergency Medicine 2007;11:092

Stroke identificationStroke identification

Study of 1247 patients; 441 diagnosed with stroke

Paramedic PPV 47%

Paramedic NPV 58%

Study of 1247 patients; 441 diagnosed with stroke

Paramedic PPV 47%

Paramedic NPV 58%

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Stroke 2007;38:501

Stroke IdentificationStroke 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

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

What causes a stroke?What causes a stroke?

77% – 94% ischemicThromboembolic

Cardioembolic

6%-23% hemorrhagicIntracerebral bleed

Sub-arachnoid hemorrhage

77% – 94% ischemicThromboembolic

Cardioembolic

6%-23% hemorrhagicIntracerebral bleed

Sub-arachnoid hemorrhage

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Anterior CirculationAnterior 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

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

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Anterior Cerebral ArteryAnterior Cerebral Artery

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Anterior Cerebral ArteryAnterior Cerebral Artery

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Middle Cerebral Artery – M 1, 2, & 3 SegmentsMiddle Cerebral Artery – M 1, 2, & 3 Segments

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Middle Cerebral ArteryMiddle Cerebral Artery

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Cerebral AnatomyCerebral Anatomy

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Posterior Circulation Vertebral-BasilarPosterior 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

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

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Posterior CirculationPosterior Circulation

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Cerebral AnatomyCerebral Anatomy

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Stroke SymptomsStroke 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

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

Left Hemisphere Right sided paralysis Speech / language

problems Expressive Receptive

Slow, cautious behavior

Good judgment about ability / disability

Right visual cut25

Visual Field DeficitsVisual Field Deficits

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Current Treatments(FDA Approved)

Current Treatments(FDA Approved)

Thrombolytics (t-PA)3 hoursRisk factors

Thrombolytics (t-PA)3 hoursRisk factors

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Current TreatmentsCurrent Treatments

ECASS 3Extends 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

ECASS 3Extends 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

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Current Treatments(Not FDA Approved)

Current Treatments(Not FDA Approved)

Intra-arterial t-PA6 hoursRisk factors

Mechanical Clot Removal8 hoursRisk factors

Other StudiesDesmotoplaseNeuroprotective agents

Intra-arterial t-PA6 hoursRisk factors

Mechanical Clot Removal8 hoursRisk factors

Other StudiesDesmotoplaseNeuroprotective agents

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So Now What?!So Now What?!

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Evidence Based ApproachEvidence 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 Clin Pharm Ther. 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.

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 Clin Pharm Ther. 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.

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Pre-Hospital InterventionPre-Hospital Intervention

Good assessments Physical exams History taking

Stroke centers

Good assessments Physical exams History taking

Stroke centers

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Reproducible AssessmentReproducible Assessment

Accuracy of stroke recognition by emergency medical dispatchers and paramedics--San Diego experience.Prehosp Emerg Care. 2008 Jul-Sep;12(3):307-13.

EMD Dispatchers had higher sensitivity and PPV for recognition of stroke than paramedic at pt side

Accuracy of stroke recognition by emergency medical dispatchers and paramedics--San Diego experience.Prehosp Emerg Care. 2008 Jul-Sep;12(3):307-13.

EMD Dispatchers had higher sensitivity and PPV for recognition of stroke than paramedic at pt side

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Stroke AssessmentStroke Assessment

NIH stroke scale42 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

NIH stroke scale42 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

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Stroke Assessment – NIH ScaleStroke 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

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

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Cincinnati Prehospital Stroke ScaleCincinnati Prehospital Stroke Scale

Facial Droop

Arm Drift

Speech

Facial Droop

Arm Drift

Speech

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Stroke AssessmentStroke 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)

Cincinatti Pre-Hospital Stroke Score (CPSS)

Facial droop

Speech

Arm drift

Los Angelas Pre-Hospital Stroke Scale (LAPSS)

Miami Emergency Neruologic Defecit Exam (MEND)

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Stroke AssessmentStroke Assessment

Differential DiagnosesSeizure / postictal

Hypoglycemia

Bell’s Palsy

Migraine

Tumor

Differential DiagnosesSeizure / postictal

Hypoglycemia

Bell’s Palsy

Migraine

Tumor

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Treatment GoalsTreatment Goals

Oxygenate the brain – there still may be some left!Oxygenate the brain – there still may be some left!

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Treatment GoalsTreatment Goals

BP management (?)CPP = MAP – ICP

If hypertensive crisis in conjunction with stroke, call medical control before lowering pressureAHA guidelines – drop systolic BP by increments – no more than 25% of initial value, or diastolic approaches 100

BP management (?)CPP = MAP – ICP

If hypertensive crisis in conjunction with stroke, call medical control before lowering pressureAHA guidelines – drop systolic BP by increments – no more than 25% of initial value, or diastolic approaches 100

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Treatment GoalsTreatment Goals

Oxygen

Blood Glucose check

Cardiac Monitor

A-fib common cause of emboli

AMI another cause

IV access

Elevate head – facilitate venous drainage

Aspirin?

Oxygen

Blood Glucose check

Cardiac Monitor

A-fib common cause of emboli

AMI another cause

IV access

Elevate head – facilitate venous drainage

Aspirin?

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What about Stroke Centers?What about Stroke Centers?

Positive effects of stroke center are comparable to the effects of timely administration of tPA…

Preferential routing to stroke centers

Positive effects of stroke center are comparable to the effects of timely administration of tPA…

Preferential routing to stroke centers

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Iowa EMS Protocol 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

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

Iowa Primary Stroke CentersIowa Primary Stroke Centers

Iowa Healthcare Collaborative

www.ihconline.org

Iowa Healthcare Collaborative

www.ihconline.org

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Questions????Questions????

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