© 2006 National Stroke Association 1 - Hunter Ambulance

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© 2006 National Stroke Association 1 - Hunter Ambulance

Facts About StrokeOver 750,000 Americans willexperience a stroke this year.© 2006 National Stroke© 2006 National Association Stroke Association4


Facts About StrokeStroke occurs every 40 seconds• Death from stroke occurs every4 minutes– 163,000 Americans die each yrfrom stroke• In 2010, an estimated $ 73.7billion will be spent on strokerelated medical/disability costs© 2006 National Stroke© 2006 National Association Stroke Association


Public AwarenessUnaware stroke can be prevented 21%Concerned about suffering a stroke 30%Did not know stroke occurs in the brain 37%Knew someone who had a stroke 40%Would call 911 if experiencing one-sidedweakness 87%Source: A 2001 National Stroke Association Survey© 2006 National Stroke© 2006 National Association Stroke Association7


WHATIS ASTROKE?© 2006 National Stroke© 2006 National Association Stroke Association8


Stroke is a Brain Attack!Stroke is anEMERGENCY!© 2006 National Stroke© 2006 National Association Stroke Association9


Stroke is a Brain Attack!Stroke isTreatable!© 2006 National Stroke© 2006 National Association Stroke Association11


Stroke is a Brain Attack!Every minute lostincreasesthe chance of patientsexperiencing stroke-relateddisabilities or death.© 2006 National Stroke© 2006 National Association Stroke Association12


What is stroke?• When a blood vessel carrying O 2 andnutrients to the brain is blocked by a clotor bursts• The affected area of the brain starts to diedue to lack of blood flow– Time is brain!© 2006 National Stroke© 2006 National Association Stroke Association13


Types of Stroke• Ischemic– 87% of all cases– Caused by fattydeposits lining vesselwalls• Cerebral thrombosisdevelops at the cloggedvessel• Cerebral embolism is aclot that forms elsewhere(heart, carotids) thenbreaks loose and travelsto brain© 2006 National Stroke© 2006 National Association Stroke Association14


Ischemic Stroke© 2006 National Stroke© 2006 National Association Stroke Association15


Types of Stroke• Hemorrhagic– 13% of stroke cases– Weakened vessels break & bloodleaks in the brain compressingsurrounding brain tissue• Aneurysm: ballooning of a weakenedvessel that then bursts• AVM (arteriovenous malformation): acluster of abnormally formed vesselsand one bursts© 2006 National Stroke© 2006 National Association Stroke Association16


Hemorrhagic Stroke© 2006 National Stroke© 2006 National Association Stroke Association17


Types of Stroke• Brain Aneurysm & AteriovenousMalformation© 2006 National Stroke© 2006 National Association Stroke Association18


Types of Stroke• TIA (transient ischemicattack or “mini stroke”)– Symptoms mimic that of astroke but resolve withinminutes to hours– Caused by a temporarydecrease in blood flow to thebrain– Usually due to tiny blood clotsthat temporarily block flow– Warning sign!• 1/3 of TIA pts will go on to have atrue stroke© 2006 National Stroke© 2006 National Association Stroke Association19


Ischemic Penumbra• Viable but threatenedbrain tissue betweenthe normal tissue andthe tissue of the infarct• Ischemic prenumbra• Core infarct© 2006 National Stroke© 2006 National Association Stroke Association20


Ischemic Penumbra© 2006 National Stroke© 2006 National Association Stroke Association21


Risk Factorsand Prevention© 2006 National Stroke Association


Risk FactorsNon-Modifiable RiskFactors• Age– Risk doubles each decadeafter 55• Heredity/race– African Americans higherrisk• Gender– Higher incidence in males– Higher death rate in womenthan men• Prior TIA, Stroke, MI– Prior TIA = 10 times morelikely to have a strokeModifiable Risk Factors• High blood pressure– Leading cause of stroke• Diabetes• Atrial fibrillation• Smoking• High cholesterol• Carotid artery disease• Sickle cell– ‘sickled’ cells can attach tovessel walls causingblockage• Poor diet• Obesity© 2006 National Stroke© 2006 National Association Stroke Association23


Stroke Signs and Symptoms© 2006 National Stroke© 2006 National Association Stroke Association24


Stroke Signs and SymptomsSevereHeadacheSuddenConfusionSuddenDizzinessTrouble Seeing inOne or Both EyesTroubleSpeakingSuddenNumbness/Weakness esp.on one side of the body© 2006 National Stroke© 2006 National Association Stroke Association25


Less Common Symptoms• Altered level of consciousness• Respiratory distress• Difficulty swallowing• Pupils unequal in size/reaction to light• Convulsions or seizures• Loss of bladder/bowel control• Nausea and vomiting© 2006 National Stroke© 2006 National Association Stroke Association26


Other Diagnoses To Consider• Trauma/head injury• Postictal state• Drug overdose• Intoxication• Metabolic imbalance– Hypoglycemia– Hyperglycemia© 2006 National Stroke© 2006 National Association Stroke Association27


Neuroanatomy andEffects of Stroke© 2006 National Stroke© 2006 National Association Stroke Association28


Cerebellar Stroke• Affects reflexes,balance and coordination•Clinical presentation:abnormal reflexes,dizziness, nausea, andvomiting© 2006 National Stroke© 2006 National Association Stroke Association29


Brain Stem Stroke•Affects involuntarylife-supportfunctions includingbreathing, blood pressure,and heartbeat•Also affected: eyemovements, hearing,speech, swallowing, andmobility© 2006 National Stroke© 2006 National Association Stroke Association30


Emergency Dispatchand Field Assessment© 2006 National Stroke© 2006 National Association Stroke Association33


Stroke Systems of Care© 2006 National Stroke© 2006 National Association Stroke Association34


Facts and Challenges• Poor public recognition of stroke symptoms• EMS is the first medical contact for over 50percent of stroke patients• Many EMS dispatchers still do not usestandardized call receiving algorithmprocedures to identify stroke patients© 2006 National Stroke© 2006 National Association Stroke Association35


Source: University of Cincinnati College of Medicine© 2006 National Stroke© 2006 National Association Stroke Association36


Dispatch Role• Identify stroke signs &symptoms• Identify when last seen “well”• Dispatch quickly– ASA recommends dispatch


First Responder Role• Identifying signs & symptoms of stroke• BLS per protocols• Notify dispatch of need for ALS unitdue to stroke symptoms© 2006 National Stroke© 2006 National Association Stroke Association39


EMT Role• Response time


Paramedic Role• Response time


ALS Pre-Hospital Management•ABC’s•2L NC unless high flow O2 neededAssist ventilations if needed•VitalsNo antihypertensive meds in the field•IV 18G 0.9% NS only•Blood glucoseD50 if glucose


Hospital Care andTreatment© 2006 National Stroke© 2006 National Association Stroke Association43


Work-up of Stroke and TIA• EvaluationPatients– VS, initial presentation, EKG, FSG• Patient History• Past medical history, co-morbidities• Physical Exam• NIHSS• Laboratory Evaluation• CBC, CCH7, coags, cardiac markers, type &screen© 2006 National Stroke© 2006 National Association Stroke Association44


Work-up of Stroke and TIAPatients, continued• Neuroimaging• Head CT or MRI if time permitsSource: UCLA Stroke Center© 2006 National Stroke© 2006 National Association Stroke Association45


Acute TherapiesThrombolysis:• Thrombolytic agent that dissolves bloodclots• Significantly reduces effects of stroke andcan reduce disability• tPA (tissue plasminogen activator)– “clot busting” drug– Only FDA approved drug for urgenttreatment of ischemic stroke– Only 3-5% of those having a strokereach the hospital in time to beconsidered a t-PA candidate*** 3 HOUR WINDOW FOR IV tPA ***© 2006 National Stroke© 2006 National Association Stroke Association46


Acute Therapies -tPA© 2006 National Stroke© 2006 National Association Stroke Association47


Acute Therapies, continued•Merci® (MechanicalEmbolus Removal inCerebral Ischemia) Retriever•Cleared by FDA in 2004•Mechanical option for patientsineligible for t-PA•Corkscrew shaped device isthreaded through artery toretrieve and remove blood clot© 2006 National Stroke© 2006 National Association Stroke Association48


EMS Related Stroke Facts• EMS responders encounter 4-10 strokesper year per ASA• Majority of emergency calls are answeredby BLS units• In 2009, MidState saw 307 stroke patients– 197 of those patients arrived via EMS– This works out to be 64% of our strokepatients arriving via ambulance© 2006 National Stroke© 2006 National Association Stroke Association49


Percentage of Patients Arriving Via EMS64%© 2006 National StrokeAssociation© 2006 National Stroke Association50


Percentage of Patients ArrivingVia EMSEMSNote: Time periods at the end of the graph and data tablehave been omitted because there were no patient records during that time.BenchmarkGroupTime PeriodEMS fromhome/scenePrivatetransport/taxi/otherfromhome/sceneTransfer fromotherhospitalND orUnknownBlank("Missing ArrivalInformation")TotalJan 200926 (76.5%)4 (11.8%)0 (0%)4 (11.8%)0 (0%)34Feb 200911 (55%)4 (20%)0 (0%)5 (25%)0 (0%)20Mar 200914 (43.8%)8 (25%)0 (0%)10 (31.2%)0 (0%)32Apr 200911 (52.4%)7 (33.3%)0 (0%)3 (14.3%)0 (0%)21May 200922 (68.8%)6 (18.8%)0 (0%)4 (12.5%)0 (0%)32My HospitalJun 2009Jul 200916 (72.7%)13 (59.1%)4 (18.2%)4 (18.2%)0 (0%)0 (0%)2 (9.1%)5 (22.7%)0 (0%)0 (0%)2222Aug 200918 (62.1%)8 (27.6%)0 (0%)3 (10.3%)0 (0%)29Sep 200916 (66.7%)7 (29.2%)0 (0%)1 (4.2%)0 (0%)24Oct 200917 (63%)8 (29.6%)0 (0%)2 (7.4%)0 (0%)27Nov 200918 (85.7%)2 (9.5%)0 (0%)1 (4.8%)0 (0%)21Dec 200915 (65.2%)7 (30.4%)0 (0%)1 (4.3%)© 2006 National Stroke© 2006 National Association Stroke Association0 (0%)2351


Percent of Pre-HospitalNotification54.5% 56.2%30.8% 30.8%36.4% 38.9% 35.3% 38.9%18.2% 18.8% 26.7%7.1%© 2006 National Stroke© 2006 National Association Stroke Association52


MidState’s Stroke Team• FAST team• Door to MD: 10 min• Door to Stroke Team: 15 min• Door to CT: 25 min• Door to CT/Lab results: 45 min• Door to Treatment: 60 min• Pre-Hospital notification helps mobilizes theteam PTA to ensures ready bed, available MD,open CT table, and meeting our goal timeframes.© 2006 National Stroke© 2006 National Association Stroke Association53


A Local Perspective•54 y/o male, truck driver in Middletown, CT•While driving, pt went to put left foot on the brake and was notable to. He also tried to put his turn signal on and his left armdid not move. He notified co-workers who then call 911.Symptoms began at 11:45 a.m.•911 call received: 11:52:11•EMS dispatched P1 at: 11:52:50•En route: 11:53:48•On scene: 12:00:07•Departed scene P1: 12:07:05 *Stroke Team activated PTA*•Arrived to MSMC: 12:15:28© 2006 National Stroke© 2006 National Association Stroke Association54


A Local Perspective• FAST team called: 12:13• FAST team arrived: 12:14• Pt arrived in ED: 12:15• MD eval: 12:18• CT scan complete: 12:30• CT/Lab results: 12:40 & 12:49• T-PA initiated: 13:45• By 14:40, the pt is able to move his left toes. At 14:43 pt is now able toraise left leg off the bed completely. At 14:46, pt is moving left arm upand down with moderately strong hand grasp. At 14:50, the patient’sfacial droop is resolving and speech clearing.• The patient was admitted on May 12, 2008 and walked out of thehospital on his discharge date of May 14, 2008.• Today the patient is doing well, with no notable deficit.© 2006 National Stroke© 2006 National Association Stroke Association55


Questions & Answers© 2006 National Stroke© 2006 National Association Stroke Association56


In ConclusionStroke is an Emergency!Stroke is a Brain Attack!Stroke is Treatable!YOU make a Difference!© 2006 National Stroke© 2006 National Association Stroke Association57


Please complete the Post-Testat this time.© 2006 National Stroke© 2006 National Association Stroke Association58


Today’s program has beenbrought to you byNeurobiological Technologies,Inc.© 2006 National Stroke© 2006 National Association Stroke Association59


ContributorAcknowledgementNational Stroke Association would like toexpress its appreciation to Jim Floyd,M.Ed., WEMT, PI, CTC of St. VincentIndianapolis Hospital for hiscontributions to the development of thispresentation.© 2006© 2006NationalNationalStrokeStrokeAssociationAssociation


For more informationcontact the National StrokeAssociation1-800-STROKESorwww.stroke.orgOr email questions toEMS@stroke.org© 2006 National Stroke Association

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