Not so long ago pre-hospital stroke care consisted of little more than O2, IV and transport to the ED. In-hospital treatment consisted primarily of therapy to help patients manage their disabilities. In 1996 thrombolytics were approved for use, ushering in the era of modern stroke care. In 2011, as hospitals are developing new methods of treatment for stroke victims, what new options are available for EMS? This program will show you new treatments like site-specific thrombolytics, clot corkscrews, neuroprotective magnesium, cranial hypothermia, stem cell implantation and the role of EMS in delivering these cutting edge care techniques. This lecture is a fast paced, fun and pertinent presentation of the emerging developments in neurovascular medicine. Teaching Formats: -Lecture -Question and Answer -Handouts Learning Objectives: Students will learn: -The Impact of Cerebrovascular Care on the US Healthcare System. -Pathophysiology and differentiation of embolic, thrombotic, hemorrhagic and lacunar strokes and stroke imitators. -Stroke specific assessment techniques including Pre-hospital and In-Hospital Stroke Scales. -Emerging cerebrovascular care technologies including interventional neurology telemedi-cine, intra-arterial TPa, microbubble therapy, clot vacuuming, cerebral hypothermia, neu-roprotective magnesium and stem cell implantation. -The role of the EMS provider in comprehensive stroke care. For more information, stroke resources and other presentations like this one, go to www.romduckworth.com

1. EMS
Stroke Care
Saving Patients’ Lifes
by
Rommie L. Duckworth, LP

2. The Problem of Stroke
Stroke is the leading cause of disability.
20% Institutionalized within 3 months.
Approx. 25% die within 1 yr of 1st stroke.
Stroke is 3rd 4th leading cause of death.

3. Target Stroke: Acute Care & EMS
The sooner that rt-PA is given to stroke patients, the greater the
benefit, especially if started within 90 minutes of symptom onset.

5. The Connecticut Plan
Stroke Prevention and Care Goals
• Plan Goal: To create a coordinated system of stroke care and
prevention in which it is possible for every Connecticut resident
to access appropriate and timely care for optimal post stroke
outcomes. A coordinated care system involves EMS, hospital
stroke teams, specialized stroke units (where applicable), and
standardized care protocols.
• Emergency Medical Services (EMS): To facilitate timely access
to EMS care, enhanced pre-hospital recognition and treatment,
and rapid transport to the appropriate health care facility of
patients experiencing a stroke event.

6. Stroke Center Designation

7. Stroke Center Designation
Trauma JCAHO CT NY VA TX
Level I CSC Level I I CSC
Level II PSC PSC DSC Level II II PSC
Level ASRH Level III SSF
III ED III
Level Level
IV IV

8. Connecticut and Surrounding PSCs

9. Why Not Better?

10. GOOD ENOUGH

11. Improving Stroke Care
THE THE THE THE THE SWEET
PROBLEM GOAL PATH RESISTANCE SUPPORT VICTORY

12. 4 Steps for EMS

14. The Stroke Process
Ischemia
Infarct
Penumbra

15. Cerebrovascular System

16. Types of Stroke

17. Stroke Assessment
At the door

18. Stroke Assessment
At the Bedside
S - Sudden Onset, Hemiparesis, Focal Neuro Def.
A – Aw, who cares!
M - Coumadin, HTN, antiepileptics
P - Stroke, Seizure, aneurysms, HTN, Mimics…
L - Last Seen Normal
E - Prior similar episodes, MI, Trauma, Surgery…
V/S - Elevated B/P, Low Pulse, Low Resp, Glucose

19. Stroke Assessment
Holding Hands
Cincinnati Pre Hospital Stroke Scale CPSS
• SMILE
• ARM DRIFT
• PHRASE
• Any Positive = greater than 70% chance stroke.
Other Pre Hospital Stroke Scales
• LAPSS
• MEND

20. Stroke Assessment
• Common Stroke Mimics Diff. Dx.
• Hypoglycemia • Migraine
– ABGT / Better w/Glucose – Past Hx.
• Tumor – Photosensitivity
– Slow & progressive onset • Head Injury
• Abscess – Recent Trauma
– Slow & progressive onset • Subdural
• Seizure – Previous Trauma
– Staring, Aura or shaking • Bell’s Palsy
• OD / ETOH – Past Hx.
– Acute Hx.

21. Stroke Assessment

22. Stroke Assessment
• Won’t they just catch it in the ED anyway?
– If stroke is missed by EMS…
• Longer transport time.
• Lower priority in the ED.
• No EMS pre-notification = No ED Prep.
• Longer time to CT scan = Missed Tx Opportunity.
• Potentially missed altogether.
• One Shoe!

23. In-Hospital Care
• CT Scan in 30 minutes
• CT Reader with CVA Experience
Primary •
•
Stroke team to patient in 15 minutes
Physician experienced with TPa and NIHSS
Stroke •
•
Door to Needle time <60 minutes
Neurosurgeon with stoke experience <2 hours
• Neurologists+ on call
Centers •
•
Diagnostics such as MRI, CT Angiography, etc.
Interventional capabilities incl IATPa
• Neuro Rehab capabilities

24. ICH Management
• Hemorrhage
– ABCs
– Seizure Prevention
– BP Management
– BS Management
– Surgery

25. Thrombolytics
• TPa
– Systemic
– 3-4.5 hours – off-label
– At 1 hr is 3x as effective as at 3 hrs
• IA-TPa
– Delivered Directly
– 6 hours – off-label
– Earlier is better

26. Surgical Options

27. Best Practices
THE BRAIN ATTACK
COALITION

28. Best Practices: IDENTIFY
• Decrease Time To 911 • Assure Correct EMS
Notification Resources
– Primary Education – Closest First Response
• Prioritize EMS Dispatch – Closest Transport
– Standardized Protocols – ALS
– Sense of Priority • E911 Coverage
– Consolidation of PSAPs – NG911 Coverage
• Better Standardization
• Single-Call 911

29. Best Practices: TRIAGE-IFY
• Triage To Best
Destination
– Standardized Protocols – Local Implementation
• State • Can Vehicles Leave
• Regional Response District
• Local • Patient Preference
• Provider Preference
– Education
• Emphasis On Dx, Not
Just Speed.
• ED Interface Staff
Feedback

30. Best Practices: NOTIFY
• Correctly Identify
Stroke In The Field
– Validated Stroke Scores • Aggregate Data To
• Sense of Priority
Facilitate ED Diagnosis
• ED Pre-Notification – Validated Assessments
– Standardized “Code – Receipt of Assessments
Stroke”
– Telemedicine
– Receipt of “Code
– NEMSIS
Stroke”
– QA/QI

31. Best Practices: CARE-IFY
• Extend The Time Frame • Reduce The Distance
– Standard Supportive – Increase Accreditation
Care of Hospitals as CSC, PSC,
– Emerging Tx ASRH
• EMS • Formal Accreditation
– Field Admin of T-PA • “Survey” Stroke Centers
– Therapeutic Hypothermia • Telemedicine
• Hospital
– IAT-PA
– Clot Retrieval

32. Best Practices:
Interfacility Transport
• Transfer to Primary Stroke Centers
• Prior Transport Arrangements
• Critical Care Training
• VS and NS q 15 minutes post tPA Admin

33. Questions

35. 4 Steps for EMS

37. GOOD ENOUGH
IS NOT
GOOD ENOUGH