Disclosures ACUTE STROKE CARE FOR THE EMS · ACUTE STROKE CARE FOR THE EMS PROVIDER ... Coronary Artery disease ... (National Institute of Neurological

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ACUTE STROKE CARE ACUTE STROKE CARE FOR THE EMS FOR THE EMS PROVIDERPROVIDER

Julie BerdisJulie Berdis--RN,BSN,CNRN,RN,BSN,CNRN,Stroke CoordinatorStroke CoordinatorProvidence Sacred Heart Medical CenterProvidence Sacred Heart Medical CenterSpokane, WashingtonSpokane, Washington

DisclosuresDisclosures

No financial disclosuresNo financial disclosures Will be discussing offWill be discussing off--label useslabel uses Always follow your local and regional Always follow your local and regional

protocolsprotocols

ObjectivesObjectives

Review the impact of strokeReview the impact of stroke Recognize signs and symptoms of strokeRecognize signs and symptoms of stroke Define risk factors for strokeDefine risk factors for stroke Identify types of strokeIdentify types of stroke Learn PreLearn Pre--hospital recommendations for Dispatchhospital recommendations for Dispatch Review stroke care in the field Review stroke care in the field Review medical management and treatment Review medical management and treatment

options for strokeoptions for stroke Review national/regional guidelines and Review national/regional guidelines and

recommendations for strokerecommendations for stroke

Key PointsKey Points

EMS play a EMS play a criticalcritical role in the Emergency care of role in the Emergency care of acute stroke patients.acute stroke patients.

Over 400,000 acute stroke patients are being Over 400,000 acute stroke patients are being transported annually by EMS providers.transported annually by EMS providers.

50% of all stroke patients use EMS, but this is the 50% of all stroke patients use EMS, but this is the majority of patients who present within the 3 hour majority of patients who present within the 3 hour treatment windowtreatment window

EMS use decreases time to hospital arrival and the EMS use decreases time to hospital arrival and the ability to implement acute stroke intervention.ability to implement acute stroke intervention.

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The Impact of StrokeThe Impact of Stroke

795,000 strokes in 2009795,000 strokes in 2009 163,000 die from stroke every year in America 163,000 die from stroke every year in America Stroke is the third leading cause of deathStroke is the third leading cause of death Stroke is the Stroke is the leading cause of disabilityleading cause of disability in adultsin adults 4.4 million survivors; only 504.4 million survivors; only 50--75% of stroke 75% of stroke

survivors regain functional independencesurvivors regain functional independence Estimated direct/indirect costs for 2007Estimated direct/indirect costs for 2007-- $62.7 $62.7

billion billion 14% of persons who survive a first stroke or TIA 14% of persons who survive a first stroke or TIA

will have another within one yearwill have another within one year

Time is Brain!Time is Brain!

Every second 32,000 neurons dieEvery second 32,000 neurons die Every minute 1.9 million neurons dieEvery minute 1.9 million neurons die Every hour 120 million neurons dieEvery hour 120 million neurons die Completed stroke: Loss of 1.2 billion neuronsCompleted stroke: Loss of 1.2 billion neurons

Blockage of one blood vessel will cause ischemia within Blockage of one blood vessel will cause ischemia within 5 minutes5 minutes

What is our goal?What is our goal?

Reduce stroke mortality Reduce stroke mortality Improve quality of life for stroke survivors and Improve quality of life for stroke survivors and

their familiestheir families

Focus:Focus: Increasing public awarenessIncreasing public awareness Timely initiation of 911 systemTimely initiation of 911 system Deployment of informed EMS personnelDeployment of informed EMS personnel Delivery to a stroke centerDelivery to a stroke center

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Did You Know?Did You Know?

The average time from symptom onset to The average time from symptom onset to the ED is the ED is 1717--2222 hours.hours.

42% of people over 50 do not recognize 42% of people over 50 do not recognize signs and symptoms of strokesigns and symptoms of stroke

17% of people over 50 can17% of people over 50 can’’t name a single t name a single stroke symptomstroke symptom

Only 38% call 9Only 38% call 9--11--11 Only 20Only 20--25% arrive within 3 hours25% arrive within 3 hours

Signs and Symptoms of StrokeSigns and Symptoms of Stroke Sudden numbness/weakness of Sudden numbness/weakness of

the face,arm,or leg, especially the face,arm,or leg, especially on one side of the bodyon one side of the body

Slurred speech/difficulty Slurred speech/difficulty speaking/understandingspeaking/understanding

Sudden change in vision Sudden change in vision (blurred or decreased vision) in (blurred or decreased vision) in one or both eyesone or both eyes

Dizziness, loss of balance or Dizziness, loss of balance or coordinationcoordination

Acute onset severe headacheAcute onset severe headache Nausea or vomiting with any of Nausea or vomiting with any of

the above symptomsthe above symptoms Confusion or disorientation with Confusion or disorientation with

above symptomsabove symptoms

Additional stroke Additional stroke symptomssymptoms Decrease level of consciousnessDecrease level of consciousness Difficulty with swallowing and Difficulty with swallowing and

secretionssecretions Respiratory distressRespiratory distress Pupil changesPupil changes ConvulsionsConvulsions

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Modifiable Risk FactorsModifiable Risk Factors

HypertensionHypertension Elevated cholesterol (statins reduce risk by 30%)Elevated cholesterol (statins reduce risk by 30%) Diabetes mellitusDiabetes mellitus--independent risk factorindependent risk factor Coronary Artery diseaseCoronary Artery disease Heart diseaseHeart disease--Valve disease/replacement, any Valve disease/replacement, any

factor that decreases ventricular contractionfactor that decreases ventricular contraction Atrial Fibrillation (3Atrial Fibrillation (3--4x risk)4x risk) Previous strokePrevious stroke Obesity Obesity Excessive alcohol Excessive alcohol Smoking (2x risk ischemic; 4x risk hemorrhagic)Smoking (2x risk ischemic; 4x risk hemorrhagic) Oral Contraceptives/HRTOral Contraceptives/HRT

NonNon--Modifiable Risk Modifiable Risk FactorsFactors AgeAge--Risk doubles per decade over 55 Risk doubles per decade over 55 GenderGender--Men have greater risk, but women live Men have greater risk, but women live

longer. longer. More women die from stroke (60% of stroke More women die from stroke (60% of stroke

deaths)deaths) RaceRace--AfricanAfrican--American, Asian and Hispanic have American, Asian and Hispanic have

greater risk, possibly due to hypertensiongreater risk, possibly due to hypertension Diabetes MellitusDiabetes Mellitus-- Exacerbated by hypertension or Exacerbated by hypertension or

poor glucose control. Even diabetics with good poor glucose control. Even diabetics with good control are at increased risk.control are at increased risk.

Family history of stroke or TIAFamily history of stroke or TIA

3 Regions of the Brain3 Regions of the Brain

CerebrumCerebrum

CerebellumCerebellum

Brain StemBrain Stem

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CerebrumCerebrum

Conscious thoughtConscious thought MemoryMemory PersonalityPersonality SpeechSpeech Motor FunctionMotor Function VisionVision Touch (tactile)Touch (tactile)

CerebellumCerebellum

CoordinationCoordination BalanceBalance Fine motor controlFine motor control ReflexesReflexes

Symptoms: dizziness, nausea, vomitingSymptoms: dizziness, nausea, vomiting

Brain StemBrain Stem

Heart functionHeart function RespirationRespiration Autonomic nervous systemAutonomic nervous system DigestionDigestion

Symptoms: Involuntary lifeSymptoms: Involuntary life--support functions support functions (breathing, heartbeat, blood pressure), eye (breathing, heartbeat, blood pressure), eye movement, hearing, speech, swallow, movement, hearing, speech, swallow, mobility on one or both sides of the bodymobility on one or both sides of the body

Cerebral Circulation Cerebral Circulation

Anterior Circulation– Carotid arteries– Anterior cerebral

arteries– Middle cerebral

arteries

Posterior Circulation– Vertebral arteries– Basilar artery– Posterior cerebral

arteries

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Cerebral CirculationCerebral Circulation Stroke: What is it?Stroke: What is it? Sudden interruption Sudden interruption

of of blood supplyblood supply to the to the brainbrain

Lack of Lack of oxygenoxygen and and glucose to nerve cells glucose to nerve cells

IschemiaIschemia within 1 within 1 hourhour

Cytotoxic and Cytotoxic and vasogenic edemavasogenic edema

Cellular Cellular deathdeath

Ischemic PenumbraIschemic Penumbra

The ischemic penumbra is the viable but threatened brain tissue The ischemic penumbra is the viable but threatened brain tissue between the normal tissue and the tissue of the infarctbetween the normal tissue and the tissue of the infarct

Acute stroke therapies focus on reversing orAcute stroke therapies focus on reversing orpreventing ischemic damage. preventing ischemic damage. ““Penumbral SalvagePenumbral Salvage””

Types of StrokeTypes of Stroke

Ischemic StrokeIschemic Stroke-- 88%88%Embolic (24%): Embolic (24%): Blood clot formsBlood clot formssomewhere in thesomewhere in thebody and travels to the brain body and travels to the brain

Thrombotic(61%):Thrombotic(61%):Clot forms on blood vessel Clot forms on blood vessel

deposits deposits

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Hemorrhagic StrokeHemorrhagic Stroke--12%12%

Intracerebral Bleed (ICB)Intracerebral Bleed (ICB) Subarachnoid HemorrhageSubarachnoid Hemorrhage (SAH)(SAH)

Hemorrhagic StrokeHemorrhagic Stroke

Responsible for 30% of stroke deathsResponsible for 30% of stroke deaths IntracerebralIntracerebral--within the brain tissue. Most within the brain tissue. Most

commonly from high blood pressurecommonly from high blood pressure SubarachnoidSubarachnoid--around the brainaround the brain’’s surface s surface

and under its protective layerand under its protective layer--Most Most commonly from aneurysm rupturecommonly from aneurysm rupture

Risk factors: hypertension, alcohol, drug Risk factors: hypertension, alcohol, drug abuse, antiabuse, anti--clotting medication and blood clotting medication and blood clotting disordersclotting disorders

The Problem With TIAThe Problem With TIA’’ss(Transient Ischemic Attack)(Transient Ischemic Attack)

A A ““TIATIA”” has sudden onset and rapid resolutionhas sudden onset and rapid resolutionRule of Thumb: The event should last 2Rule of Thumb: The event should last 2--20 minutes20 minutes

If the event lasts more than 1 hour it is probably a minor If the event lasts more than 1 hour it is probably a minor strokestroke

The likelihood of stroke is greatest in the first 48 hours The likelihood of stroke is greatest in the first 48 hours after the eventafter the event

More than 1/3 of all persons who experience TIAMore than 1/3 of all persons who experience TIA’’s will s will go on to have a strokego on to have a stroke

The Problem with The Problem with TIATIA’’ss

TIAs should not be ignoredTIAs should not be ignored Patients need to seek immediate Patients need to seek immediate

medical attention in order to prevent a medical attention in order to prevent a possible full blown stroke possible full blown stroke

MRI may be needed to determine TIA MRI may be needed to determine TIA VS. StrokeVS. Stroke

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Stroke is a Time Critical TransportStroke is a Time Critical TransportACLS GuidelinesACLS Guidelines

IV IV AlteplaseAlteplase (tPA(tPA--tissue Plasminogen Activator) tissue Plasminogen Activator) improves neurologic outcome in patients when improves neurologic outcome in patients when administered within 3 hours of onsetadministered within 3 hours of onset

Stroke presenting within *3 hours should be triaged Stroke presenting within *3 hours should be triaged on an emergent basis with urgency similar to acute on an emergent basis with urgency similar to acute STST--elevation myocardial infarctionelevation myocardial infarction

Patients who may be candidates for fibrinolytic Patients who may be candidates for fibrinolytic therapy should be transported to hospitals therapy should be transported to hospitals identified as capable of providing acute stroke care, identified as capable of providing acute stroke care, including 24including 24--hour availability of CT scan and hour availability of CT scan and interpretationinterpretation

Goals for EMS Response and Goals for EMS Response and Acute InterventionAcute Intervention

Rapid Recognition and Reaction to Rapid Recognition and Reaction to Stroke warning signsStroke warning signs

Rapid EMS DispatchRapid EMS Dispatch Rapid EMS transport and hospital Rapid EMS transport and hospital

prenotificationprenotification Rapid diagnosis and treatmentRapid diagnosis and treatment

Emergency DispatchEmergency Dispatch

Use of 911 system is recommended for Use of 911 system is recommended for symptoms of strokesymptoms of stroke

Many callers do not use the word Many callers do not use the word ““strokestroke”” Dispatchers should recognize the seriousness of Dispatchers should recognize the seriousness of

stroke and be familiar with stroke symptoms.stroke and be familiar with stroke symptoms. Strokes should be dispatched as a high priority Strokes should be dispatched as a high priority

call, send closest unitcall, send closest unit-- similar to acute MI or similar to acute MI or traumatrauma

An EMD callAn EMD call--receiving algorithm is recommended receiving algorithm is recommended to ask appropriate questions to callersto ask appropriate questions to callers

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Emergency DispatchEmergency Dispatch

Dispatch should ask the caller when (what time) Dispatch should ask the caller when (what time) the patient was last seen normal (without the patient was last seen normal (without weakness, facial droop, loss of speech)?weakness, facial droop, loss of speech)?

Try to determine pertinent past medical historyTry to determine pertinent past medical history Relay information to ResponderRelay information to Responder Request feedback from Responder regarding Request feedback from Responder regarding

outcomeoutcome Dispatchers should receive education recognizing Dispatchers should receive education recognizing

stroke symptomsstroke symptoms

EMS Stroke CareEMS Stroke Care

Rapid IdentificationRapid Identification of stroke as the cause of stroke as the cause of the patientof the patient’’s findingss findings

Elimination of conditions that could mimic Elimination of conditions that could mimic strokestroke

StabilizationStabilization Rapid transportationRapid transportation of the patient to the of the patient to the

closest appropriate EDclosest appropriate ED Pre notificationPre notification to the receiving hospital to the receiving hospital

about impending arrival of a patient with about impending arrival of a patient with suspected strokesuspected stroke

Suspected Stroke Suspected Stroke PrehospitalPrehospitalProtocol Guidelines Protocol Guidelines

((Washington State Emergency Stroke Care System)Washington State Emergency Stroke Care System)

Scene SizeScene Size--Up/Initial Patient Assessment Up/Initial Patient Assessment (Sick or Not Sick)(Sick or Not Sick)

A.A. Support ABCsSupport ABCsB.B. Check glucose, temperature, SpO2Check glucose, temperature, SpO2C.C. Treat hypoglycemiaTreat hypoglycemiaD.D. NPONPO


(Washington State Emergency Stroke Care System)(Washington State Emergency Stroke Care System)

Focused History and Physical ExamFocused History and Physical ExamA.A. FAST Assessment (FAST Assessment (FFace/ace/AArms/rms/SSpeech/peech/TTime ime

last normal)last normal)If one component abnormal, high probability If one component abnormal, high probability of stroke. Refer to stroke destination triage of stroke. Refer to stroke destination triage tool. Time from last normal will determine tool. Time from last normal will determine destination.destination.

B.B. Limit scene time with goal of Limit scene time with goal of ≤≤ 15minutes15minutes

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Time is Brain and you Time is Brain and you must act FAST!must act FAST!

F F –– A A –– S S –– T T FFace ace –– smilesmile

AArm raiserm raise

SSay a phraseay a phrase

TTime ime –– Time Last Time Last NormalNormal

Key Components of Taking Key Components of Taking Patient History (SAMPLE)Patient History (SAMPLE)

SS--Symptoms/ onset (When was the person last seen Symptoms/ onset (When was the person last seen normal?)normal?)

AA--AllergiesAllergiesMM--MedicationsMedications--anticoagulants (anticoagulants (warfarinwarfarin), ),

antithromboticsantithrombotics, Insulin, , Insulin, antihypertensivesantihypertensives, , antiepilepticsantiepileptics

PP--Past Medical HistoryPast Medical History--Hypertension, Diabetes Hypertension, Diabetes (hypoglycemic patients may have symptoms that (hypoglycemic patients may have symptoms that mimic stroke), seizures, prior stroke, aneurysmsmimic stroke), seizures, prior stroke, aneurysms

LL--Last oral intakeLast oral intakeEE--Events PriorEvents Prior--stroke, MI, trauma, surgery, bleedingstroke, MI, trauma, surgery, bleeding

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TransportTransportA.A. Early hospital notificationEarly hospital notification--specify specify

FAST findings (abnormal physical FAST findings (abnormal physical findings and time last normal)findings and time last normal)

B.B. If closest appropriate facility greater If closest appropriate facility greater than 30 minutes, consider air than 30 minutes, consider air transport when appropriatetransport when appropriate



Management/Ongoing Assessment en routeManagement/Ongoing Assessment en routeA.A. Lay patient flat unless signs of airway compromise, in Lay patient flat unless signs of airway compromise, in

which case elevate no higher than 20 degrees.which case elevate no higher than 20 degrees.(Protocols vary! Follow your local protocol)(Protocols vary! Follow your local protocol)

A.A. IV access (as able)IV access (as able)1.1. Normal saline (avoid glucoseNormal saline (avoid glucose--containing solutions)containing solutions)2.2. 16 or 18 16 or 18 gaga IV in unaffected arm (affected arm is acceptable)IV in unaffected arm (affected arm is acceptable)3.3. Optional: Blood draw with IV startOptional: Blood draw with IV start4.4. 22ndnd exam/neuro reassessexam/neuro reassess5.5. Optional: Perform tPA checklistOptional: Perform tPA checklist

RecommendedRecommended

Manage ABCsManage ABCs Cardiac monitoringCardiac monitoring Intravenous accessIntravenous access--18gauge w/leur18gauge w/leur--lok lok

preferredpreferred Oxygen (as required 02 saturation <92%)Oxygen (as required 02 saturation <92%) Assess for hypoglycemiaAssess for hypoglycemia NPONPO Alert receiving EDAlert receiving ED Rapid transport to closest appropriate Rapid transport to closest appropriate

facility capable of treating acute strokefacility capable of treating acute stroke

Not RecommendedNot Recommended

DextroseDextrose--containing fluids in containing fluids in nonhypoglycemic patientsnonhypoglycemic patients

Excessive blood pressure reduction Excessive blood pressure reduction (can cause hypotension, decrease (can cause hypotension, decrease cerebral perfusion and worsen stroke)cerebral perfusion and worsen stroke)

Excessive intravenous fluids (can Excessive intravenous fluids (can cause increased intracranial pressure)cause increased intracranial pressure)

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In Addition:In Addition:

If local protocol allows, take a family If local protocol allows, take a family member to the hospital/phone numbermember to the hospital/phone number

Minimize scene time; procedures can be Minimize scene time; procedures can be performed during transportperformed during transport

Transport patient to the nearest Transport patient to the nearest appropriateappropriate hospital per local transport hospital per local transport protocolsprotocols

Notify receiving hospital en routeNotify receiving hospital en route

Recommendations fromRecommendations from NINDSNINDS((National Institute of Neurological National Institute of Neurological Disorder and Stroke)Disorder and Stroke)

1.1. Take the patient to the nearest hospital if Take the patient to the nearest hospital if there are no stroke centers nearbythere are no stroke centers nearby

2.2. Bypass hospitals unable to provide care if Bypass hospitals unable to provide care if there are stroke centers close by. Follow local there are stroke centers close by. Follow local destination protocolsdestination protocols

3.3. If remote, consider airIf remote, consider air--evacuation if:evacuation if:–– The closest center is > 1hour away, ORThe closest center is > 1hour away, OR–– The closest center cannot provide stroke care, ORThe closest center cannot provide stroke care, OR–– If the patient can reach a center within the *3If the patient can reach a center within the *3--hour hour

time window or tPA treatmenttime window or tPA treatment

Destination ProtocolsDestination Protocols

Coming soon!Coming soon!Washington State destination protocols Washington State destination protocols

for strokefor stroke

Northwest Medstar Response TimesNorthwest Medstar Response Times

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National Stroke Association RecommendationsNational Stroke Association Recommendations

““EMS System Medical Directors should EMS System Medical Directors should have a process to identify and provide have a process to identify and provide transport protocols to authorize EMS transport protocols to authorize EMS to transport stroke patients to the to transport stroke patients to the nearest appropriate hospitals, nearest appropriate hospitals, including recognized stroke centersincluding recognized stroke centers””

Evaluation of Current SystemsEvaluation of Current Systems

What is your general EMS environment in What is your general EMS environment in your state?your state?

What processes are in place that provide What processes are in place that provide rapid access to EMS for patients with acute rapid access to EMS for patients with acute stroke?stroke?

What are your EMS dispatch protocols?What are your EMS dispatch protocols? Where are suspected stroke patients Where are suspected stroke patients

transported?transported? What communications occur between local What communications occur between local

hospitals and EMS systems?hospitals and EMS systems?

Stroke is a time criticalStroke is a time critical

IV tPA (Alteplase)IV tPA (Alteplase)--Time from last normal to 3 Time from last normal to 3 hours. (Extended window 3hours. (Extended window 3--4.5 hours)4.5 hours)

Dose is based on patientDose is based on patient’’s weight. 10% of s weight. 10% of determined dose as an IV bolus, remaining 90% determined dose as an IV bolus, remaining 90% over one hourover one hour

May cause intracranial bleeding but has not May cause intracranial bleeding but has not been shown to increase mortalitybeen shown to increase mortality

CT ImagingCT Imaging

Large Ischemic stroke with midline shiftLarge Ischemic stroke with midline shift

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CT ImagingCT Imaging

CT Angiogram CT PerfusionCT Angiogram CT Perfusion

Acute Stroke Acute Stroke InterventionsInterventionsIntraarterialIntraarterial tPAtPA Time last normal to 6 hours.Time last normal to 6 hours.

Mechanical clot retrieval Mechanical clot retrieval 00--8 hours8 hours--anterior circulationanterior circulation 00--12 hours (or longer)12 hours (or longer)--posterior circulationposterior circulation

MerciMerci™™--Mechanical Clot Mechanical Clot Retrieval DeviceRetrieval Device

© Concentric Medical 2007

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ACA/A1

ICA

ICA -T

MCA/M1

MCA/M2

MCA/M3ACA/A2

Anterior Circulation – AP View

APM0189/B/3073, 2007-12

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Circle of Willis

PCA PCA

Basilar

VertVert

Posterior CirculationPosterior Circulation

APM0189/B/3073, 2007-12


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Patient HistoryPatient History

47 year old male, history of excessive alcohol abuse47 year old male, history of excessive alcohol abuse Last seen normal at midnight, found at 4 am unable to move Last seen normal at midnight, found at 4 am unable to move

his right side and unable to speakhis right side and unable to speak Family called 911, transfer to stroke centerFamily called 911, transfer to stroke center Not a candidate for IV tNot a candidate for IV t--PA, symptom onset >3 hoursPA, symptom onset >3 hours ER Physicians notified interventional team and arranged for ER Physicians notified interventional team and arranged for

transfertransfer Patient arrived to and was in the angiography suite by 6:30 Patient arrived to and was in the angiography suite by 6:30

amam Clinical Neurologic exam: unable to move right arm and leg, Clinical Neurologic exam: unable to move right arm and leg,

confused and unable to express language, NIHSS 18 (0 confused and unable to express language, NIHSS 18 (0 –– 42)42)

Patient not a candidate for IV t-PA as symptom onset >3 hours. He was

identified as a candidate for intervention.APM0189/B/3073, 2007-12


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PrePre--intervention Cerebral Angio 1intervention Cerebral Angio 1stst pass Merci pass Merci RetrieverRetriever

Intervention with Merci Retriever

Clot completely blocking flow in the left middle cerebral artery

Merci Retriever positioned in the left middle cerebral artery

APM0189/B/3073, 2007-12


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The cerebral artery is opened post procedure. The cerebral artery is opened post procedure. Patient had a dramatic clinical improvement.Patient had a dramatic clinical improvement.

Post InterventionPost Intervention Clinical OutcomeClinical OutcomeFirst division of the left middle

cerebral artery is open Neurologic Exam after interventional procedure:

• Alert and oriented, moving all extremities with subtle right sided weakness and mild language difficulties

• Following day NIHSS 3 decreased from 18

• Discharged to rehab• Awaiting home transfer with

24/7 supervision• Ambulates with quad cane

and has some persistent mixed aphasia

APM0189/B/3073, 2007-12

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EMS Role in ResearchEMS Role in Research

Identification of an effective neuroprotective Identification of an effective neuroprotective therapy may further expand the role of EMS in therapy may further expand the role of EMS in the treatment of acute stroke.the treatment of acute stroke.

HypothermiaHypothermia--Reduces cytotoxic cascade, Reduces cytotoxic cascade, Stabilizes bloodStabilizes blood--brain barrier, Reduces freebrain barrier, Reduces free--radical formation, May prevent neurotoxicity of radical formation, May prevent neurotoxicity of tPAtPA

IV MagnesiumIV Magnesium--(FASTMAG Trial)(FASTMAG Trial)IV Magnesium loading dose given in the field. IV Magnesium loading dose given in the field. Cytoprotective and vasodilating effects. Cytoprotective and vasodilating effects.

Public EducationPublic Education--Reducing RiskReducing Risk

Lifestyle ModificationLifestyle Modification Low fat diet/Controlling weight/ExerciseLow fat diet/Controlling weight/Exercise Treating Atrial FibrillationTreating Atrial Fibrillation Monitoring Alcohol consumption Monitoring Alcohol consumption Quit smokingQuit smokingMedical ManagementMedical Management Antihypertensive MedicationAntihypertensive Medication--For blood pressure For blood pressure

greater than 140/90. (Tighter control for diabetics)greater than 140/90. (Tighter control for diabetics) Cholesterol reducing medication for cholesterol > Cholesterol reducing medication for cholesterol >

200 mg/dl or LDL > 100 (statins)200 mg/dl or LDL > 100 (statins) Clot prevention medication(Anticoagulants) Clot prevention medication(Anticoagulants)

WarfarinWarfarin Antiplatelet drugsAntiplatelet drugs--Aspirin, Aggrenox, Plavix,TiclidAspirin, Aggrenox, Plavix,Ticlid

Questions?Questions? Donald RumsfeldDonald Rumsfeld

There are known There are known knownsknowns. . These are things we know These are things we know that we know. There are that we know. There are known unknowns. That is known unknowns. That is to say, there are things to say, there are things that we know we don't that we know we don't know. But there are also know. But there are also unknown unknowns. unknown unknowns. There are things we don't There are things we don't know we don't know. know we don't know.

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ReferencesReferences

American Stroke Association. Guidelines for the Early American Stroke Association. Guidelines for the Early Management of Adults With Ischemic Stroke. Management of Adults With Ischemic Stroke. StrokeStroke May May 2007. 2007. ““Prehospital Management and Field TreatmentPrehospital Management and Field Treatment””..

American Heart Association/ACLS Provider Manual. 2006American Heart Association/ACLS Provider Manual. 2006 National Institute of Neurological Disorders and Stroke National Institute of Neurological Disorders and Stroke

(NINDS)(NINDS) Concentric MedicalConcentric Medical--Merci Retrieval deviceMerci Retrieval device GenentecGenentec--AlteplaseAlteplase National Stroke AssociationNational Stroke Association--EMS Provider informationEMS Provider information Thanks to Michael DayThanks to Michael Day--Trauma Services Coordinator Sacred Trauma Services Coordinator Sacred

Heart Medical CenterHeart Medical Center Northwest Regional Stroke NetworkNorthwest Regional Stroke Network--Destination protocols,Destination protocols,

EMS Online TrainingEMS Online Training

You are dispatched to a call of a 75-year-old female with sudden onset of trouble walking; she has become dizzy and very nauseated. She cannot walk without holding onto furniture. Her blood pressure is 160/90. Her blood sugar is normal. The cardiac monitor shows sinus rhythm. She has no c/o chest pain. She is a non-drinker/non-smoker, but takes medication for high blood pressure. She has no facial droop or arm weakness. You suspect this could be stroke. What area of the brain could give you these symptoms?

Super Secret Question

Questions?

Contact: Carolyn StovallContact: Carolyn Stovall509509--242242--42634263

[email protected]

Fax: 509Fax: 509--232232--81688168

Documents

Disclosures ACUTE STROKE CARE FOR THE EMS · ACUTE STROKE CARE FOR THE EMS PROVIDER ... Coronary Artery disease ... (National Institute of Neurological