Leon County EMS

Stroke Protocol Update January 2017

Objectives:

• Identify the different causes and types of stroke. • Assess stroke patients using the Cincinnati Prehospital Stroke Scale (CPSS) and

Rapid Arterial Occlusion Evaluation (RACE) scale. • Understand the differences between a Primary and Comprehensive stroke

center.• Identify the Primary and Comprehensive Stroke Centers in the region. • Utilize the results of the CPSS and RACE scales to formulate a treatment plan

and determine the appropriate receiving facility .

“Stroke is a "brain attack". It can happen to anyone at any time. It occurs when blood flow to an area of brain is cut off. When this happens, brain cells are deprived of oxygen and begin to die. When brain cells die during a stroke, abilities controlled by that area of the brain such as memory and muscle control are lost.How a person is affected by their stroke depends on where the stroke occurs in the brain and how much the brain is damaged. For example, someone who had a small stroke may only have minor problems such as temporary weakness of an arm or leg. People who have larger strokes may be permanently paralyzed on one side of their body or lose their ability to speak. Some people recover completely from strokes, but more than 2/3 of survivors will have some type of disability”

http://www.stroke.org/understand-stroke/what-stroke

Types of Stroke“Ischemic Stroke:

Ischemic stroke occurs when a blood vessel carrying blood to the brain is blocked by a blood clot. This causes blood not to reach the brain. High blood pressure is the most important risk factor for this type of stroke. Ischemic strokes account for about 87% of all strokes. An ischemic stroke can occur in two ways.”

• “Embolic stroke, a blood clot or plaque fragment forms somewhere in the body (usually the heart) and travels to the brain. Once in the brain, the clot travels to a blood vessel small enough to block its passage. The clot lodges there, blocking the blood vessel and causing a stroke. About 15% of embolic strokes occur in people with atrial fibrillation (Afib). The medical word for this type of blood clot is embolus.”

• “Thrombotic Stroke, occurs when a blood clot that forms inside one of the arteries supplying blood to the brain. This type of stroke is usually seen in people with high cholesterol levels and atherosclerosis. The medical word for a clot that forms on a blood-vessel deposit is thrombus.”

Thrombotic Stroke

Thrombotic Strokes can be broken down into two groups as well

• “Large Vessel ThrombosisThe most common form of thrombotic stroke (large vessel thrombosis) occurs in the brain’s larger arteries. In most cases it is caused by long-term atherosclerosis in combination with rapid blood clot formation. High cholesterol is a common risk factor for this type of stroke.”

• “Small Vessel DiseaseAnother form of thrombotic stroke happens when blood flow is blocked to a very small arterial vessel (small vessel disease or lacunar infarction). Little is known about the causes of this type of stroke, but it is closely linked to high blood pressure.”

Types of StrokeHemorrhagic Stroke:

“A hemorrhagic stroke is either a brain aneurysm burst or a weakened blood vessel leak. Blood spills into or around the brain and creates swelling and pressure, damaging cells and tissue in the brain. There are two types of hemorrhagic stroke called intracerebal and subarachnoid.”

Intracerebal Hemorrhage:

“The most common hemorrhagic stroke happens when a blood vessel inside the brain bursts and leaks blood into surrounding brain tissue (intracerebal hemorrhage). The bleeding causes brain cells to die and the affected part of the brain stops working correctly. High blood pressure and aging blood vessels are the most common causes of this type of stroke. Sometimes intracerebral hemorrhagic stroke can be caused by an arteriovenous malformation (AVM). AVM is a genetic condition of abnormal connection between arteries and veins and most often occurs in the brain or spine. If AVM occurs in the brain, vessels can break and bleed into the brain. The cause of AVM is unclear but once diagnosed it can be treated successfully.”

Subarachnoid Hemorrhage:

“A Subarachnoid Hemorrhage stroke involves bleeding in the area between the brain and the tissue covering the brain, known as the subarachnoid space. This type of stroke is most often caused by a burst aneurysm. “

Stroke Assessment:

Quick and correct identification of stroke patient is one of the most important interventions provided in the prehospital setting.

When stroke is suspected an onset of symptoms is a crucial factor in treating ischemic strokes. A slight terminology change accompanies this update as well, instead of “Last Seen Normal” use “Last Time Known Well”. Remember to Clearly Document a “Last Time Known Well” or LTKW in the EPCR.

If the onset of symptoms is less than 6 hours notify dispatch of a “Stroke Alert” and restate this during your radio report to the facility. Please also include symptoms and a RACE scale in your radio report.

Beware of Mimics:

Remember that other conditions can mimic symptoms of a stroke and should be considered during a stroke assessment!

• Hypoglycemia (Always Check a Suspected Stroke Patient’s Glucose).• Drug Overdose.• Hypoxia.• Todd’s Paralysis.• And others

“Todd's paralysis is a neurological condition characterized by a brief period of transient (temporary) paralysis following a seizure. The paralysis - which may be partial or complete - generally occurs on one side of the body and usually subsides completely within 48 hours. Todd's paralysis may also affect speech or vision. The cause is not known. Remember to consider possible seizure activity in your stroke assessment and relay this information the receiving facility.”

Assessing the Stroke PatientThe initial exam performed will be the CPSS

If any of the 3 criteria in the CPSS are found to be “Abnormal” the CPSS is considered positive for stroke and should move to the RACE scale for further assessment.

Assessing the Stroke Patient:The Rapid Arterial Occlusion Evaluation (R.A.C.E.) is based on an abbreviated version of the National Institutes of Health Stroke Scale (NIHSS), the “gold standard” for evaluating stroke victims. The maximum score is 9 (not 11) because the evaluation of the final two components is done based on the left or right side presentation, not both simultaneously

Please Clearly Document the RACE Score in the Narrative Section of the EPCR

Assessing the Stroke Patient: To clarify this assessment

If your patient is exhibiting symptoms (weakness or paralysis) on the RIGHT you will complete• Facial Palsy• Arm Motor Function • Leg Motor Function• Head and Gaze Deviation• Aphasia

If your patient is exhibiting symptoms (weakness or paralysis) on the LEFT you willcomplete • Facial Palsy• Arm Motor Function• Leg Motor Function • Head and Gaze Deviation• Agnosia

Assessing the Stroke Patient:

Comparing CPSS to RACE,

CPSS: Determines the presence of a stroke. 1 abnormal finding in the CPSS finds a probability of stroke at 72%.

Race: Aids in determining the severity of a stroke and attempts to predict the presence of a Large Vessel Occlusion in the event of an Ischemic Stroke. These particular patients benefit from interventional neurosurgery that is available at Comprehensive Stroke Center but not at Primary Stroke Center.

Assessing the Stroke Patient:

All patients with a score of 5 or greater on the RACE should be transported to a Comprehensive Stroke Center.

This assessment tool should be considered the primary factor for determining patient destination even above patient’s choice.

Primary Vs. Comprehensive Centers:

Primary:

• Patient care: Takes care of most cases of ischemic (blood vessel blockage) types of stroke.

• Minimally invasive catheter procedures: Not available.

• Specialized ICU: No requirement for a separate intensive care for stroke patients. • Neurosurgery: Access to neurosurgery within 2 hours.

• Patient transfers: Sends complex patients to a Comprehensive Stroke Center.

Primary Vs. Comprehensive Centers:

Comprehensive:

• Patient care: Cares for all types of stroke patients, (blood vessel blockage) including bleeding (or hemorrhagic) strokes, such as those caused by brain aneurysms.

• Minimally invasive catheter procedures: 24/7 access to minimally invasive catheter procedures to treat stroke.

• Specialized ICU: Dedicated neuroscience intensive care unit for unit stroke patients.

• Neurosurgery: On-site neurosurgical availability 24/7 with the ability to perform complex neurovascular procedures, such as brain aneurysm clipping, vascular malformation surgery and carotid endarterectomy.

• Patient transfers: Receives patients from Primary Stroke Centers.

Primary Vs. Comprehensive Centers:

So… When Caring for the Citizens or Visitors of Leon County

Patients with Suspected Stroke Greater that 6 hours (Patients suffering from a stroke that are not “Stroke Alerts”) can go to either Primary or Comprehensive Centers

Patients with Suspected Stroke “Stroke Alerts” but a RACE of Less than 5 (No clear evidence of Large Vessel Occlusion) can go to either primary or Comprehensive Centers

Patients with Suspected Stroke “Stroke Alerts” with a RACE of Greater than 5 Will Go To A Comprehensive Center .

Local Centers

PrimaryCapital Regional Medical Center

Comprehensive Tallahassee Memorial Hospital (Main)

Summary:

To conclude, good assessment and identification, proper documentation and transition at the most appropriate receiving facility will undoubtedly lead to the best possible outcomes for these patients suffering from stroke.

All strokes must go to a Primary or Comprehensive Stroke Center

All Stroke Alerts with a RACE score of greater than 5 will go to a Comprehensive Stroke Center if available.

Please keep reference material handy during the video that follows.

References:

http://www.epilepsy.com/connect/forums/living-epilepsy-adults/todds-paralysis

http://www.stroke.org/understand-stroke/what-stroke

https://www.ems1.com/mobile-healthcare/articles/3014604-Stroke-scales-10-things-you-need-to-know-to-save-lives/

http://www.emsworld.com/video/12249915/race-stroke-assessment-for-prehospital-providers