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COURSE OBJECTIVE: The purpose of this course is to present a current and evidence-based discussion of the recommended emergency response for acute stroke.
Upon completion of this course, you will be able to:
A stroke—also called a cerebrovascular accident (CVA) or a brain attack—is a reduction or an interruption of the flow of blood through an artery to one or more areas of the brain within the territory supplied by that artery. The end result is varying degrees of neurological and/or cognitive malfunction lasting longer than 24 hours.
There are two major stroke classifications:
Two types of stroke. (Source: CDC, 2010b.)
Both types of vascular damage—clots and ruptured vessels—may also occur in the spinal cord. These occurrences are referred to as spinal cord strokes. The simple term stroke, however, generally refers to vascular damage to the brain.
The current definition of transient ischemic attack (TIA) endorsed by the American Heart Association is “a brief episode of neurological dysfunction caused by focal brain, spinal cord, or retinal ischemia, without acute infarction” (Siket & Edlow, 2013). TIA is sometimes referred to as a “warning stroke” or a “mini-stroke” that results in no lasting damage (CDC, 2010b).
In the United States, most strokes are ischemic and caused by the sudden blockage of a cerebral artery.
Strokes reduce the blood flow to particular regions of the brain, and the loss of circulating blood causes the affected regions to stop functioning. As a consequence, the patient loses the ability to perform the tasks that are localized in those regions. Loss of blood flow is called ischemia, and both ischemic strokes and hemorrhagic strokes cause neurological deficits due to ischemic damage. In hemorrhagic strokes, bleeding can also cause nonischemic physical damage.
Stroke symptoms depend on the area of the brain that is affected, which is most often the middle cerebral artery or one of its deep branches.
Symptoms can include:
These particular deficits result from ischemia in brain regions that are especially prone to stroke damage.
TIAs often present as amaurosis fugax, a transient loss of vision in one eye (Panagos, 2012). A TIA can also present with one or more of these symptoms:
Because TIAs have been associated with an increased risk of acute stroke, it is currently recommended that all patients showing symptoms of TIA be treated as stroke patients. It is estimated that 15% of all strokes are preceded by an episode of TIA.
Stroke is a serious health hazard. On the average, someone in the United States has a stroke every 40 seconds (Go et al., 2013). One person dies of a stroke every four minutes, and it is estimated that 1 of 19 people die of stroke (Roger et al., 2012; Sidney et al., 2013). A recent study of Americans found that “25% of people who had a stroke died within a year and 8% had another stroke within one year. … [Altogether,] 50% died or had another stroke or a heart attack within four years” (Feng, 2010).
Stroke is also an economic drain. The American Heart Association estimated stroke costs of $74 billion in 2010, including the cost of healthcare services, drugs, and lost productivity (Lloyd-Jones et al., 2010).
The morbidity, mortality, and cost of strokes are not spread equally among the population. Those at higher risk include the elderly, African Americans, those of lower socioeconomic status, and residents of the southeastern United States.
Age. Most people who have a stroke are older than 65 years of age. Additionally, the chance of dying from a stroke increases with the patient’s age (NCHS, 2012).
Gender. Stroke is most common in people older than age 75, and because women live longer than men, overall about 1.5 times more women than men die of stroke in the United States each year. However, men younger than 75 have a higher incidence of stroke than women of the same age (CDC, 2010a, b).
Racial Demographics. African Americans and Hispanic Americans are at higher risk of death from strokes. Native Americans or Alaska Natives have an even higher risk of stroke (NCHS, 2012).
Age-adjusted death rates for stroke by race/ethnicity and sex, U.S., 1999–2010. (Source: NHLBI, 2013.)
Socioeconomic Status (SES). Low SES is associated with an increased risk of stroke. A lower level of educational achievement is also associated with an increased risk of stroke (CDC, 2012).
Geographic Location. In the United States, living in the Southeast carries with it the highest risk for stroke compared to the rest of the nation’s population.
PERCENTAGE OF PEOPLE WHO WERE EVER TOLD THEY HAD A STROKE, 2008
The heavy concentration of strokes in the southeast has given that region the nickname “the stroke belt.” (Source: CDC, 2010a.)
At the moment, there is still no effective “in-the-field” treatment for a stroke; for medical care, stroke patients must be taken to a hospital. Moreover, they must be taken quickly, because the clock is ticking for acute stroke victims—secondary damage from strokes increases as time passes, and early intervention can save critical brain tissue. Therefore, stroke victims need to be taken immediately to an emergency department that has the personnel and equipment to provide comprehensive acute stroke treatment.
For stroke management, the motto is “time lost is brain lost.” After an ischemic stroke, the amount of irreversible damage increases steadily as long as brain regions remain without sufficient blood supply. In those parts of the affected region that have no blood flow, neurons begin to die in less than 10 minutes. In those areas with <30% of the normal blood flow, neurons begin to die within an hour. In those areas with 30%–40% of the normal blood flow, some neurons begin to die within an hour, but others can be revived for many hours.
The impetus for high-priority emergency stroke treatment began in 1996 when the FDA approved the use of a thrombolytic agent for stroke. For some patients, this drug—recombinant tissue plasminogen activator (rtPA, also known as tPA)—can reverse the neurological effects of an acute ischemic stroke. RtPA must generally be administered within 4.5 hours after a stroke occurs, and the new paradigm considers all stroke symptoms to be potential emergencies in the class of acute myocardial infarctions (heart attacks). Although there has not yet been the same dramatic innovation for treatment of hemorrhagic strokes, which are less common than ischemic strokes, they too require emergency care.
Health professionals cannot assume that their patients know how to recognize potential strokes. Even people who have suffered one or more strokes need education: a survey by the American Heart Association (2010) found that only 55% of patients who had had a stroke could identify even one stroke warning sign.
All patients at risk for a stroke should be told its signs and symptoms, which include these sudden occurrences:
Classic signs of a stroke. (Source: NINDS, 2013.)
Patients should be told that if they are having any of these symptoms, they should call 911 or get someone else to call 911.
However, even people who have been taught the warning signs may not realize that they are having a stroke. Some factors contributing to this problem are:
Because people may not realize they are having a stroke, it is often the family or a bystander who first realizes that a medical problem is occurring. The public should understand that if there is the possibility that someone is having a stroke, they should not hesitate—they should call 911 immediately.
The signs of a stroke are being publicized through a number of different campaigns (e.g., the American Heart Association and the Stroke Awareness Foundation). A modified form of the Cincinnati Prehospital Stroke Scale (CPSS) (see “Cincinnati Prehospital Stroke Scale” later in this course) has been presented as a simple STRoke test, with the first three letters of stroke standing for:
The sudden appearance of any one of these three symptoms indicates a possible stroke, and members of public are advised to immediately call 911 (Jones et al., 2010).
People often wonder what first aid to give to a stroke victim. The best first aid is professional transport to a hospital, and getting an ambulance is the most important thing that a bystander can do for a stroke victim.
In addition, the one critical medical step that the public should know is how to control external bleeding. First aid providers should be taught to press on a bleeding area until the bleeding stops or an emergency medical services (EMS) team arrives.
When a person calls 911, the operator can give additional guidance for any other necessary first aid (CDC, 2012; Go et al., 2013).
In an emergency, people often feel that time is being lost by waiting for an EMS team to arrive, and family members or bystanders often hurriedly drive patients to the hospital. In fact, however, patients usually get to the appropriate hospital faster if they use the EMS system by calling 911. EMS teams are trained to choose the most appropriate hospital in the region, and this is not necessarily the closest hospital. In addition, the care and assessment that an EMS team gives a stroke victim shortens the time lag between the onset of stroke symptoms and the evaluation and treatment of the stroke.
EMS teams should advocate for widely available 911 capabilities in their region. All landlines and wireless phones should be able to reach local 911 operators. It is also important that the caller’s number and location be displayed automatically for dispatchers. At the moment, two telephone systems do not always give 911 operators the detailed locations of callers: Multiline Telephone Systems (MLTS), which are used by many large organizations, and Voice over Internet Protocol (VoIP) services.
The medical care of stroke victims begins with the receipt of a 911 call. Strokes account for about 2% of all 911 calls, but those calls should set off a well-planned and speedy treatment protocol. Thrombolytic treatment of ischemic strokes ideally begins within a 4.5-hour window after the onset of symptoms, and strokes should be given the same priority of treatment as acute myocardial infarctions and trauma (Alspach, 2013; Berglund et al., 2012; Tan & Christensen, 2012).
Besides stabilizing patients, dispatchers and EMS technicians make the first triage of potential stroke victims, collect critical background information, and expedite transport to the nearest hospital equipped to handle strokes. To plan for an effective response, directors of EMS units should:
In general, EMS telephone operators and dispatchers have these responsibilities:
There are additional responsibilities regarding potential stroke victims:
When assigning response teams, EMS dispatchers need to assess the type and severity of the emergency. To make decisions for stroke victims, 911 operators should be taught how to identify likely stroke symptoms. When a dispatcher is able to flag a possible stroke victim, the EMS team can be given time to review and plan during their outbound trip and to notify the nearest stroke center. Studies have indicated that notifying a primary stroke center significantly improves outcomes (Patel et al., 2011).
Since strokes account for only 2% of all 911 calls, this translates to only four to ten stroke patients each year for the typical EMS team. The infrequency of stroke calls means that EMS operators may not have stroke-appropriate questions committed to memory, so a written set of screening questions should be on each operator’s desk.
Normally, the 911 operator asks these questions, using the same sequence:
A person may have had a stroke if any of the following problems have appeared in the course of a few hours or less:
When the caller’s description includes any of the preceding signs, the 911 operator asks three stroke questions:
911 dispatchers decide what type of response is appropriate for each emergency. They choose:
Acute strokes require the same level of emergency treatment as heart attacks and trauma. The current American Heart Association/American Stroke Association guidelines recommend that potential strokes be given the highest level of priority and that EMS dispatchers send the highest level of emergency care available (Jauch et al., 2013).
When available, an ALS team is sent, “fully equipped with ventilation and oxygenation capabilities, including the ability to provide advanced airway maintenance, endotracheal tube checks, end-tidal CO2 monitoring, and ECG monitoring. Ideally, there should be a minimum of two paramedics who are certified in AHA Advanced Cardiovascular Life Support (ACLS) and are prepared to administer all ACLS Class I and Class II interventions on each stroke response” (Acker et al., 2007).
If a choice has to be made, however, speed of transport to a stroke center is the first consideration. Therefore, if an ALS team is not immediately available, a BLS team should be dispatched.
When patients having a stroke are more than one hour’s travel time by ambulance from a hospital that is equipped to treat acute strokes, then air transport should be considered. Helicopters or other aircraft can be used to take the EMS team to the patient and then to transport the patient and the EMS team to a stroke center. Helicopters can also be used for secondary transport of patients from a remote receiving emergency department (ED) to a stroke center.
When an EMS operator suspects that a call concerns a stroke victim, the operator begins collecting critical background information. For strokes, dispatchers should make a special effort to get an estimate of the time since any potential stroke symptoms first appeared (Berglund et al., 2012; Patel et al., 2011).
Written records of the information collected during the first contact with the patient can be critical for emergency department providers when they are making decisions about treatment. EMS operators should have a blank checklist that can be filled in with essential background information. This document, along with the results of stroke screening questions, is then faxed or sent by computer to the ED that is receiving the patient.
Nurse educators are often responsible for teaching first response techniques for strokes to local emergency medical technicians (Cameron, 2013; Ireland et al., 2010). The basic information to be covered is found in the American Heart Association’s ACLS provider manual and online (AHA, 2010). Nurse educators place special emphasis on:
As an EMS instructor, a nurse needs to be able to tailor the emergency response protocols to the local region. First, the nurse must know which medical techniques can be performed by paramedics and emergency medical technicians under local regulations. Second, the nurse must learn which area hospitals are equipped and staffed for treating acute strokes.
A typical EMS team responds to only four to ten stroke patients per year, and it has been estimated that emergency personnel forget about one half of the stroke care instructions by 12 months after a training session. Moreover, the needs of a community, the availability of acute stroke care, and the recommended prehospital assessments and care protocols continue to be updated. Therefore, continuing education courses should ideally be held as frequently as twice each year (Jauch et al., 2013; Patel et al., 2011).
When they reach the victim, members of the EMS response team follow the standard protocol by assessing the situation and stabilizing the patient. In cases in which there is a question of stroke, paramedics then determine the likelihood of stroke and collect critical background information. Speed has a major impact on patient outcomes, requiring the EMS team to provide as much of the patient care as possible while en route to the hospital (Mears et al., 2010; Millin et al., 2007).
More components of the EMS responders’ protocol for likely stroke victims (modified from NHTSA, 2002) include:
Responders first state their name and tell the patient that they are part of the emergency team that has come to help.
Manage airway, breathing, and circulation. Ischemic strokes—the most common strokes—tend to leave the patient responsive and breathing autonomously. Hemorrhagic strokes, however, can worsen quickly and deteriorate into stupor or coma with respiratory depression or breathing irregularities. Therefore, even when a potential stroke victim appears to need no airway care, the EMS response team must be alert to the sudden appearance of breathing problems.
After stabilizing the patient, EMS responders assess the patient’s level of consciousness, document any signs of stroke, and collect critical background information. It is essential to use a standardized screening test for stroke, as studies have shown that a prescreening test is significantly useful in identifying stroke patients (Berglund et al., 2012). Therefore, first characterize the level of consciousness—A, V, P, or U:
Second, determine the likelihood that the patient has had a stroke using the Cincinnati Prehospital Stroke Scale.
One of the simplest and most widely used stroke assessment tools is the Cincinnati Prehospital Stroke Scale (CPSS), developed by Kothari et al. (1999). This is the recommended tool for EMS assessment (Bray et al., 2010; Govindarajan et al., 2012; Mingfeng et al., 2012).
In the CPSS, the patient is asked to perform three actions. An abnormal response to any of the three indicates that it is likely that the patient is having or has recently had a stroke. The actions and the range of stroke and nonstroke responses are:
A stroke that affects the motor system can cause weakness in the muscles of only one side of the face. The request to “please smile” is an attempt to gauge whether the facial muscles contract with equal strength on the right and left sides. In order to make this assessment, some health professionals ask potential stroke victims to try to smile. However, the normal smile of a healthy person is often asymmetric, and an asymmetric smile in a patient can be the result of habit rather than a sign of a stroke.
Instead of asking for a smile, neurologists ask potential stroke victims to “show me your teeth,” which is intended to demonstrate a grin that bares both sides of their upper teeth. This task requires the patient to strongly contract facial muscles on both the right and the left sides of the mouth. Weakness on one side produces a lopsided grin that reveals more upper teeth on the stronger side.
The public is often told to use “please smile” because its use requires less explanation, but “show me your teeth” is the preferred stroke test.
Regardless of the information already collected by the 911 dispatcher, paramedics should attempt to collect essential information about the patient (see the “Critical Background Information about Potential Stroke Victims” box above).
Because time is of the essence, responders should gather telephone numbers of relatives and witnesses. If knowledgeable acquaintances are available, they are asked to meet responders at the receiving hospital, or if necessary, to travel with responders. For emergency treatments, it will be helpful if next-of-kin are immediately available for consent.
Records are completed and then passed on to the medical team at the receiving hospital. Ideally, EMS teams will use developed checklists with the essential questions to capture all the critical information.
Marcella has just finished her training to become an EMS first responder. She performed well in all the training classes, but she is still quite nervous about her first call as a full-fledged EMS professional. Within the first half hour of her first shift, Marcella hears the call from the dispatcher about a likely stroke victim. Rushing to the scene, Marcella and her team are greeted at the door by the patient’s daughter, who is frantic with worry.
The patient is an 86-year-old African American woman sitting on the sofa. Marcella does an initial visual assessment and notices that the woman’s face appears to be sagging on the right side. While another team member is getting the woman’s vital signs, Marcella asks the woman to “Smile and show me your teeth.” The woman’s face clearly shows asymmetry. Then Marcella asks the woman to stretch out her arms as far apart as she can. The woman tries, but Marcella notices that her left arm is drifting down. More certain that the team is dealing with a stroke victim, Marcella asks the woman to repeat the sentence “The sky is blue in Cincinnati.” When the woman slurs her words, Marcella tells the other team members that they need to take the woman to the nearby primary stroke center. The team is able to quickly transport the woman, whose vital signs remain stable, in under 10 minutes to the stroke center.
Later that evening, while reflecting on her first day as an EMS professional, Marcella realizes the importance of her stroke training. Within 30 minutes of the onset of symptoms, the woman was examined by stroke specialists and now has a good prognosis for eventual recovery.
Maintaining airway, breathing, and circulation are the first priorities. For strokes, keeping the head flat (i.e., supine or 0-degrees elevation) usually offers better brain circulation than keeping the head elevated, when the flat position does not impair the ABCs.
After stabilizing the patient, time is paramount. As soon as possible, begin transporting the patient to the appropriate ED and continue the rest of the prehospital care en route. Each EMS unit should be provided with maps showing the nearest appropriate ED for stroke management in any area (Jauch et al., 2013).
As they manage the patient, members of the EMS team should make contact with the destination ED. Simply notifying the receiving hospital that a potential acute stroke patient will be arriving has been shown to shorten the eventual time between delivery to the hospital and receipt of treatment (Abdullah et al., 2008). Describing the patient’s condition, time of onset of symptoms, and medical history allows the mobilized physicians, nurses, imaging specialists, and pharmacists of the acute stroke team to begin planning.
Information is exchanged between the EMS team and the ED stroke team. The hospital stroke team can tell the paramedics about the size and placement of the IV access that will be needed, and hospital specialists can advise the paramedics about managing complications, such as severe hypertension, hyperglycemia, or cardiac dysfunction.
Oxygen. Strokes are crises of insufficient oxygen delivery to the brain, so it is important to keep the patient’s blood oxygen saturation at normal levels. Attach a pulse oximeter and treat hypoxemia (in this case, oxygen saturation <95%) with supplemental O2. Currently, there is no indication that supplemental oxygen will benefit a patient who already has normal levels of blood oxygen saturation.
IV access. When acute resuscitation is needed, insert an IV line immediately. Otherwise, consider starting an IV en route after consulting the destination ED. Some key brain imaging studies require large bore IV lines that must be inserted proximally (i.e., no more distal than the antecubital fossa). If the receiving hospital will need a specialized IV line, placing the appropriate line in advance can save time.
IV fluids. Treat shock or significant dehydration with balanced salt solutions (isotonic crystalloids, such as normal saline). Otherwise, saline lock the IV or set the IV to drip the minimum amount of balanced salt solution to keep the line open. In general, the goal is to add only a minimal amount of extra fluid, because overhydration can cause cerebral edema. Another concern is hyperglycemia, which can worsen the injury in a stroke. Therefore, do not use dextrose solutions unless you are correcting hypoglycemia.
Blood glucose level. Hypoglycemia produces symptoms that look like stroke, and persistent hypoglycemia will cause brain injury. Therefore, as soon as possible, check the patient’s capillary blood glucose level and treat hypoglycemia with glucose.
ECG. Attach a 3-lead ECG and monitor the patient’s heart continuously with two specific objectives:
Hypertension management. Hypertension is a common finding in acute stroke. However, blood pressure management is a delicate matter in the acute phase of strokes, and the choice of treatment depends on a detailed diagnosis that can only be made in a hospital. Therefore, current recommendations are that EMS and nursing personnel not attempt to treat high blood pressure en route to the hospital.
Recently trained as an EMS provider, John takes a call from the dispatcher about an 83-year-old female patient with a possible stroke. On arrival, after taking the patient’s vital signs, John notes that the patient has a blood pressure of 200/90 mm Hg, a respiration rate of 28 breaths/minute, and a blue tinge around her mouth. John’s supervisor instructs him to place an oxygen mask on the patient, start an IV line, and continue monitoring the patient’s blood pressure.
When John asks about the potential dangers of the patient’s high blood pressure, the supervisor tells him that during an acute stroke, the current recommendations are to avoid attempting to control blood pressure until the patient can be fully evaluated by medical personnel. John continues to monitor the patient’s blood pressure, which remains the same, and her other vital signs. After five minutes on oxygen, John notices the patient’s color and her respiration rate normalizing. Another five minutes later, the EMS team and the patient arrive at the hospital, where the stroke team takes over the patient’s care.
Strokes, also called cerebrovascular accidents (CVAs), result from limitations in cerebral perfusion, usually due to clots. Occasionally, the reductions in perfusion are accompanied by intracranial bleeding. Symptomatically, all strokes appear as acute impairments in brain functioning. Victims may suddenly have difficulty walking, seeing, speaking, or understanding. A common presentation of a stroke is the sudden loss of sensation or movement on one side of the body or face. Most ischemic strokes are painless, although hemorrhagic strokes can produce severe headache.
Treatment for an acute stroke is given high priority by EMS teams and emergency room personnel. For a stroke, there is a 4.5-hour interval after the onset of symptoms in which thrombolytic therapy (i.e., intravenous administration of rtPA) has a chance to reopen clogged cerebral arteries and save some of the underperfused brain tissue. Given this time constraint, EMS teams have the goal of getting potential stroke victims stabilized, evaluated, and to a primary stroke center in less than an hour.
The early recognition and diagnosis of a stroke is facilitated by using standardized tests, such as the Cincinnati Prehospital Stroke Scale, which can be administered in three to five minutes using no special equipment. Such standardized diagnostic tools give accurate and reproducible predictions of the likelihood that a person has had an acute stroke. It has been shown that 911 operators can even administer the Cincinnati Prehospital Stroke Scale over the phone with the help of cooperative bystanders.
NIH Stroke Scale Training (free online training course)
NIH Stroke Scale Training (free on a mobile phone)
NOTE: Complete URLs for references retrieved from online sources are provided in the PDF of this course (view/download PDF from the menu at the top of this page).
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