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The brain:
Your intellect. Your memory.
York cognitive and automatic body functions.
Operating at the speed of light transmitting and receiving infotmation 24 hours a day.
At the center of the human universe is your brain.

Stroke Alert!!!

On 06/18/96 the FDA announces approval of t-PA (Activase) for the treatment of acute ischemic stroke.

1996: t-PA has been cleared by the FDA for treatment of eligible adult patients with an acute ischemic stroke within three hours of symptom onset. UCSD (the University of San Diego Medical Center) and eight other centers around the country have brought the first drug to the American public for the treatment of stroke.

Per UCSD protocols; all stroke patients will be treated "code status"priority. Any patients that arrive in the ED within the first 24 hours of symptom onset should have a Stroke Code called. All appropriate patients who arrive within 3 hours of symptom onset will be evaluated for t-PA. Research indicates that less than 24% of stroke patients arrive at the E.D. within the 3 hour window form the onset of symptoms. Patients who are not appropriate for the treatment (fall out of the inclusion criteria) or arrive greater than 3 hours of onset will be evaluated for other research protocols. The risk of using t-PA is an increased chance of bleeding within the brain. In-services should be planned at your ED or department.

Results of the research was published in The New England Journal of Medicine, Dec. 1995. Copies of this article can be obtained from the UCSD Stroke Team @ (619) 543-7765. Contact Karen Rapp, RN.

We have changed the way stroke will be view from this time forward, NOW stroke is an EMERGENCY!

Time is Brain!
Rapid Intervention and Treatment of Acute Stroke

"Beyond the clear need for public education initiatives, the currently available educational offerings and clinical approaches practiced in emergency medical systems indicate that widespread re-education and re-orientation of pre-hospital care services are now clearly in order if we want to ensure the optimal management of patients with acute stroke"

Paul E.Pepe, M.D., M.P.H., F.A.C.E.P.,F.C.C.M., F.A.C.P.
Allegheny University of Health Sciences, Allegheny General Hospital
Pittsburgh, Pennsylvania

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Brain Attack
The Cost of Stroke
  • Stroke is the nation's third leading cause of death.
  • Every year, 750,00 Americans experience a new or recurrent stroke.
  • Over the course of a lifetime, four out of every five American families will be touched by stroke.
  • Of the 600,00 Americans that survive a stroke each year, about 10 to 18 percent will have another stroke within a year. The rate of having another stroke there after is 10 percent. Approximately one third die, one third become disabled, and one third recover.
  • The financial toll of stroke amounts to an estimated $30 billion to $40 billion in direct and indirect cost annually.
Risk Factors
  • Hypertension
  • Heart Disease
  • Diabetes
  • Previous stroke
  • Tobacco smoking
  • High dose estrogen therapy
  • Cocaine/Crack use
  • Blood abnormalities
  • Excessive Alcohol use
  • Sudden, unexplained and intense headache
  • Dizziness, loss of balance or coordination,
    especially when combined with another symptom
  • Blurred or decreased vision in one or both eyes
  • Difficulty speaking or understanding simple statements
  • Weakness, numbness or paralysis of the face, arm or leg,
    especially on one side of the body
New evaluation and diagnostic skills for E.M.S.
It has been proven that patients with strokes more commonly experience localized neurological deficits versus global dysfunction. The Glascow Coma Scale while used by E.M.S. personnel for head injured patients is not accurate for Stroke Evaluation.

The Cincinnati Pre-Hospital Stroke Scale (C.P.S.S.) has been endorsed by The American Heart Association. The Center for Research in Medical Education at The University of Miami School of Medicine has developed an innovative, standardized Stroke Curriculum for E.M.S. Providers, The M.E.N.D. exam.
The expanded version of the Cincinnati evaluation is detailed below.
C.P.S.S. Evaluation
Additional M.E.N.D. Evaluation Assessments
Miami Emergency Neurological Deficit Exam
  • Mental Status:

    Level of Consciousness::
    Determine if the patient is awake and alert. Are they lethargic but responsive to verbal stimuli or unresponsive to all stimuli.

    Ask them to repeat this: "The weather is perfect today and I feel great!" Use this same statement for all patients as it will gauge all of the responses to the same level.

    Ask the patient: How are you? What is your name? How old are you? What time is it? What is your birth date? What did you have for breakfast, lunch or dinner? Asking someone where they are is a question that can be asked, but it will usually cause someone who is alert to become offended and you can lose the patient cooperation. remember, these patients are sometime frustrated and also in some cases from their perspective, there might not be anything wrong.

    Ask the patient to open and close their eyes. Do they follow simple commands?

  • Cranial Nerves:

    Facial Droop:
    Ask the patient to smile. Determine if both side are equal. Is the asymmetry unilaterally?

    Visual Fields:
    Ask the patient to look at your nose. Place your hands just above the level of your nose and wiggle your fingers on one hand at a time. Determine if the patient can see movement in each upper quadrant. Then place your hands below the level of your nose. Evaluate movement in each lower quadrant.

    Horizontal Gaze:
    Ask the patient to keep their head stationary and have them follow your finger form side to side. Evaluate for equal movement form right to left.

  • Limbs:

    Motor - Arm Drift::
    Ask the patient to hold out both arms with palms down and eyes closed for five seconds. Observe for drift.

    Motor - Leg Drift:
    Ask the patient to lift one leg and hold it up for five seconds. Observe for drifting. Repeat with the other leg.

    Sensory - Arms and Legs:
    Ask the patient to close their eyes and uncross their arms and legs. Gently touch or pinch each limb and determine if the patient can feel the stimuli equally on both sides.

    Coordination - Arms:
    Ask the patient to touch your finger with one finger, then have them touch their nose, and then your finger again. Observe for limb ataxia (clumsiness or dyscoordination). repeat with the other arm.

    Coordination - Legs:
    Ask the patient to touch their knee of one leg with of their heal of the opposite leg and slide the heel down the shin. Observe for limb ataxia. Repeat with the other leg.

Risk Factors
  • Hypertension
  • Heart Disease
  • Diabetes
  • Previous stroke
  • Tobacco smoking
  • High dose estrogen therapy
  • Cocaine/Crack use
  • Blood abnormalities
  • Excessive Alcohol use
The Stroke Subjective Evaluation
  • When was the patient last known to be without symptoms?
  • Did the patient have a seizure or a head injury at the onset of the symptoms?
  • Is the patient taking a blood thinner (Coumadin)?
  • Obtain witness information
The Stroke Objective Examination
Preform the Cincinnati Pre-Hospital Stroke Scale
If time permits, do the complete Stroke MEND evaluation.
Stroke Management
  • Access A.B.C.'s

Maintain an airway, straighten patients head

Apply 2 - 4 L/min O2 via Nasal cannula. Only use high flow O2 via Mask if the Oxygen Saturation is diminished or hypoxia is expected.

  • Prevent Aspiration

Keep the patient from ingested anything by mouth.

Elevate the patients head to at least 30 degrees

If the patient vomits, turn them to the side and use suction, then return them to the semi fowlers position

  • Prevent LOW Blood Pressure

Do not treat HIGH Blood Pressure

  • Evaluate Blood Glucose levels

Establish an IV of Normal Saline (DO NOT use Dextrose Solutions.

Treat Low Blood Glucose levels only if the value is less than 50 mg / dl.

  • Transport to the MOST appropriate destination without delay and make radio contact ASAP to get the Stroke Team immobilized.
  • Sudden, unexplained and intense headache
  • Dizziness, loss of balance or coordination,
    especially when combined with another symptom
  • Blurred or decreased vision in one or both eyes
  • Difficulty speaking or understanding simple statements
  • Weakness, numbness or paralysis of the face, arm or leg,
    especially on one side of the body
Five Major Stroke Syndromes and typical symptoms
Left Dominant Hemisphere
Right Non-Dominant Hemisphere
CT Scan to confirm
  • Aphasia
  • Left Gaze
  • Right Visual field deficit
  • Right hemiparesis
  • Right hemiparesis loss
  • Neglect / Left Hemi-inattention
  • Right Gaze Preference
  • Left Visual field Deficit
  • Left Visual field deficit
  • Right hemiparesis
  • Right hemiparesis Loss
  • Hemiparesis or Quadriparesis
  • Hemiparesis Loss or Sensory Loss in all four extremities
  • Crossed signs
  • Diplopia, Disconjugate Gaze
  • Dysarthia, Dysphagia
  • High dose estrogen therapy
  • Vertigo, Tinnitis
  • Blood abnormalities
  • Nausea, Vomiting
  • Hiccups, Abnormal Respirations
  • Decreased Consciousness
  • Truncal / Gait Ataxia
  • Limb Ataxia
  • Headache
  • Neck Stiffness
  • Neck Pain
  • Light Intolerance
  • Nausea, Vomiting
  • Decreases Consciousness
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Crossed signs: Weakness or numbness on one side of the face and the opposite side of the body

Diplopia: Double vision in which one image is seen at a higher level than the other.

Dysarthria: Slowed or distorted speech caused by weakening of the tongue or other muscles essential to speech.

Dysconjugate Gaze: Failure of both open to move together simultaneously.

Dyphagia: Difficulty swallowing

Gaze Palsy: Weakness of the eye muscles in which both eyes fixed to the side or midline.

Hemiparesis: Partial weakness on one side of the body.

Hemisensory Loss: Weakness or absence of sensation on one side of the body.

Light Intolerance: Abnormal reaction to light when opening eyes: "photophobia."

Neglect: A condition in which the patient does not acknowledge left sides body parts: may include denial of visual or tactile stimulation on the left: "Left Hemi-inattention."

Quadriparesis: Partial weakness of all four limbs.

Tinnitus: Ringing in the ears.

Truncal / Gait Ataxia: Imbalance while walking; manifested by walking with a wide base.

Vertigo: A sensation of movement that is not actually present; often described as a spinning sensation.

With the recent recognition of the potential for reversing or limiting acute stroke through early interventions, patients with "brain attack" have now joined the ranks of those with acute myocardial infarction. and major trauma.

This indicates:

"The Chain of Recovery"

As in the case of the trauma patient, professional responders must promptly begin certain limited interventions and rapidly evacuate the stroke patient to a pre-alerted specialty center capable of providing definitive interventions. Also, as in the case of the a trauma center, experts must be available around the clock, ready to rapidly diagnose the stroke etiology and provide immediate intervention. Furthermore, those specialists must prepared to deal with the potential complications of their interventions and to evaluate the patient for predisposing or complicating conditions.

However, unlike the clinical scenario of bodily injury, the clinical presentation of stroke is often much more subtle. More importantly, the patient with acute stroke symptoms does not evoke the same level of anxiety or action as the patient with an abdominal gunshot wound. This relative lack of anxiety and responsiveness applies not only to the lay person witnessing the onset of symptoms, but also to the emergency medical personnel responsible for such patients. Such relatively cavalier reactions to stoke patients cannot be thought of as insensitivities or lack of concern on the part of those medical care providers. Their reactions simply reflect the general "state-of-the-art" in current medical education, particularly for emergency medical services (EMS) personnel.

Up until the present time, acute stroke has largely been considered an unfortunate medical problem requiring only supportive care and monitoring. In turn, with the exception of those experiencing loss of consciousness and or respiratory compromise, a sense of urgency regarding stroke stroke patients generally has not been conveyed in either the training of 911 dispatchers or the training of responding EMS personnel. Compounding the problem has been the evolution of managed care (primary care screening) as well as sophisticated priority dispatch systems (911 centers). Specifically, in some circumstances, dispatchers may purposefully triage and dispatch lesser trained personnel, using a non-emergent response mode (no lights and siren), when a non life threatening situation is not identified during the telephone in-take. In addition, few dispatch centers actually utilize triage algorithms that help to identify and in turn, prioritize patients with "brain attach." Likewise, the responding EMS personnel have not been routinely trained to identify stroke victims and take them directly (and rapidly) to specific centers capable of providing immediate diagnosis and intervention (as done in the case of trauma center triage and transportation).

Why is there a Time-Dependant Chain of Recovery for Stroke?

Prior to 1995, most of the medical community considered the management of stroke to be largely supportive care. The recently published study of t-PA for acute stroke management, sponsored by the National Institute of Neurological Disorders and Stroke (NINDS), as well as other studies, helped to re-orient the mentality of most practitioners toward the urgency of managing stroke.

But rapid evacuation to definitive care depends on having a series of sequential, interdepartmental factors in place in order to optimize the outcome for acute stroke patients. Just as the American Heart Association (AHA) has fostered the concept of a Chain of Survival for patients with cardiac arrest, a similar metaphor is also befitting for stroke patients. In the AHA model, the sequential., interdependent links include access (911 call); bystander CPR; early defibrillation; and early advanced life support. If one the links is missing in this time dependent situation, survival chances become bleak. A similar chain of survival has been described for trauma patients. In the case of stroke, a Chain of Recovery may be a more appropriate metaphor in that many untreated patients may survive, but do so with devastating neurological deficits that might have been reversed or ameliorated with earlier intervention. As in the case of cardiac arrest or trauma, it still takes a series of interdependent, sequential events during the emergency phase of care to make the chances of full recovery from stroke possible.

Paul E.Pepe, M.D., M.P.H., F.A.C.E.P.,F.C.C.M., F.A.C.P.
Allegheny University of Health Sciences, Allegheny General Hospital
Pittsburgh, Pennsylvania

Also Contact: Center for Neurologic Study for more info and new treatment modalities and research for stroke patients.

E-Mail: C.N.Sor:Mohammad Nazarior write to:
Center For Neurologic Study
9850 Genesee Ave., Suite 320
San Diego, CA 92037
Some of this information originated through The Center for Neurologic Study and U.C.S.D.
And: J.E.M.S. Magazine Oct. 2000
Contact David M. LaComb NREMT-P @ mailto:dlacombe@miami.edu

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