Stroke Assessment Care Review Misty Plumley EMS Specialist

Stroke Assessment & Care Review Misty Plumley, EMS Specialist

Objectives �Review definitions of ischemic and hemorrhagic stroke. �Identify risk factors for stroke �Discuss signs and symptoms of posterior stroke �Review changes to REMSA policies regarding stroke treatment and transport �Discuss and review documentation needs for stroke patients

Stroke Definitions �Ischemic Stroke: occurs as a result of a buildup of fatty deposits lining blood vessel walls. ◦ Cerebral embolism ◦ Cerebral thrombus

Stroke Statistics �Estimated cost of over $35 billion annually for stroke care, disability and work hours missed � 5 th leading cause of death in the U. S.

Ischemic Stroke

Stroke Definitions �Hemorrhagic stroke: bleeding into the brain resulting from a weakened or ruptured blood vessel. ◦ Intracerebral hemorrhage ◦ Subarachnoid hemorrhage

Intracerebral Hemorrhage Subarachnoid Hemorrhage Hemorrhagic Stroke

Uncontrollable Controllable / Treatable � Age � Hypertension � Gender � Cigarette � Heredity � Race � Prior TIA/Stroke smoking � Diabetes mellitus � Poor diet � Obesity � Peripheral artery disease � Drug abuse Risk Factors for Stroke

Assessment & Care STROKE

Stroke Assessment �Signs and symptoms of stroke vary based on the area of the brain with limited/no blood flow. �Time dependent! Treatment geared from Last known well time ◦ Necessity to know the last time the patient was seen normal & when stroke symptoms began

Stroke Assessment �High index of suspicion �Evaluate �Classic patient for risk factors �Atypical Presentation

Major Brain Regions

Cincinnati Prehospital Stroke Scale

B-E-F-A-S-T assessment tool - B-Balance- Sudden trouble walking, dizziness, loss of balance or coordination - E-Eyes- Sudden trouble seeing in one or both eyes

B-E-F-A-S-T assessment tool �F-Face Drooping – Does one side of the face droop or is it numb? Ask the person to smile. Is the person's smile uneven? �A- Arm-Is one arm weak or numb? Ask the person to raise both arms. Does one arm drift downward? �S-Speech Difficulty – Is speech slurred? Is the person unable to speak or hard to understand? Ask the person to repeat a simple sentence, like "The sky is blue. " Is the sentence repeated correctly? �T-Time-What was the time the person was last known well? When did the signs/symptoms appear?

Atypical Presentations of Stroke POSTERIOR AND CEREBELLAR STROKE

Posterior Stroke �Prevalent in an estimated 20 -25% of ischemic strokes �Can be misdiagnosed as vertigo �Resulting from occlusion of a branch of the cerebellar artery, vertebral or basilar arteries

Posterior Brain Circulation

Cerebellar Circulation

Posterior/Cerebellar Stroke � Common signs/symptoms: ◦ Nausea and/or vomiting ◦ Dizziness* ◦ Prominent headache ◦ Visual disturbance or visual field loss �Gaze evoked nystagmus ◦ Auditory disturbance ◦ Dysmetria / ataxia*

Posterior/Cerebellar Stroke �High degree of severe disability �High mortality �Patients with dizziness & ataxia/dysmetria & visual disturbance should be suspected to have a stroke until imaging/consult directs otherwise. ◦ Stroke Receiving Center transport beneficial!!

Documentation & Data Collection �Clinically indicated data elements: ◦ Name, gender, DOB/age, medical history, medications, allergies, GCS, pupils, skin signs, vital signs (at minimum: SBP, DBP, PR, RR, pulse ox, BGL) ◦ Cincinnati Prehospital Stroke Scale results by category

Documentation & Data Collection ◦ Treatment specific data elements: �Last known well time (in time format, i. e. LKWT 2315) �Time symptoms began (i. e. onset of OPQRST) �Time patient discovered �Specificity is important �Next of kin contact name and contact phone number

Documentation & Data Collection �Treatment ◦ ◦ Specific Data Elements Treatment rendered to patient Response to therapy Base hospital utilized Transport destination

REMSA Policy Changes �REMSA 4503: ◦ Added dizziness into the physical section of pertinent findings ◦ Added Last Known Well Time, time patient was discovered & time symptoms began into emergency stabilization ◦ Removal of Stroke-Ready Hospital �All hospitals need to be Stroke Receiving centers approved by CMS authorized accrediting organization prior to REMSA authorization and site visit

REMSA Policy Changes �REMSA 5701 ◦ Removal of “Stroke-Ready Hospital” �All facilities need to be designated either Primary Stroke Center or Interventional Stroke Center ◦ Change in data collection time frame for hospitals

Case Study #1 � 911 is called from a local gym, for a 48 year female. She is complaining of a headache and dizziness. She has been feeling unwell for 2 hours, she was feeling dizzy and had a headache prior to her yoga class. She leaned against the wall and rested, felt mildly better and took her class. After class she was so dizzy she stumbled into wall to avoid falling.

Case Study #1 �Medical history: ◦ Hysterectomy, acid reflux, family history of cardiac disease �Medications: ◦ Hormone replacement therapy, prilosec as needed for acid reflux �Allergies: iodine, aspirin

Case Study #1 �Next Assessment steps? �What assessment tools should be used? ◦ ◦ Vital Signs w/ pulse oximetry CPSS Blood glucose 12 lead ECG

Case Study #1 �At scene her vitals are: BP 170/92, PR 84, RR 20, pulse oximetry: 96% room air, BGL 98 mg/d. L � 12 lead unremarkable �Physical Exam: ◦ ◦ ◦ No arm drift, no facial droop, clear speech Nausea Vomits during secondary assessment Headache rated at 5/10 Skin normal and warm �Differential Diagnosis?

Case Study #1 �Patient assisted to stand/pivot to sit on gurney �Additional Exam Findings: ◦ ◦ Profound dizziness Right hand clumsiness Unsteady gait, veers right when standing Pupils PERRL �Refined Differential Diagnosis Possibilities? �Transport Decision?

Case Study #1 �Patient transported to stroke receiving center �Labs and imaging studies ordered ◦ CT head negative ◦ Lab results within normal limits �Orthostatic vital signs taken ◦ Patient veers to the right ◦ MRI ordered

From: Management of Acute Cerebellar Stroke Figure Legend: Magnetic resonance image showing an infarct of the left cerebellum with narrowing of the fourth ventricle but no hydrocephalus. Date of download: 12/28/2015 Copyright © 2015 American Medical Association. All rights reserved.

Case Study #2 � 64 year female patient found at home, reporting 1 day of nausea/vomiting and dizziness, worsening for 3 hours. Home health care worker at scene, reports patient has a history of vertigo, recently was hospitalized for a GI issue and she just returned home yesterday morning.

Case Study #2 �Scene overview: ◦ 3 bedroom home on the independent living side of a care facility ◦ Patient in a hospital bed ◦ Row of 8 medicine bottles lined up on the dresser ◦ Home health worker has been with patient since she broke her hip 4 months ago.

Case Study #2 �Medical History: ◦ Vertigo, Hypertension, Atrial Fibrillation, TIA osteoporosis, arthritis �Medications: ◦ warfarin, meclizine, digoxin, calcium w/ vitamin D 3, estrogen, ibuprofen, naproxen, phenergan �Allergies: PCN

Case Study #2 �Review of symptoms ◦ Describes dizziness as room spinning all the time ◦ Vomiting x 3 this morning, total of 8 times since being home ◦ Minimal abdominal discomfort after vomiting, none currently �Risk Factors? Probable Differential Diagnoses?

Case Study #2 �What assessment/diagnostic tools should be used? ◦ ◦ ◦ Cincinnati Prehospital Stroke Scale 12 Lead ECG Pulse oximetry Vital signs Blood glucose

Case Study #2 �Assessment results: ◦ BP 200/110; HR 110 & irregular; RR 18, lungs CBL; pulse ox 94% room air; skin signs: pale/warm and dry ◦ Blood glucose: 80 mg/d. L ◦ 12 Lead ECG: uncontrolled AFIB, no ectopy or ST changes ◦ CPSS: no facial droop, clear speech, no arm drift

Case Study #2 �Transport Decision? ◦ Why? �Continued treatment en route? ◦ Vascular access ◦ Repeated CPSS ◦ Medication for nausea/vomiting

Case Study #2 �Transported to Stroke Receiving ED, mild relief of nausea, no vomiting en route, dizziness remains �CT ordered, labs drawn ◦ CT negative

Imaging Results – Case Study #2

Resources � www. americanstrokeassociation. org � http: //epmonthly. com/article/take-a-hints/ � https: //patienteducation. osumc. edu/Documents/Effects Cerebellar. Stroke. pdf � Jensen M, M. D. ; Erik St. Louis M. D; JAMA Neurology Management of Acute Cerebellar Stroke 2005; 62 (4), 537 -544. � Kattah et al. Stroke H. I. N. T. S. to Diagnose Stroke in the Acute Vestibular Syndrome—Three-Step Bedside Oculomotor Exam More Sensitive than Early MRI DWI 2009 Nov; 10 (40) 3504 -3510 � Nelson, James M. D. ; Erik Viirre, M. D. , Ph. D. West JEM The Clinical Differentiation of Cerebellar Infarct from Common Vertigo Syndromes 2009 Nov; 10 (4), 273 -277

Objectives �Review definitions of ischemic and hemorrhagic stroke. �Identify risk factors for stroke �Discuss signs and symptoms of posterior stroke �Review changes to REMSA policies regarding stroke treatment and transport �Discuss and review documentation needs for stroke patients

Questions?