Slumping, Slurring and Slipping Away: Stroke Assessment. Laurie A. Romig, MD, FACEP Medical Director Pinellas County (FL) EMS

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1 Slumping, Slurring and Slipping Away: Stroke Assessment Laurie A. Romig, MD, FACEP Medical Director Pinellas County (FL) EMS

2 Caution! This discussion relates only to nontraumatic neurological problems!

3 Prehospital Stroke Care MYTH: It doesn t make a difference FACT: It does! (as with AMI) Better field management can help to limit stroke deficit Rapid transport to the right facility is an important component of the overall treatment strategy CHALLENGE: Not all areas have the appropriate infrastructure in place (i.e., Stroke Centers)

4 Prehospital Stroke Care Use the FAST-G # exam and history to determine hospital destination Evaluation and treatment criteria are based on latest AHA/ASA guidelines # Pinellas County adaptation of Cincinnati Stroke Scale

5 Stroke Facts and Rationale for Acute Care

6 Stroke in the United States Affects > 700,000 persons per year 1/3 die, 1/3 become disabled, 1/3 recover Third leading cause of death Leading cause of long-term disability Costs $50 billion per year

7 Change in Terminology: Acute Brain Attack (Not CVA ) Term aids public education efforts Identifies the brain as the organ involved Implies appropriate sense of urgency Likens event to heart attack CVA = cerebrovascular accident Bad term because stroke is preventable and treatable

8 Stroke Definition and Types General Definition Sudden brain dysfunction due to blood vessel problem Ischemic stroke (80%) decreased blood supply to a focal area of brain mostly thromboembolism (blood clot) Hemorrhagic stroke (20%) blood vessel rupture within skull not due to trauma intracerebral (inside the brain tissue) or subarachnoid (under the coverings of the brain)

9 Ischemic Stroke INFARCT Most common cause: thromboembolism CLOT Possible sources of clot: Heart Large artery (to brain) Small artery (in brain) Clot occluding artery

10 Intracerebral Hemorrhage Most common cause: chronic hypertension Other causes: Vessel malformation Tumor, bleeding abnormalities Bleeding into brain

11 Subarachnoid Hemorrhage Most common cause: aneurysm rupture Other causes: Vessel malformation Tumor, bleeding abnormalities Bleeding around brain

12 Transient Ischemic Attack (TIA) Reversible focal dysfunction present for minutes to less than 1 hour Among TIA patients who go the ED: 5% have stroke in next 2 days 10% have stroke in next 3 months 25% have a recurrent event (TIA or stroke) within 3 months Stroke risk can be decreased with proper therapy Do not enable patients to disregard the importance of a TIA, even if they have had them before and know what they are!

13 Ischemic Stroke: Nonmodifiable Risk Factors Advanced age Male gender Family history of early stroke or MI

14 Ischemic Stroke: Modifiable Risk Factors Hypertension (systolic and diastolic) Cigarette smoking Prior stroke/ TIA Heart disease Diabetes mellitus, hyperlipidemia Hypercoagulable states Carotid bruit Cocaine, excess alcohol Could this be you?

15 The Stroke Battle Cry Time is Brain: Save the Penumbra!!

16 Time Is Brain: Save The Penumbra Clot in Artery (DEAD) The penumbra is a zone of reversible ischemia around a core of irreversible infarction. This area of brain is salvageable in the first few hours after onset of acute ischemic stroke symptoms.

17 Time is Brain: Save the Penumbra Patient symptoms are due to both the infarcted core and the ischemic penumbra One cannot determine by exam how much brain can still be saved Therefore, the full extent of the damage is not immediately clear. Deficits could get worse or could get better Treatment aims to salvage the circulation to the penumbra If treated early enough, all of the brain tissue could be salvageable

18 Time is Brain: Save the Penumbra Thrombolytic agent t-pa can limit brain damage safely if given within 3 hours it reduces risk of disability due to ischemic stroke by 30% t-pa is currently administered only if: clinical diagnosis (no hemorrhage) confirmed by CT scan within 3 hours of onset (the sooner, the better) age 18 or older no other absolute contraindications

19 Time is Brain: Save the Penumbra Other interventions such as intraarterial thrombolytics and clot retrieval devices are being used in facilities with specialized capabilities for some stroke patients Treatment windows are expanding to 6 to 8 hours or more as facilities gain more experience with new devices The Penumbra is damaged by seizure, hypotension, hyperglycemia, fever, acidosis This has implications for what we need to evaluate, monitor and treat in the field

20 Time is Brain: Determine Cause In ED: define likelihood of ischemic stroke Full evaluation may take days and requires admission to the hospital Differential diagnosis is not extensive Ischemia vs. hemorrhage Mimics include: tumor, trauma, seizure, migraine, hypoglycemia, overdose

21 Stroke Mimics These conditions can result in focal cerebral dysfunction and mimic a stroke: hypoglycemia improves w/d50 seizure w/postictal state staring/limb shaking at onset migraine previous similar events tumor onset over weeks to months abscess onset over weeks to months subdural hematoma posttrauma

22 The Stroke Primary Survey : The FAST-G Exam

23 Cincinnati Prehospital Stroke Scale FAST Perform as part of Primary Survey under D for Disability Also incorporated in the FAST stroke primary evaluation tool and the MEND stroke secondary evaluation tool that you ll hear about later Facial droop Arm drift Speech Time patient was last seen or known to be normal This is a BLS level evaluation tool!

24 Facial Droop (Cranial Nerves): Show Teeth or Smile Abnormal: One side of face does not move as well as the other side Right-sided droop AHA 1997

25 Facial Droop You may have to encourage the patient to try Even in unresponsive patients, facial droop may be obvious It s common also to see drooling from the affected side Left facial droop Facial droop can be caused by other disorders as well (such as Bell s Palsy), so a complete detailed stroke examination is VERY important. If ONLY cranial nerve function is disrupted, stroke is less likely.

26 Arm Drift (Motor): Hold arms out, palms down and close eyes Abnormal: One arm cannot be lifted or drifts down Right-sided drift AHA 1997

27 Arm Drift Normal finding is for both arms not to move once extended or to move together If patient is unable to obey commands, look for spontaneous movement or movement in response to verbal/painful stimulus If patient is unresponsive and not moving at all DO NOT mark this as abnormal. You just don t know the answer.

28 Speech: Repeat Phrase You can t teach an old dog new tricks. Abnormal: Wrong or inappropriate words or unable to speak (aphasia) Caused by left hemispheric deficit Slurred words (dysarthria) Caused by cranial nerve deficit

29 Time last seen or known normal Forget the concept of time of symptom onset and change to time last seen or known normal This is CRUCIAL because time is the major determinant in what interventions may be effective Time of onset is often difficult to determine, so we default to the level of time last normal This also accounts for patients with previous deficits, because we re asking about normality for that patient

30 You are called to a 76 year old female found on the floor in her apartment with obvious right-sided weakness and aphasia. She can t t give you history of when the symptoms started, but the neighbor is able to tell you that she last spoke with the patient the previous evening, when she was acting normally. The patient s s son shows up and says that he talked to her on the telephone just one hour ago, and she was normal at that time.

31 What difference would the determination of last seen or known normal make? The actual time of onset of symptoms is unknown If the son had not known that the patient was normal one hour prior, we would have had to assume that the stroke symptoms began outside of the several hour window for intervention because we would have had to default to the last time she was contacted by the neighbor This is similar to the situation of a patient waking up with deficits we don t truly know when the symptoms started

32 FAST-G Adaptation (Pinellas County) Adds field determination of blood glucose in order to rule out hypoglycemia as a reversible cause of stroke-like symptoms This is a high priority assessment tool, especially in diabetic patients or those with other potential reasons to be hypoglycemic You d be surprised at how many hypoglycemia patients present with stroke symptoms, so don t think that this is a rare occurrence!

33 PLEASE NOTE!!! ALTERED MENTAL STATUS without focal neurological findings as evaluated in the FAST-G exam should NOT be attributed by default to stroke. Other medical problems are far more common causes of isolated mental status changes Intoxication/overdose Sepsis Metabolic problems Head injury Etc.

34 Important Supplemental Medical History

35 Important History Elements Help to pin down symptoms and last known normal time Help to determine risk factors and underlying causes as well as potential for stroke imitators Assist in differentiating ischemic from hemorrhagic stroke Assist in determining appropriate out-ofhospital and in-hospital treatment A Brain Attack form can prompt you for appropriate history

36 Importance of Witness Documentation Witnesses can be your only source of history We need to document specific witness testimony AND provide the hospital with witness contact information if they are not going to the hospital Hospital staff may need to ask for additional information Notify hospital staff if witness is coming to hospital and who to look for Record witness information on Brain Attack form or run report

37 Important History Elements: HPI Potential symptoms to question Extremity weakness General weakness (i.e., nonfocal) Vision changes Slurred or inappropriate speech Nausea/Vomiting Syncope/Near-syncope

38 Important History Elements: HPI More potential symptoms to question Dizziness/Vertigo Altered sensation (dull, increased, pins and needles, etc.) Altered level of consciousness* Severe or otherwise unusual headache* Stiff/painful neck* Symptoms resolved? TIA rather than stroke * Potential hemorrhagic stroke indicators

39 Relevance of specific symptoms Severe or unusual headache, especially combined with nausea/vomiting and/or altered LOC most typical of hemorrhagic stroke May indicate transport to a Neurosurgery capable facility. Dizziness/vertigo, lack of coordination possible cerebellar stroke Dysarthria (slurred speech) rather than aphasia (wrong words or none) possible brainstem stroke

40 Past Medical History (Risk Factor Assessment) Dysrhythmias (particularly acute or chronic a. fib.) Diabetes Current or very recent pregnancy (within days) Sickle cell disease (common cause of stroke in younger patients) Previous stroke (and whether ischemic or hemorrhagic, if known)

41 Past Medical History (Risk Factor Assessment) Chronic hypertension Coronary artery disease or other vascular atherosclerosis Recent systemic cancer (common cause of pediatric stroke) Resuscitation status (prehospital DNR?) And our other routine past history questioning

42 A Word About Old Deficits Patients with old strokes or other neurological deficits may, of course, have abnormal findings on the FAST exam even on their best days You may be in the best position to determine from witnesses or the patient what is NORMAL FOR THEM Document all deficits on the run report and try to make clear which are old, new or worse than usual

43 Fibrinolytic Screening Not all positive responses are ABSOLUTE contraindications for fibrinolytics Criteria are dynamically changing with new modes of therapy Risk is balanced against potential benefit NOTE: Age is NOT a primary factor!

44 Fibrinolytic Screening Head trauma at onset of symptoms Which came first? Seizure at onset? Could symptoms be Todd s Paralysis (postictal paralysis) due to the seizure or did a stroke cause the seizure? Symptoms consistent with cerebral bleed?

45 Fibrinolytic Screening Patient on Coumadin or Warfarin? Aspirin or NSAIDs do NOT have the same effect, but note these separately History of bleeding or clotting disorder? Previous hemorrhagic stroke? Increased likelihood of recurrence rather than new ischemic stroke

46 Fibrinolytic Screening Current pregnancy or very recent delivery? Pregnant women can be hypercoagulable and fibrinolytics can be contraindicated at very early stages of pregnancy or in first few days after delivery Surgery or significant hemorrhage within the last 3 months? GI, vascular, thoracic, orthopedic, cranial surgery GI bleed, variceal bleed, intracerebral bleed, major traumatic hemorrhage

47 Summary Stroke has joined Acute Myocardial Infarction as a very time-sensitive prehospital disorder

48 Summary Rapid and basic assessment on scene with expedited transport is, in effect, therapy for these patients Basic stroke assessment is a BLS skill. More advanced assessment can improve your understanding of the disorder and facilitate clear communication with Stroke Teams at Stroke Centers

49 Prehospital Stroke Management

50 Basic Principles of Prehospital Stroke Care First do no harm avoid giving glucose unless absolutely indicated avoid treating hypertension avoid causing aspiration pneumonia Report to ED details of symptom onset neurologic exam witness information

51 Avoid Giving Glucose THE RULE: Do NOT give glucose-containing solutions to acute stroke patients THE REASON: Hyperglycemia causes lactic acidosis and damages the penumbra THE EXCEPTIONS: Hypoglycemic patients with known history of hypoglycemic episodes (such as insulin dependent diabetics) should still be treated as usual. The symptoms may be due to the low blood sugar. Patients without a REASON to be hypoglycemic should only treated if their blood sugar is < 50 gm/dl

52 Avoid Treating Hypertension THE RULE: EMS should not treat hypertension in acute stroke patients THE REASONS: HTN is commonly caused by the stroke It may be required for penumbra perfusion It often subsides without treatment

53 On Scene Care Summary Complete FAST-G Priority interventions Maintain SpO2 of at least 95% No benefit to maintaining higher SpO2 Keep head straight, elevate head of stretcher to no more than 30 degrees unless hypotensive Left lateral recumbent position if nauseated or vomiting

54 On Scene Care Summary Priority interventions (cont.) Maintain systolic BP of at least 90 mm Hg DO NOT treat hypertension Treat blood glucose if < 50 mg/dl (< 40 mg/dl for neonate) and no history of hypoglycemia Treat patients with known hypoglycemia history as usual Make destination decision based on exam and history Get at least HPI and witness information on scene

55 On Scene Care Summary IV insertion can be delayed until during transport if it is not needed for a priority intervention Same for cardiac monitor and 12 lead ECG Key is to minimize scene time in order to maximize window for definitive treatment

56 En Route Care Summary Document thoroughly Treat clinical complications as they arise Contact receiving facility as soon as possible to give them time to prepare for the patient

57 Quick Radio Report Template Patient age and gender Symptoms and FAST-G results Make sure to include time last seen normal and blood glucose Most PERTINENT history (history of previous bleed or ischemic stroke, pregnant?) Vital signs, cardiac rhythm if available Interventions performed Fibrinolytic screening negative, positive for possible contraindications, or in progress (don t necessarily need details over the radio) ETA

58 How does a good radio report help the ED? Clear a bed for the patient if necessary and prep to receive patient report on arrival Notify CT and reshuffle other patients waiting for same Notify Stroke Team so that they can be present or en route when you arrive Prep their registration processes so that tests can be ordered more quickly In general, get everybody into the same kind of mindset a Trauma Team or STEMI Team has

59 Example of ED Report 64-year-old man, last known to be without symptoms at 0130 today, with a chief complaint of right-sided weakness. He was found by his wife at 0300; she is with us. There was no observed trauma or seizure activity observed. His glucose is 140 and his BP is 168/105. Fibrinolytic screening is negative for contraindications

60 Example of ED Report He is alert with mild dysarthria, no aphasia, normal visual fields, & moderate weakness of the right face, arm, & leg. (MEND exam) Monitor shows atrial fibrillation with a ventricular response rate of lead shows no signs of ischemia. He has maintained a pulse ox of 96% on 2 liters of O2 by cannula and we ve performed no other interventions. Our ETA is approximately 10 minutes.

61 The Major Stroke Syndromes

62 Brain: Major Divisions Cerebral Cortex gray matter computer center Note: Cerebrum = R and L hemispheres = cortex and subcortex Cerebral Subcortex deep white matter wires connecting cortex and brainstem Brainstem connects cerebrum and spinal cord ( funnel of of the brain) contains nerves to to face/head Cerebellum coordination center

63 Functional areas of the cerebral cortex A stroke in these particular areas will likely affect the functions shown for that area.

64 Major Stroke Syndromes 1. Left Hemisphere 2. Right Hemisphere 3. Brainstem 4. Cerebellum 5. Hemorrhagic Stroke syndromes are named for the location of the injured area of the brain. HEMORRHAGIC stroke is separated out because of its potential importance in destination and treatment decision making, but it can occur in any area of the brain.

65 Right and Left Hemispheric Strokes Motor and sensory deficits are found on the side OPPOSITE to the affected side of the brain Visual field deficits are also found on the side OPPOSITE to the affected side of the brain Horizontal gaze is also affected in the direction OPPOSITE to the affected side of the brain Because the eye can t move to the opposite side, it actually appears to be looking AT the affected side of the brain in hemispheric strokes

66 Left (Dominant) Hemisphere Typical Signs: Right Side Weakness and Aphasia Right Visual Field Deficit Aphasia Right Hemiparesis Right Hemisensory Loss Left Gaze Preference (in hemispheric stroke, looks TOWARD the side of the injury) Hemiparesis: weakness or partial paralysis Hemiplegia: paralysis

67 Aphasia In right hand dominant people, the speech center of the brain is found in the left hemisphere So left hemispheric stroke is the most likely cause of aphasia in most people HOWEVER, some left hand dominant people have their speech centers on the right side of the brain, so they may present with right hemispheric stroke symptoms and aphasia

68 Right (Nondominant) Hemisphere Typical Signs: Left Side Weakness Left Hemi-inattention inattention (Neglect) Right Gaze Preference (in hemispheric stroke, looks TOWARD the side of the injury) Left Visual Field Deficit Left Hemiparesis Left Hemisensory Loss

69 Hemi-inattention or Neglect Patients with neglect tend not to acknowledge (i.e., they neglect ) anything about the affected side of their body People who experience damage to the right parietal lobe sometimes show a fascinating condition called hemi-inattention. When this occurs, the person is unable to attend to the left side of the body and the world. A person with hemi-inattention may shave or apply makeup only to the right side of the face. While dressing, he or she may put a shirt on the right arm but leave the left side of the shirt hanging behind the body. The person may eat from only the right side of the plate, not noticing the food on the left side. This condition is not due to visual problems or the loss of sensation on the left side of the body, but is a deficit in the ability to direct attention to the left side of the body and the world. (Psychobiology, Salem Press)

70 Hemi-inattention or Neglect The most common form of neglect is neglect of the left side of the body due to a right hemispheric lesion, but neglect can affect other areas as well If a patient appears not to acknowledge your presence from one side of the body, try changing sides to rule out the presence of hemi-inattention (neglect) Patients can often eventually totally recover from hemi-inattention deficits

71 Brainstem Typical Signs: Bilateral Abnormalities Quadriparesis Sensory Loss in All 4 Limbs Crossed Signs (1 side of face and contralateral body) Hemiparesis Hemisensory Loss

72 Brainstem Typical Signs: Cranial Nerve and Other Deficits Decreased LOC Nausea, Vomiting Hiccups, Abnormal Respirations Oropharyngeal Weakness: Dysarthria (speaking), Dysphagia (swallowing) Vertigo, Tinnitus Eye Movement Abnormalities: Diplopia Dysconjugate Gaze Gaze Palsy (horizontal gaze deficit or gaze preference)

73 Cerebellum Typical Signs: Lack of Coordination Ipsilateral (same side) Limb Ataxia (dyscoordination) Truncal or Gait Ataxia (imbalance) Tremors, or Limb Ataxia, result from lack of coordination of opposing muscle groups (flexors vs. extensors), causing the muscle groups to fight each other

74 Hemorrhage and the Brain Coverings Cranium (skull): hard container enclosing brain Meninges: 3-layered cloth-like covering of brain and spinal cord Hemorrhagic stroke suddenly increases intracranial pressure Subarachnoid hemorrhage irritates the meninges

75 Symptoms Suggestive of Hemorrhage Both Subarachnoid and Intracerebral Hemorrhage: Headache Nausea, Vomiting Decreased LOC (not always present) None of these signs are DIAGNOSTIC of hemorrhage; hemorrhage may be totally indistinguishable from ischemic stroke without imaging studies Subarachnoid Hemorrhage: Intolerance to Light Neck Stiffness / Pain Intracerebral Hemorrhage: Focal Signs Such as Hemiparesis

76 Other potentially distinguishing characteristics of hemorrhagic stroke New onset of seizures is more common with hemorrhagic than ischemic strokes Altered mental status is more commonly associated with hemorrhagic strokes Remember that isolated altered mental status is NOT very likely to be due to stroke Most hemorrhagic strokes will have some combination of the listed symptoms and signs, not just one abnormal finding

77 Hemorrhagic Stroke You may NOT be able to detect a hemorrhagic stroke merely by doing the FAST-G exam History questions are extremely important to focus you on further findings!! A minority of strokes are hemorrhagic and the minority of hemorrhagic stroke patients end up going to surgery Know your local protocols about transport destinations for possible hemorrhagic stroke patients

78 Noncontrast CT Scans: Ischemic Stroke Initial CT scans of ischemic stroke patients may be NORMAL or may only show signs of cerebral edema You can see the sulci and gyri on the right side of the brain, but the same area is more blurry on the left side R Sulcus (space between gyri) 4 Hours L Gyrus (a fold of cortex) Subtle blurring and compression of sulci

79 Noncontrast CT Scans: Ischemic Stroke The CT scan usually later develops the more typical dark changes of ischemic infarction Quick Quiz: What neurological findings would you expect this patient to have? (answer on next slide) R 4 Days L Obvious dark changes of infarction

80 Answer This is a left hemispheric infarct; therefore, you would expect to find aphasia and right sided weakness/paralysis and/or sensory deficits along with a possible left horizontal gaze deficit (= right gaze preference) and right visual field deficits

81 Noncontrast CT Scan: Hemorrhagic Strokes Intracerebral Hemorrhage Subarachnoid Hemorrhage Ball of white blood in thalamus White blood in cisterns & 4th ventricle

82 Quick Summary of Major Stroke Syndromes

83 Major Syndrome Deficits 1 LEFT HEMISPHERE Speech Aphasia Right Body Visual Motor, Sensory RIGHT HEMISPHERE 5 Left Body Neglect, Visual, Motor, Sensory 3 BRAINSTEM 4 Right and/or Left Motor, Sensory 3 4 Eye Movements Speech/Swallowing Dizziness/Nausea Consciousness CEREBELLUM Imbalance Dyscoordination 5 POSSIBLE HEMORRHAGE Headache Neck Pain/Stiffness Light Intolerance Nausea/Vomiting Consciousness + Focal Findings

84 5 Major Syndromes: Typical Signs FOCAL DEFICITS SPEECH LEFT HEMISPHERE Aphasia wrong or inappropriate words RIGHT HEMISPHERE Says correctly BRAINSTEM Dysarthria slurring CEREBELLUM Says correctly HEMORRHAGE * + Says correctly but slowly (often sleepy) FACIAL DROOP Right facial droop Left facial droop May have bilateral droop No droop No droop ARM DRIFT Right arm drift (weakness) Left arm drift (weakness) May have bilateral drift (weakness) No drift No drift +* Finger-to to-nose and/or heel-to to-shin testing typically abnormal Decreased level of consciousness with headache and stiff neck are e typical; this syndrome without associated focal neurologic deficits is most consistent with subarachnoid hemorrhage. With intracerebral hemorrhage, focal deficits may occur.

85 Special Thanks! To Dr. Laurie Romig MD, FACEP Medical Director-Pinellas County, Florida EMS for the use of her materials for this presentation

86 Questions?

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