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OCHT Term II > PCTH - Stroke Protocol > Flashcards

PCTH - Stroke Protocol Flashcards

1
Q

In Ontario, someone experiences CVA/TIA -like symptoms or an attack, every ___________.

A

10 minutes

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2
Q

Increased incidence of CVA/TIA is due to what?

A

increasingly educated public and thus more 911 calls with S/S recognition

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3
Q

CVA is the ____ leading cause of death and the _______ leading cause of disability.

A

4th leading cause of death

1st leading cause of disability

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4
Q

Annually, what % of patients who are having CVAs are being transported by 911?

A

50%

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5
Q

What is the time duration in which it took people to recognize S/S of stroke and call/seek medication attention?

A

1-8 hours

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6
Q

What are the two types of strokes?

A

1) hemorrhagic
2) Ischemic

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7
Q

Hemorrhagic strokes - causes, incidence, S/S

A

Causes: from ruptures such as aneurysms (blood accumulates and compresses the surrounding tissue)

Incidence: ~30%

S/S: rapidly decreased LOC, combative, seizures (seen only in hemorrhagic strokes, not ischemic), actively vomiting

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8
Q

Ischemic strokes - causes, incidence, S/S

A

Causes: blockage in artery that serves the brain leading to ischemia

Incidence: ~70% (therefore more often than hemorrhagic strokes)

S/S: some confusion, some decreased LOC, slurred speech

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9
Q

Transient Ischemic Attacks (TIAs)

A

reduction in blood flow to the brain causing symptoms of CVA but these Sx resolve eventually. TIAs are a warning sign to CVAs.

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10
Q

Tissue plasminogen activator (tPA)

A

Drug that dissolves clot to restore blood flow (works to stimulate conversion of plasminogen to plasmin that would dissolve fibrin strands in clots that cause ischemic strokes; but not given to hemorrhagic strokes because this can WORSEN the bleeding into the injury site)

The only way to determine the difference between hemorrhagic and ischemic stroke to determine whether to deliver tPA is with use of a CT scanner, this is why not every hospital has tPA

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11
Q

In the study done to investigate tPA’s benefit for stroke patients, what % of stroke patients took tPA and have symptom improvement?

What % of stroke patients took tPA and had no change?

What % of stroke patients took tPA but did not recover, resulting in death?

A

29% Sx improvement

52% no difference

19% did not recover, resulting in death

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12
Q

The best results with tPA were for people who were able to get to the stroke center within ____ hours of onset of symptoms.

A

4.5 hrs

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13
Q

Resource facilities for strokes (3)

A

Regional Stroke Centres

District Stroke Centres

Stroke Prevention Clinics

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14
Q

What’s the difference between Regional and District Stroke Centres?

A

Regional Stroke Centres: able to do CT and give tPA, and has neurologist on site/able to be accessed

District Stroke Centres: able to do CT and give tPA, but has access to neurologist only (none on site)

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15
Q

Endovascular Treatment (EVT)

A

Image guided mechanical clot removal aka embolectomy (the treatment involves placing a catheter into the brain and removing the clot that’s causing the stroke)

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16
Q

tPA limitations?

A
  • not effective in removal of large arterial occlusions
  • bleeding risks (busting clots that will exacerbate bleed)
  • Recent surgeries (patients may need the clotting and tPA may result in high risk of bleeding)
17
Q

Entry point for EVT

A

radial or femoral

18
Q

1) With EVT, what % of stroke patients took received EVT and have symptom improvement?
2) What % of stroke patients received EVT and had no change?
3) What % of stroke patients received EVT but did not recover, resulting in death?

A

1) 53% positive outcome
2) 37% disability
3) 10% death

19
Q

If patient can get to the appropriate stroke facility within _____ hours of onset of Sx, they can receive EVT.

A

6

20
Q

As per the Cerebrovascular Accident (CVA) Standard, the paramedic shall:

A
  1. consider other potentially serious conditions that may mimic a stroke, such as,
    1. drug ingestion (eg. cocaine)
    2. hypoglycemia
    3. severe HTN, hypertensive emergency, or
    4. CNS infection (eg. meningitis)
  2. ​ perform, at a minimum, a secondary survey to assess,
    1. ​head/neck for:
      1. ​facial symmetry,
      2. pupillary size, equality, and reactivity,
      3. abnormal speech
      4. present of stiff neck,
    2. CNS for,
      1. ​abnormal motor function (eg. hand grip strength, arm/leg movement/drift, and
      2. sensory loss, and
    3. for incontinence of urine/stool;
  3. ​ensure adequate support for the patient’s body/limbs during patient movement and place extra padding and support beneath affected limbs;
  4. prepare for potential problems, including,
    1. ​possible airway obstruction (if loss of tongue control, gag reflex),
    2. decreasing LOC,
    3. seizures, and
    4. agitation, confusion, or combativeness
  5. ventilate the patient if patient is apneic or respirations are inadequate,
    1. ​if ETCO2 monitoring is available,
      1. ​attempt to maintain ETCO2 values of 35-45 mmHg,
      2. notwithstanding paragraph 5(a)(i) above, if signs of cerebral hernation are present after measures to address hypoxemia and hypotension, hyperventilation patient to attempt to maintain ETCO2 values of 30-35mmHg. Signs of cerebral hernation include a deterioraring GCS <9 with any of the following: note that CVA can present the same as cerebral herniation due to increased ICP from blood/edema
        1. ​dilated and unreative pupils,
        2. asymmetric pupillary response, or
        3. a motor response that shows either unialteral or bilateral decorticate or decerebrate posturing, or
    2. if ETCO2 monitoring is unavailable, and measures to address hypoxemia and hypotension have been taken, and the patient shows signs of cerebral herniation (as per 5(a)(ii)) above, hyperventilate the patient as follows:
      1. ​Adult: approx 20 breaths per minute
      2. Child: approx 25 breaths per minute
      3. Infant < 1 year old: approx 30 breaths per minute
21
Q

Evaluation for stroke S/S - face/arm/leg

A

Looking for: sudden numbness or weakness of the face, arm, or leg, especially on one side of the body

  • unilateral arm/leg weakness or drift
  • grip strength
  • palms up, eyes closed, arms out for 5 seconds
22
Q

Evaluation for stroke S/S - speaking and comprehension

A

Look for: Sudden confusion, trouble speaking or understanding

  • ask the person simple questions (person, place, time, item)
  • look for slurred speech
  • loss of speech
23
Q

Evaluation of stroke S/S - eyes

A

Looking for: Sudden trouble seeing in one or both eyes

  • loss of vision
  • double vision
  • blurred vision
24
Q

Evaluation of Stroke S/S - headaches

A

Looking for: sudden, severe headache with no known cause

  • check for hx or migraine or head injury
25
Q

Evaluation of stroke S/S - coordination and balance

A

Looking for: sudden trouble walking, dizziness, loss of balance or coordination

26
Q

LSN

A

Last seen normal time (i.e. last time seen without symptoms)

27
Q

If Sx onset is within _____, patient can go to a designated stroke facility.

A

within 6 hours

note: you need to CONFIRM onset of symptoms, so if someone woke up with stroke like symptoms, you cannot confirm that it happened within the last 6 hours

28
Q

Los Angeles Motor Scale - LAMS

What is it and what three things are you assessing?

A

identfies if there is potential of a large vessel occlusion (in which cause you need EVT)

1) Facial droop - smile, show teeth, raise eyebrows and squeeze eyes shut

2) Arm drift: elevate with palm down, 45 deg if lying, 90 deg if sitting, 10 second count

3) Grip strength: have patient try to grasp examiner’s fingers

29
Q

LAMS scale: Facial droop

A

0 - Absent (No facial asymmetry aka normal)

  • Facial palsy 0-1 (NIHSS score)

1- Present (Partial or complete lower facial droop)

  • Facial palsy 2-3 (NIHSS score)
30
Q

LAMS scale - Arm Drift

A

0- Absent (No drift, normal)

  • Motor arm 0 (normal) - NIHSS

1 - Drifts down (Drifts down but does not hit the bed within 10 sec)

  • Motor Arm 1 (drift) - NIHSS

2 - Falls rapidly (Arm cannot be held up against gravity and falls to bed within 10 sec)

  • Motor Arm 2-4 (NIHSS)
31
Q

LAMS Scale - Grip Strength

A

0- Normal (no NIHSS)

1- Weak grip (weak but some movement)

  • NIHSS: grip strength weak (4), some movement against gravity (3), or some movement but not against gravity (2)

2- No grip (no movement; muscle contraction be seen but without movement)

  • NIHSS: muscle contraction but no movement (1) or no muscle contraction (0)
32
Q

LAMS of what score is highly predicted of large artery occlusion?

A

≥4 (max score is 5)

33
Q

What assessments are you completing for a stroke patient?

A

1) primary
2) stable vs unstable - determine what their LAMS score is and if they are stable enough to make the trip
3) indicators for CVA

34
Q

As per the CVA Standard, what is the Acute Stroke Bypass Protocol?

A
  1. Assess patient to determine if he/she has one or more of the symptoms consistent with the onset of an acute stroke, as follows:
    1. inappropriate words or mute,
    2. slurred speech
    3. unilateral arm weakness or drift
    4. unilateral facial droop, or
    5. unilateral leg weakness or drift;
  2. if the patient meets criteria listed above, determine if patient can be transported to a Designated Stroke Centre* within 6 hours of a clearly determined time of symptom onset or time the patient was last seen in his/her usual state of health;
  3. if the patient meets criteria listed in (1) and (2) above, assess the patient to determine if he/she has any of the following contraindications:
    1. CTAS 1 and/or an uncorrected airway, breathing or circulation issue (GO TO CLOSEST FACILITY)
    2. stroke symptoms resolved prior to paramedic arrival or assessment (or improving)
    3. BGL <3 mmol/L (however if symptoms persist after correction of BGL, patient is not contraindicated)
    4. seizure at onset of symptoms or that is observed by the paramedic
    5. GCS <10
    6. Terminally ill or is in palliative care
    7. Duration of transport to the Designated Stroke Centre will exceed two hours;
  4. if patient does not meet any of the contraindications listed in paragraph 3 above, perform a secondary screen for a Large Vessel Occlusion (LVO) stroke using Los Angeles Motor Scale (LAMS);
  5. inform the CACC/ACS of the LAMS score to assist in determination of the closest or most appropriate*** Designated Stroke Centre; and
  6. if transport has been initiated to a Designated Stroke Centre and the patient’s symptoms improve significantly or resolve during transport, continue transport to the Designated Stroke Centre
35
Q

As per the CVA Standard in the BLS, a Designated Stroke Centre includes what?

A

Regional Stroke Centre, District Stroke Centre or a Telestroke Centre regardless of EVT capability

36
Q

According to the CVA Standard in the BLS, when determining the most appropriate Designated Stroke Centre (in collaboration with CACC/ACS), the most appropriate refers to:

A

a Designated Stroke Centre as defined by a patient priority system (PPS)

37
Q

A patient presents with stroke-like symptoms. Upon further assessment, you discover that the patient has a DNR however is not terminally ill/palliative. Do you still treat under the Acute Stroke Bypass Protocol?

A

Yes

38
Q

A patient is suspected to have a CVA en route to the hospital. Where do you go?

A

If does not meet any contraindications, divert to Designated Stroke Centre

39
Q

As per Dysphagia Standard, the paramedic shall:

A

1) consider potential life/limb/function threats, such as,

  • anaphylaxis, and
  • upper airway infections (eg. epiglottitis);

2) perform, at a minimum, a secondary survery to assess,

  • head/neck for
    • drooling
    • hoarse voice or cough
    • nasal flaring
    • swelling or masses, and
    • tracheal deviation, and
  • lungs, for adventitious sounds through auscultation

3) notwithstanding paragraph 2 above, if epiglottitis is suspected, not open and inspect airway;

4) if epiglottitis is suspected and oxygen administration is indciated as per Oxygen Therapy Standard, attemp to minimize agitation;

5) position patient sitting or semi-sitting; and

6) prepare for potential problems, including complete airway obstruction

OCHT Term II (31 decks)

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