PCTH - Stroke Protocol

Question 1

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

Answer 1

10 minutes

Question 2

Increased incidence of CVA/TIA is due to what?

Answer 2

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

Question 3

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

Answer 3

4th leading cause of death

1st leading cause of disability

Question 4

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

Answer 4

50%

Question 5

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

Answer 5

1-8 hours

Question 6

What are the two types of strokes?

Answer 6

1) hemorrhagic
2) Ischemic

Question 7

Hemorrhagic strokes - causes, incidence, S/S

Answer 7

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

Question 8

Ischemic strokes - causes, incidence, S/S

Answer 8

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

Question 9

Transient Ischemic Attacks (TIAs)

Answer 9

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

Question 10

Tissue plasminogen activator (tPA)

Answer 10

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

Question 11

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?

Answer 11

29% Sx improvement

52% no difference

19% did not recover, resulting in death

Question 12

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

Answer 12

4.5 hrs

Question 13

Resource facilities for strokes (3)

Answer 13

Regional Stroke Centres

District Stroke Centres

Stroke Prevention Clinics

Question 14

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

Answer 14

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)

Question 15

Endovascular Treatment (EVT)

Answer 15

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)

Question 16

tPA limitations?

Answer 16

• 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)

Question 17

Entry point for EVT

Answer 17

radial or femoral

Question 18

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?

Answer 18

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

Question 19

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

Answer 19

6

Question 20

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

Answer 20

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

Question 21

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

Answer 21

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

Question 22

Evaluation for stroke S/S - speaking and comprehension

Answer 22

Look for: Sudden confusion, trouble speaking or understanding

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

Question 23

Evaluation of stroke S/S - eyes

Answer 23

Looking for: Sudden trouble seeing in one or both eyes

• loss of vision
• double vision
• blurred vision

Question 24

Evaluation of Stroke S/S - headaches

Answer 24

Looking for: sudden, severe headache with no known cause

• check for hx or migraine or head injury

Question 25

Evaluation of stroke S/S - coordination and balance

Answer 25

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

Question 26

LSN

Answer 26

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

Question 27

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

Answer 27

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

Question 28

**Los Angeles Motor Scale - LAMS** What is it and what three things are you assessing?

Answer 28

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

Question 29

LAMS scale: Facial droop

Answer 29

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)

Question 30

LAMS scale - Arm Drift

Answer 30

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)

Question 31

LAMS Scale - Grip Strength

Answer 31

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)

Question 32

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

Answer 32

≥4 (max score is 5)

Question 33

What assessments are you completing for a stroke patient?

Answer 33

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

Question 34

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

Answer 34

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

Question 35

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

Answer 35

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

Question 36

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:

Answer 36

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

Question 37

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?

Answer 37

Yes

Question 38

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

Answer 38

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

Question 39

As per *Dysphagia Standard*, the paramedic shall:

Answer 39

**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**