Patient Care, Trauma

‘Time Is Brain’ in Prehospital Stroke Treatment

Issue 6 and Volume 37.

You’re called to the home of a 55-year-old female because of a fall. On arrival, you find her sitting up in a chair in her living room, which smells strongly of cigarette smoke. She stares at you blankly when you attempt to question her about what happened. Her husband tells you he was in another room when he heard a thump and that he found her on the living room floor. He says he was able to move her into a chair, but says she has been unable to tell him what happened.

The patient’s blood pressure is 200/110; her pulse is 88, strong at the radial but irregularly irregular. You administer oxygen and start an IV. Her husband tells you she takes a “blood pressure pill,” but her medications are nowhere to be found. She’s able to follow your commands, but now when she tries to speak, her words are garbled. You suspect she’s suffered a stroke.

Types of Strokes
Stroke, or cardiovascular accident (CVA), represents a serious medical condition in which the blood supply to areas of the brain is interrupted, resulting in ischemia. There are two basic types of strokes: ischemic and hemorrhagic. The majority of CVAs (87%) are ischemic.

In ischemic stroke, a blood vessel is blocked. The tissue distal to the blockage becomes ischemic and will eventually die if blood flow isn’t restored. Reperfusion therapy is the goal of treatment for ischemic stroke. The extent and severity of the stroke will be dictated by the location of the blockage. An ischemic CVA in the brainstem is a life-threatening condition.
In contrast, the other 13% of strokes are caused when a blood vessel in the brain ruptures, causing bleeding into the surrounding tissue. Fibrinolytic therapy is contraindicated.

Hemorrhagic stroke tends to worsen over time due to bleeding within the cranium. The bleeding increases intracranial pressure (ICP) and leads to brainstem herniation. One hallmark of a hemorrhagic CVA is a patient who complains of “the worst headache of my life.”

Incidence & Risk Factors
Each year, about 795,000 Americans have either a new or recurrent stroke. Every 40 seconds, someone in this country suffers a stroke. Stroke kills more than 137,000 people each year; every four minutes someone in the U.S. dies from a stroke.

It’s the fourth leading cause of death and the leading cause of disability in adults in the U.S. Approximately 40% of stroke deaths occur in males and 60% in females. Although men have more CVAs, women die of them more often.

Stroke falls under a larger classification of cardiovascular disease. The American Stroke Association (ASA), a division of the American Heart Association, is now heavily focused on stroke prevention and has identified numerous risk factors for stroke, including hypertension, age, elevated serum cholesterol, smoking, diabetes and most notably, elevated body mass index (BMI) and the “obesity epidemic.”

Race can also be a risk factor, with 2010 statistics showing that an estimated 2.5% of Caucasians had a stroke; 3.9% of African Americans; 2.6% of Hispanics and Asians; 5.9% of Native Americans; and 10.6% of Hawaiians and Pacific Islanders. Family history may also indicate a risk factor for stroke, particularly if family members had strokes while they were young.

Atherosclerosis—a systemic disease process in which fatty deposits, inflammation and scar tissue build up within the walls of arteries—is the underlying cause of most cardiovascular disease and stroke. Individuals who develop atherosclerosis tend to develop it in a number of different arteries, both large and small. This is especially true in those arteries that feed the brain, heart, lungs, kidneys and extremities, although the patient may have much more disease in some places than others.

Time Is Brain
Although the call may come in as a stroke, it also may come in as a fall, a seizure, an unconscious person, a person with “difficulty speaking” or any one of several other categorizations.

Every minute of delay to treatment is said to cost a patient 1.9 million brain cells. EMS dispatchers using priority dispatch systems are trained to place stroke symptoms as high-priority calls for which minutes matter. Because they do.

When EMS arrives, patients presenting with stroke can exhibit a variety of signs and symptoms, including paralysis. This numbness or weakness can appear in the face, arms or legs. It is usually on the side of the body opposite the side of the brain damaged by the stroke. It’s called hemiplegia if it involves complete inability to move and hemiparesis if it involves weakness.

Patients may have difficulty swallowing, called dysphagia. Cerebellar strokes can cause ataxia.
Other symptoms include sudden onset of confusion, difficulty speaking or understanding due to aphasia, trouble seeing in one or both eyes, dizziness, or loss of balance or difficulty walking due to ataxia. Some patients will complain of the sudden onset of a severe headache.

As with all patients in the prehospital setting, assessment of the airway, breathing and circulatory status of stroke patients is essential. Administer oxygen if appropriate and obtain a set of vital signs. Gather patient history and medications, paying particular attention to whether the patient is being treated with anticoagulants or antiplatelet drugs. Try to find out the time of onset of symptoms because this is the “start time” from which the three-hour window for fibrinolytic therapy will be calculated. Obtain IV access and a glucometry reading because hypoglycemia can mimic stroke but it’s much simpler to treat in the prehospital setting.

Stroke assessment tools, such as the Cincinnati Prehospital Stroke Scale (see Table 1) or the Los Angeles Prehospital Stroke Screen, were created to increase the accuracy of field evaluations of potential stroke patients.

Use of a stroke assessment tool improves prehospital triage in stroke patients. These evaluations can be performed in less than one minute. With standard training in stroke recognition, paramedics have demonstrated a sensitivity of 61–66% for identifying patients with stroke; however, paramedic sensitivity for identifying stroke patients rose to 86–97% after receiving training in use of a stroke assessment tool. EMS personnel should follow their local service protocols with respect to evaluation tools for stroke and triage in suspected stroke patients to the hospital best able to care for them.

Evaluation of the three factors of facial droop, arm drift and abnormal speech can assist EMS in rapidly identifying potential stroke patients. To evaluate facial paralysis, ask the patient to smile and show their teeth so that you can see whether both sides of the mouth elevate the same way. To evaluate for hemiparesis, ask the patient to hold out both arms palms up and close their eyes for 10 seconds to see if one arm drifts downward or doesn’t move.

To evaluate speech, ask the patient to repeat a common phrase, such as “You can’t teach an old dog new tricks.”

If the left side of the brain is affected, patients often present with right-sided hemiparesis and such language effects as aphasia, dysphasia and apraxia, as well as facial droop and ataxia. Sudden blindness can also be a symptom of stroke.

Patients may experience such changes in level of consciousness as decreasing level of consciousness, cognitive impairment, seizures and even coma. Hypertension may be present. Patients with right-sided strokes may present with left-sided hemiplegia.

Obtain a 12-lead ECG. Although no arrhythmias are specific to stroke, the ECG can identify recent acute myocardial infarction or atrial fibrillation as a potential cause for embolic stroke. In general, the ECG of a stroke patient will be monitored in the hospital for 24 hours to detect potentially life-threatening arrhythmias.

Prehospital Treatment
The goal of stroke care is to minimize brain injury and maximize the patient’s recovery. The Stroke Chain of Survival described by the ASA is similar to the chain of survival for sudden cardiac arrest, linking actions to be taken by patients, family members, and healthcare providers to maximize stroke recovery.

The links are 1) rapid recognition and reaction to stroke warning signs; 2) rapid EMS dispatch; 3) rapid EMS system transport and pre-arrival notification to the receiving facility; and 4) rapid diagnosis and treatment in the hospital.

Target times and goals are recommended by the National Institute of Neurological Disorders and Stroke (NINDS,) which has recommended measurable goals for the evaluation of stroke patients. The hope is to meet these goals in 80% of the patients presenting with acute stroke.
Ischemic stroke patients may be eligible for treatment with fibrinolytics, but the time elapsed between onset of symptoms and initiation of treatment must be within a three-hour window. Selected patients may have slightly more time—up to 4.5 hours. This is why it’s critically important to identify potential stroke patients and promptly transport them to an appropriate facility to avoid loss of the chance of an improved outcome with fibrinolytic therapy.

For EMS, destination decisions are critical, and stroke patients should be directed to an accredited stroke center if one is available. An early alert to the stroke center by EMS can get the stroke team activated while you’re en route, and they can be waiting for your patient when you arrive.

In-Hospital Care
As of Jan. 1, 2011, more than 800 primary stroke centers (PSC) are certified by the Joint Commission in 49 states. The Joint Commission launched the primary stroke center certification program in 2003 in collaboration with the ASA, following the successful model of designated trauma centers. PSCs must have the capability to administer fibrinolytic drugs, written protocols for the administration of these drugs within three hours of symptom onset, a multidisciplinary team, as well as lab and neuroimaging available 24 hours a day, seven days a week.

The Joint Commission has also developed an advanced certification for comprehensive stroke centers, incorporating all the elements of PSC with additional requirements for volume of stroke patients, number of stroke-related procedures performed, research capability, availability of neurosurgery 24 hours a day, seven days a week, availability of advanced neuroimaging studies and interventional procedures, and dedicated neuro-intensive care units for complex stroke patients.

The prevalence of stroke centers has lowered morbidity and mortality from stroke. Studies have documented improvement in one-year survival rates, functional outcomes and quality of life when patients hospitalized for acute stroke receive care in a dedicated unit with a specialized team.

Patients with suspected stroke should be admitted to a stroke unit when one with a multidisciplinary team is available within a reasonable transport time, which is usually defined as one hour. Receiving hospitals should make their stroke care capability known to the community and to EMS providers in particular, and should not hesitate to divert or transfer suspected stroke patients to facilities with dedicated stroke units.

Critical time goals also exist for in-hospital stroke care. The NINDS has recommended immediate general assessment by the stroke team, emergency physician or another expert within 10 minutes of arrival, with an urgent order for a computed tomography (CT) scan without contrast. If CT isn’t available, the patient should be stabilized and rapidly transported to a facility with CT capability. Within 25 minutes of arrival, the stroke team or designee should complete a neurological assessment, and the CT scan should be performed.

The CT scan should be interpreted within 45 minutes of arrival in the emergency department. Patients without contraindication should receive fibrinolytic therapy within one hour of hospital arrival and within three hours of onset of symptoms. The total door-to-admission time should be no more than three hours.

CT imaging will determine the type and location of the stroke. A critical decision point in the hospital assessment of suspected stroke patients is the performance and interpretation of the CT scan. The CT scan may also identify other structural abnormalities in the brain that may be responsible for stroke-like symptoms or that represent contraindications to fibrinolytic therapy. Patients with hemorrhagic stroke shouldn’t receive thrombolytics, aspirin or heparin.
Not all patients with embolic stroke will qualify for fibrinolytic therapy; those with mild symptoms, who are outside of the three-hour window or who do not meet other criteria may not be candidates.

Exclusion criteria include patients with head trauma or stroke within the past three months, symptoms suggestive of subarachnoid hemorrhage, history of previous intracranial hemorrhage, elevated blood pressure, current use of anticoagulants, history of diabetes and previous prior ischemic stroke or demonstration of multilobular infarctions on CT.

Children less than 18 and adults more than 80 years of age generally aren’t candidates. As with all drugs, fibrinolytic drugs have potential adverse effects, including intracranial hemorrhage and other bleeding complications, and the stroke team will perform a risk-to-benefit analysis before administration of these drugs.

Additional imaging studies, such as CT angiography or MRI, may be indicated for some patients. These studies should be rapidly interpreted by physicians with experience in diagnostic neuroradiology. In eligible patients, the performance of these studies shouldn’t delay the administration of fibrinolytic therapy.

Currently, some hospitals don’t have the resources to safely administer fibrinolytics, and this should be made known to the community so patients can be routed to facilities with this capability.

The NINDS trials have reported excellent outcomes in both community and tertiary care hospitals when the hospitals have, and follow, written protocols for stroke care. Institutions with commitment to comprehensive stroke care and rehabilitation have better outcomes.

Patent Foramen Ovale & Stroke
Recent research has identified a relationship between patent foramen ovale (PFO) and stroke. The existence of PFO has been cited as a stroke risk factor. PFO is a defect in the atrial septum that, under certain circumstances, may allow venous blood to pass directly from the right atrium to the left atrium without traveling first to the lungs (right-to-left shunt). This situation is called a paradoxical embolism.

For patients whose cause of stroke is unidentified (cryptogenic stroke), the presence of PFO may be investigated by transesophageal echocardiogram and “bubble study.” This may determine whether the defect exists, as well as its size and whether right-to-left shunting is present. Patients are asked to cough or perform a modified Valsalva maneuver to increase the pressure and cause the PFO to open during the study.

Potential mechanisms of stroke in patients with atrial septal abnormalities include paradoxical embolus from a venous source, direct embolization from thrombi formed within an atrial septal aneurism and the formation of thrombus as a result of atrial arrhythmias.

PFO exists in about 25% of the population; in patients with cryptogenic stroke, the incidence has been found to be approximately 40%.

At present, repair of patent foramen ovale is controversial; numerous devices, such as plugs and patches, have been developed for percutaneous PFO repair by interventional cardiologists. However, the procedure still carries a number of serious risks and the risk-to-benefit ratio of PFO repair remains in controversy.

After the Stroke
About half of all stroke survivors are left with some disability. With an aging population in the U.S., the number of people disabled from stroke is on the rise. The economic burden of stroke requires increasing attention from health officials for more effective healthcare planning and allocation of resources. Informal care is important to maintain stroke survivors within the community and allow them to function up to the highest level of their ability.

Morbidity and rehabilitation: It’s estimated that .27% of gross domestic product is spent on stroke by national health systems. Stroke care accounts for approximately 3% of total healthcare expenditures. In the U.S., it’s estimated that $65.5 billion was spent on stroke in 2008. This figure includes the cost of physicians and other healthcare professionals, acute and long-term care, medications and durable medical equipment, and lost productivity of stroke survivors.

Early and aggressive rehabilitation efforts are essential to ensure stroke survivors can recover as much functionality as possible, and to increase the likelihood of being able to return to being productive members of the community. Post-stroke rehabilitation starts during the inpatient phase and may involve physicians, rehabilitation nurses, physical therapists, occupational therapists, speech/language pathologists and vocational therapists. Outpatient facilities often continue rehabilitation efforts once the patient is released from inpatient status.

The type and degree of disability following stroke depends on the area of the brain that’s damaged and the extent of the damage. In general, stroke causes five types of disability: paralysis or problems controlling movement; sensory disturbances, including pain; problems using or understanding language; problems with thinking and memory; and emotional disturbances.

Sensory disturbance and pain: Stroke survivors may lose their sense of touch, pain, temperature or position, or may experience pain, numbness or paresthesias. They may also initially become incontinent, although permanent incontinence is uncommon. Neuropathic pain may be present due to nervous system damage, and patients with weakened or paralyzed arm muscles often experience moderate to severe pain radiating from the shoulder, often resulting from lack of movement in a joint causing tendons and ligaments to become fixed in one position.

Language problems: At least one-fourth of stroke survivors experience language impairments. The dominant language centers are located on the left side of the brain, known as Broca’s area. Damage to this area causes expressive aphasia which is characterized as difficulty with speaking and writing.

Damage to a language center in the rear of the brain known as the Wernecke’s area results in receptive aphasia, which is characterized as difficulty understanding spoken language and reading. Global aphasia, a more severe form of aphasia, is caused by damage to several areas of the brain involved in language function; these patients are significantly impaired by inability to communicate or understand language.

Thinking and memory problems: Stroke survivors may have dramatically shortened attention spans, short-term memory deficits, or they may lose the ability to perform complex mental tasks. Patients with apraxia find themselves unable to plan the steps involved in a complex task and carry them out in the proper sequence. The extent of brain damage will dictate how well these patients will be able to function independently. Cognitive rehabilitation efforts using computer programs with increasingly difficult tasks have proven helpful in regaining some function.

Emotional disturbances: Stroke survivors often feel fear, anxiety, frustration, anger and a sense of grief for their physical and cognitive losses. Some emotional disturbances are caused by the structural effects of brain damage.

Clinical depression, a sense of hopelessness that disrupts an individual’s ability to function, is commonly experienced by stroke survivors. Signs of clinical depression include sleep disturbances, lethargy, social withdrawal, irritability, fatigue and suicidal thoughts. Treatment may involve counseling and antidepressant medications, although exercise has also been shown to be helpful.

There’s a large role for EMS in community education, stroke awareness and prevention activities. The National Stroke Association’s Act FAST (face, arms, speech and time) program teaches community members to be aware of the signs of stroke, and to act quickly in summoning EMS personnel to the scene for rapid evaluation and transport to an appropriate facility.

EMS personnel can become involved in community awareness programs, teaching the community how to recognize the signs of a stroke and encouraging an immediate 9-1-1 call for help. When 9-1-1 responds to the potential stroke patient, it’s critical to remember that time is brain, and to quickly assess and transport the patient to optimize their chance for the best possible outcome.

Stroke is a costly disease from human, family and societal perspectives. It’s a global epidemic that isn’t limited to a particular socioeconomic group. Thus, reduction of the frequency and severity of stroke by preventive measures is essential to avoid the natural trend of increasing the human, economic and social burden of stroke. JEMS

W. Ann Maggiore, JD, NREMT-P, is an attorney and a paramedic in Albuquerque, N.M. She’s a shareholder in the Albuquerque law firm of Butt, Thornton & Baehr, P.C., where she practices law full-time, defending physicians, police and EMS personnel against lawsuits. She’s a frequent lecturer on EMS legal issues at national conferences and holds a clinical faculty appointment at the University of New Mexico School of Medicine. She’s a member of the JEMS Editorial Board and the 2012 winner of the James O. Page/JEMS Leadership Award. Contact her at [email protected].

>> Office of Communications and Public Liaison. (April 20, 2012.) Transient Ischemic Attack Information Page. In National Institutes of Health National Institute of Neurological Diseases and Disorders.

>> Office of Communications and Public Liaison. (July 26, 2011.) Post Stroke Rehabilitation Fact Sheet. In National Institutes of Health National Institute of Neurological Diseases and Disorders.

>> National Stroke Association. (2012.) A Hole in the Heart: Patent foramen ovale. In National Stroke Association.

>> Roger VL, Go AS, Lloyd-Jones DM, et al. (Dec. 15, 2011.) Heart Disease and Stroke Statistics—2012 Update: A report from the American Heart Association. In Circulation.

>> Di Carlo A. Human and economic burden of stroke. Age Ageing. 2009;38(1):4–5.

>> Joint Commission. (February 2011.) Facts about Primary Stroke Center Certification. In The Joint Commission.

>> Joint Commission. (2012.) Final Certification Eligibility Criteria for Comprehensive Stroke Centers (CSC). In The Joint Commission.
>> American Heart Association. (2011.) Advanced Cardiovascular Life Support. In American Heart Association.—Classroom_UCM_306643_Article.jsp.

>> American Academy of Orthopaedic Surgeons: Nancy Caroline’s Emergency Care in the Streets, Sixth Edition. Jones and Bartlett: Burlington, Mass. Chapter 28: Neurological Emergencies, 2008.

>> Beacock, DJ, Watt VB, Oakley GD, et al. Paradoxical embolism with a patent foramen ovale and atrial septal aneurysm. Eur J Echocardiogr. 2006;7(2):171–174.

>> Lechat, P, Mas JL, Lascault G, et al. Prevalence of PFO in patients with stroke. N Engl J Med. 1988;318(18):1148–1152.

>> DiTullio MR, Sacco RL, Sciacca RR, et al. Patent foramen ovale and the risk of ischemic stroke in a multiethnic population. J Am Coll Cardiol. 2007;49:797–802.

This article originally appeared in June 2012 JEMS as “Stroke of the Clock: ‘Time is brain’ when treating stroke patients.”