UMD



Neurological Emergencies: Stroke

by: Scott P. Whetsell

MFRI Field Instructor

Revised - November 18, 2019

Neurological Emergencies: Stroke

LESSON PLAN

|TOPIC |Neurological Emergencies: Stroke |

|TIME FRAME |3 hours |

|LEVEL OF INSTRUCTION |Cognitive (1.5 hours), Psychomotor (1.5 hours) |

| | |

|LEARNING OBJECTIVES |Following the lecture, the student will have a greater understanding of the causes, identification, management and |

| |recovery of a stroke patient. |

| |Following demonstration, the student will be able to assess and identify a probable stroke patient. |

|RESOURCES / |PowerPoint Presentation |

|MATERIALS NEEDED |Maryland Medical Protocols for Prehospital Providers |

| |Simulated patient(s) – students may be used as simulated patients. |

| | |

|PRE-REQUISTIES |None |

|REFERENCES |American Stroke Association |

| |MIEMSS |

| |National Institute of Health |

| |Western Maryland Health System Stroke Center |

| |The Joint Commission |

| |Wikipedia |

| | |

|LESSON SUMMARY |This lesson is designed to provide knowledge in the identification, management, and recovery of strokes. |

|ASSIGNMENTS |None. |

|SPECIAL NOTE |Slide 26 lists examples of MIEMSS Designated Stroke Centers. The instructor should update the examples according to |

| |the stroke centers in their respective areas. |

| | |

| |Slide 27 lists examples of Nationally Recognized Stroke Centers by The Joint Commission. The instructor should |

| |consider looking up Comprehensive Stroke Centers outside of Maryland that may be close to their respective areas. |

LESSON OUTLINE

INTRODUCTION

a. Instructor Name

b. We are going to discussstrokes.

MOTIVATOR

Strokes pose significant threat to survivability of our patients. Being able to identify, prioritize, and treat strokes can help decrease morbidity and mortality in these patients.

OBJECTIVES

1. Following the lecture, the student will have a greater understanding of the causes, identification, management and recovery of a stroke patient.

2. Following demonstration, the student will be able to assess and identify a probable stroke patient.

OVERVIEW

In order to meet these objectives, we will:

- discuss stroke facts.

- discuss the types of strokes.

- discuss assessment of a stroke patient.

- discuss pertinent Maryland Medical Protocols for Prehospital Providers.

- divide into groups of three to five members and practice the following practical skills:

▪ Medical Assessment

▪ Cincinnati Prehospital Stroke Scale

▪ Posterior Cerebellar Assessment

▪ Los Angeles Motor Scale

▪ Identify closest Stroke Centers for the student’s run area

BODY

I. Introduction / General Stroke Facts

II. Types of Strokes

a. Ischemic

i. Thrombosis

ii. Embolism

iii. Systemic hypoperfusion (shock)

iv. Cerebral Venous Sinus Thrombosis

b. Hemorrhagic

i. Intracerebral

ii. Subarachnoid

c. CVA vs TIA

d. Risk Factors

i. Controllable

1. Hypertension

2. Hyperlipidemia

3. Diabetes

4. Tobacco

5. Alcohol

6. Physical Inactivity

7. Obesity

8. Heart Disease

9. Atrial Fibrillation

10. Pregnancy

ii. Non-controllable

1. Age

2. Gender

3. Race

4. Family History and Genetics

5. History of Stroke or TIA

III. Signs and Symptoms

a. Generalized

i. Hemiparesis

ii. Aphasia

iii. Headache

iv. Confusion or Altered Mental Status

v. Dizziness

vi. Numbness, weakness, or paralysis

vii. Loss of bladder or bowel control

viii. Impaired vision or loss of vision in one eye

ix. Hypertension

x. Dyspnea

xi. Nausea or vomiting

xii. Seizures

xiii. Unequal pupils

xiv. Unconsciousness

b. Ischemic Strokes

i. Left Hemisphere Stroke

1. Speech problems

2. Problems with comprehension

3. Left gaze preference

4. Weakness or numbness on right side

ii. Right Hemisphere Stroke

1. Dysarthria

2. Left sided neglect

3. Right gaze preference

4. Weakness or numbness on left side

iii. Brain Stem Stroke

1. Nausea, vomiting, or vertigo

2. Speech problems

3. Dysphasia

4. Abnormal eye movements

5. Decreased consciousness

6. Crossed findings

iv. Silent Stroke

1. Asymptomatic

2. Statistically significant

3. Only detected by MRI

c. Hemorrhagic Strokes

i. Intracerebral

1. Nausea and vomiting

2. Headache

3. One sided weakness

4. Decreased consciousness

ii. Subarachnoid

1. Worst headache of life

2. Intolerance to light

3. Neck stiffness or pain

d. Common Mimics (Differential Diagnoses)

i. Alcohol intoxication

ii. Cerebral infections

iii. Drug overdose / toxicity

iv. Epidural hematoma

v. Hypoglycemia

vi. Metabolic disorders

vii. Migraines

viii. Neuropathies (Bell’s Palsy)

ix. Seizure and post seizure (Todd’s Paralysis)

x. Brain tumors

xi. Hypertensive encephalopathy

e. Early Recognition

i. BE-FAST

IV. Patient Assessment

a. Scene size-up

i. BSI

ii. Scene safety

iii. Mechanism of injury / Nature of illness

iv. Number of patients

v. Additional resources

vi. Consider C-spine

b. Primary assessment

i. General impression

ii. Check responsiveness

iii. ABC / CAB

I. Airway

II. Breathing

III. Circulation

iv. Disability

v. Exposure

vi. Patient priority / transport decision

c. Secondary Assessment

i. Focused assessment

ii. Obtain vital signs

1. Obtain glucometer reading

iii. Stroke Assessments

1. Cincinnati Prehospital Stroke Scale

2. Posterior Cerebellar Assessment

3. Los Angeles Motor Scale

d. Treatment Protocols

i. No aspirin

ii. Transport in semi-fowlers position at 30 degrees

iii. Acute stroke patient is Priority 1

iv. Transport to nearest stroke center

v. Consider aeromedical transport

vi. Obtain contact information of person with patient’s medical history

vii. Provide oxygen by NC unless respiratory distress

viii. Treat hypoglycemia if present

ix. ALS interventions

1. IV access with LR

a. Consult for hypotensive patient

2. Consider obtaining blood sample

3. Do not treat hypertension

x. Pediatric patients

1. Uncommon

2. Causes

a. Congenital heart defects

b. Infections

c. Brain injury

d. Blood disorders

3. Most likely in infants

4. Consult pediatric base station – transport to pediatric trauma center

a. Johns Hopkins Children’s Center, Baltimore

b. Children’s National Medical Center, DC

e. Transport

i. Initiate transport

1. “STROKE ALERT”

ii. Reassessment

f. Hospital treatment options for acute ischemic stroke

i. IV-tPA

ii. Intra-arterial thrombolysis

iii. Mechanical thrombectomy

V. Stroke centers

a. Acute stroke ready

i. Acute stroke team available 24/7 within 15 minutes

ii. No designated beds

iii. Neurological services available within 3 hours

iv. Telemedicine available within 20 minutes

v. IV thrombolytics and transfer of patient to PSC or CSC

b. Primary Stroke Center

i. Acute stroke team available 24/7 within 15 minutes

ii. Stroke unit or designated beds for acute stroke patients

iii. Neurological services available within 2 hours or 24/7 on site

iv. Telemedicine available

v. IV thrombolytics and medical management of stroke

c. Comprehensive Stroke Center

i. Acute stroke team available 24/7 within 15 minutes

ii. Dedicated neuro intensive care beds with on-side neurointensivist 24/7

iii. 24/7 availability of Neurointerventionist, Neuroradiologist, Neurologist, Neurosurgeon

iv. Telemedicine available

v. IV thrombolytics, full range neurological procedures, medical management of stroke

d. Designated Stroke Centers

i. Acute Stroke Ready

ii. Primary Stroke Centers

iii. Comprehensive Stroke Centers

iv. Nationally Recognized Stroke Centers

VI. Recovery

a. Rehab

i. Physical

ii. Occupational

iii. Speech-language

iv. Patient / family education

v. Support groups

b. Reducing risks of additional strokes

i. Healthy blood pressure

ii. Healthy blood sugar and cholesterol

iii. Address other health issues including AFib and sleep apnea

iv. Adopt healthy lifestyle habits

v. Limit or eliminate alcohol, tobacco, and vaping

vi. Maintenance medications

VII. Skills Practice

a. Demonstrate the medical assessment, stroke assessment, and treatment procedures.

b. Divide into groups of three to six.

c. Groups should practice the medical assessment, stroke assessment, and treatment procedures.

i. Ensure all team members get a chance to practice.

ii. Instructor should provide feedback and guidance.

CONCLUSION

I. Summary

II. Review

EVALUATIONS

Students shall correctly perform the skills in a timely manner without input from an instructor. An in-class quiz may be administered at the discretion of the instructor. Emphasis should be placed on observed areas of weaknesses in the knowledge base of the target audience.

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