NREMT NCCR Content Covered

Broad Topic: Cardiology

Subtopic: Stroke

Available NCCR CME: 1.5 Hours

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LESSON OBJECTIVES

• Identify the options for out-of-hospital stroke assessment tools
• Explain oxygen administration during a stroke emergency
• Discuss the importance of knowing a timeline of stroke events
• Identify patients needing rapid transport to the most appropriate stroke hospital
• Discuss the importance of starting the fibrinolytics check sheet

LESSON CONTENT

1. Stroke
   1. Definitive care for the stroke patient is delivered at a hospital that specializes in the management for stroke patients. Optimal out-of-hospital care for the stroke patient is recognition and rapid transport.
   2. Evaluate blood glucose levels
      1. Treat only if hypoglycemic, in accordance with local protocol
      2. Hyperglycemia is associated with a poor clinical outcome
      3. Hypoglycemia may mimic stroke
   3. Pediatric strokes, while rare, do happen
2. Out-of-hospital stroke assessment tools
   1. Specific tools used will be determined by local protocol
      1. Examples include
         1. Cincinnati Prehospital Stroke Scale, 1999
         2. Los Angeles Prehospital Stroke Screen-LAPSS, 2000
         3. Miami Emergency Neurologic Deficit Checklist, 2001
   2. Signs and Symptoms assessed by these tools
      1. Symmetry of the face
      2. Weakness of extremities
      3. Speech difficulties
      4. Coordination
   3. Communicate assessment findings to the hospital while en route
      1. Allows for early activation of the stroke team

3. Management of stroke patients
   1. Provide supportive care
   2. Maintain an SpO₂ of 94% to 99% to avoid oxygen toxicity
      1. Consider 2 L/min O₂ via nasal cannula instead of O₂ via high flow mask
         1. High flow oxygen decreases cerebral blood flow
         2. High levels of oxygen produce free-radicals
            1. May cause cerebral edema and vasodilation

3. Consider obtaining IV or IO access
4. Rapid transport to an appropriate receiving facility

4. Importance of accurately determining the time that the patient was last seen normal
   1. Some strokes are treated with fibrinolytics (tPA) which has a limited therapeutic window
   2. Some strokes are treated with endovascular interventions
      1. Angioplasty and stenting
      2. Mechanical clot disruption
      3. Clot extraction
5. Fibrinolytics check sheet should be started during transport when patient condition permits. Use is determined by local protocol
   1. Expedites the care at receiving hospital
   2. May be the only time the information can be gathered if the patient’s condition deteriorates

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