Emergency stroke management: intervention on the patient

By Cristiano Antonino On Jan 9, 2023

Stroke is one of the 15 most common emergencies responded to by emergency room professionals, accounting for 2% of all Emergency Numbers calls

Its management is addressed in different ways in different areas of the world, in this article we will see how this happens between EMTs and paramedics in the USA.

What is Stroke

Stroke is a medical condition in which poor blood supply to the brain causes cell death and impaired brain function.

There are two main types of strokes: ischemic stroke and hemorrhagic stroke

Signs and symptoms of a stroke may include the inability to move or feel on one side of the body, problems understanding or speaking, dizziness, or loss of vision on one side.

Symptoms often appear soon after the stroke.

If symptoms last for less than an hour or two, the stroke is a transient ischemic attack (also known as a min-stroke).

A hemorrhagic stroke can also be associated with a severe headache.

The symptoms of a stroke can be permanent.

Long-term complications can include pneumonia and loss of bladder control.

The main risk factor for stroke is high blood pressure.

Other risk factors are tobacco smoking, obesity, high cholesterol, diabetes mellitus, a previous TIA, end stage renal disease and atrial fibrillation.

Hemorrhagic stroke is caused by bleeding directly into the brain or into the space between the membranes of the brain.

Cryptogenic stroke is a stroke without an obvious explanation.

The term cryptogenic means “of unknown origin”.

Approximately 30%-40% of ischemic strokes are cryptogenic.

What is an ischemic stroke?

In an ischemic stroke, the blood supply to a part of the brain is reduced, causing the brain tissue in that area to malfunction.

There are four possible causes:

Thrombosis: Obstruction of a blood vessel by a blood clot that forms locally.
Embolism: Obstruction of a blood vessel by an embolism. An embolus is an unattached mass that travels in the bloodstream and can block blood flow. Possible causes of an embolism include blood clots, cholesterol crystals or plaques, fat globules, gas bubbles, and foreign bodies.
Systemic hypoperfusion: A general decrease in blood supply, such as in shock).
Cerebral venous sinus thrombosis: Presence of a blood clot in the dural venous sinuses, which drain blood from the brain.

What is a hemorrhagic stroke?

Hemorrhagic stroke is due to bleeding.

There are two main types of hemorrhagic stroke:

Intracerebral hemorrhage: Hemorrhage within the brain itself. It occurs when an artery in the brain bursts and floods the surrounding tissue with blood.
Subarachnoid hemorrhage: Hemorrhage that occurs outside the brain but still inside the skull, in the delicate innermost layer of the meninges, three membranes that surround the brain and spinal cord.

How is stroke diagnosed?

Diagnosis is usually based on a physical exam and supported medical images such as a CT scan or MRI.

CT scans can rule out hemorrhage, but not necessarily ischemia, which usually goes undetected on CT scans in the early stages.

Other tests, such as an electrocardiogram (ECG) and blood tests, determine risk factors and rule out other possible causes.

A drop in blood sugar can cause symptoms similar to those of a stroke.

How to prevent stroke

Prevention includes risk factor reductions, surgery to open cerebral arteries in people with problematic carotid narrowings, and warfarin in people with atrial fibrillation.

Doctors may recommend the use of aspirin or statins to prevent strokes.

A stroke or TIA often requires emergency assistance.

If detected within three to four and a half hours, an ischemic stroke can be treated with a drug that breaks up the clot.

Some hemorrhagic strokes benefit from surgery.

Stroke rehabilitation can be used to attempt to regain lost function and ideally takes place in a stroke unit; however, these are not available in most parts of the world.

Signs and symptoms of stroke

Use the letters F.A.S.T. to identify a stroke, following the meaning of the Anglo-Saxon acronym:

Sagging face: Does one side of the person’s face sag or feel numb? Ask the person to smile. If your smile is uneven or lopsided, call emergency number.
Arm Weakness: Is one arm weak or numb? Ask the person to lift both arms. Does an arm slide down? In that case, call the emergency number.
Speech: Is the person slurred or difficult to understand? Is the person unable to speak? Ask the person to repeat a simple sentence. If you have difficulty speaking, call the emergency number.
Time to call Emergengy Number: If the person has any of the symptoms described above, even if the symptoms go away or seem mild, call Emergency Number right away.

Other stroke symptoms

Sudden numbness or weakness in the face, arm or leg, especially on one side of the body.
Sudden confusion, trouble speaking or understanding language
Sudden trouble seeing in one or both eyes
Sudden trouble walking, dizziness, loss of balance or coordination
Sudden, severe headache with no known cause

When to call the Emergency number

Call Emergency Number right away if you get any of the following warning signs of a serious stroke:

Sudden weakness or numbness in the face, arms or legs, especially on one side of the body.
Sudden trouble seeing in one or both eyes
Sudden confusion, difficulty speaking or understanding. Slurred or slurred speech may occur.
Sudden trouble walking, severe dizziness, loss of balance or coordination.
Sudden severe headache for no reason
Difficulty swallowing

How to treat a stroke

Have the stroke suspect lie down while waiting for a rescuer or paramedic to arrive.

Look at the person and lift their chin to open the airways.

Check breathing and pulse. If necessary, perform cardiopulmonary resuscitation (CPR).

If the person is breathing but not conscious, roll them onto their side. (Do not move the person if you suspect a head, neck or back injury).

If the person is conscious, try to reassure and comfort them.

Loosen constricting clothing or jewelry.

If the person has trouble swallowing, try to roll them onto their side.

Do not give the person anything to eat or drink.

How do US first responders and paramedics treat stroke victims?

In a stroke emergency, a first responder or paramedic will likely be the first health care provider to evaluate and treat your condition.

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Emergency responders have a clear set of protocols and procedures for most emergencies, including stroke symptoms.

For all suspected strokes, the first step is a rapid and systematic evaluation of the patient.

For this assessment, most rescuers use the ABCDE approach

ABCDE is the Anglo-Saxon acronym for Airway, Breathing, Circulation, Disability, and Exposure.

The ABCDE approach is applicable in all clinical emergencies for immediate assessment and treatment.

It can be used on the street with or without equipment.

It can also be used in a more advanced form where emergency medical services are available, including emergency rooms, hospitals or intensive care units.

USA, treatment guidelines and resources for medical first responders

The National Association of State EMT Officials (NASEMSO) National Model EMS Clinical Guidelines provides guidelines for the treatment of stroke and transient ischemic attack on page 43.

These guidelines are maintained by NASEMSO to facilitate the creation of clinical guidelines, protocols and operating procedures of state and local EMS systems.

These guidelines are evidence-based or consensus-based and have been formatted for use by emergency room professionals.

The guidelines include the following patient assessment for suspected stroke and transient ischemic attack:

Assessment

Use a validated prehospital stroke scale which may include, but is not limited to:

Facial smile / grimace – ask the patient to smile
Drift of the arms – close the eyes and keep the arms open for a count of 10 seconds.
Phonesis

Relevant historical data includes:

Anamnesis – “last known fact” and source of that information
Assessment of neurological status.

The patient is taking warfarin or other anticoagulant drugs.

Evaluate for the presence of stroke mimics, including:

Hypoglycemia
convulsions
sepsis
Migraine
Intoxication
Treatment and interventions
Determine the time of last hospitalization
Administer oxygen as appropriate with a goal of achieving 94-98% saturation.
If seizure activity is present, treat according to seizure guideline.
Check your blood glucose level
Treat only if glucose is below 60 mg/dL
Acquire a 12-lead electrocardiogram if possible.
Notify the hospital according to the local stroke plan

EMS protocol in the USA for stroke emergencies

Protocols for prehospital seizure management vary according to the type of EMS provider and may also depend on the patient’s symptoms or medical history.

The following are typical guidelines for the management of patients with suspected stroke.

Manage CABs (chest compressions, airways, breathing); provide oxygen if necessary.
Perform prehospital stroke assessment
Establish and record the exact time the patient was last seen normally.

If possible, bring a witness to the hospital; alternatively, record the name and telephone number (preferably mobile) of the witness.

Medical history:

Identify the patient’s current medications, especially blood thinners (aspirin, warfarin, etc.).
Record recent illness, surgery, or trauma, and any history of stroke, medication abuse, migraine, infection, and pregnancy.

Formal stroke assessment tools can increase the sensitivity of paramedics in identifying stroke to 90% or more.