Lesson Guide and Assessment For Learning (A4L) and Summary Stroke

Instructions to the learner: Without using any references, quickly answer the questions in the “Assessment For Learning (A4L)” section below. Then, use the resources listed in the “Lesson Sequence” section to help you fill in any missing answers or verify items where you were uncertain. Finally, complete these same questions again at the end of this document as another assessment of your learning. There is a section at the end of this document with suggested answers and notes for the A4L questions—-use this as a guide. The A4L questions are for your use—-your learning is assessed in the classroom or proctored testing environment.

If you are a BCFPD member and desire CEUs for this learning activity, you may schedule a proctored written learning assessment at Fire District Headquarters by contacting Bryant Gladney at . This activity is worth 1 CEU in Medical for BLS and 1 CEU in Medical for ALS.

If you want a digital copy of this document, go to or scan

Objectives / Learning Targets: The learner who successfully completes this course will be able to demonstrate understanding of the following concepts:

•General pathophysiology of Stroke.

•Field assessment and management of stroke.

Answer these questions without using a reference to test your prior knowledge (these questions are the “Assessment For Learning (A4L)”.

  1. Explain the two major types of Stroke and state which is more common.
  1. How can you differentiate between these two types of Stroke in the field?
  1. How can these two types of Stroke be differentiated in the hospital?
  1. Why is it important to determine which type of Stroke is happening to a patient?
  1. Name a very common and easily testable mimic of Stroke.
  1. List the three parts of the Stroke assessment in the Cincinnati Pre-hospital Stroke Scale (CPSS).
  1. Describe how you would perform the CPSS.
  1. Explain the purpose of a “Stroke Alert”.
  1. Why is the “last known well” time so important to the Stroke Team / hospital caregivers for the patient?
  1. Why is urgent transport important for Stroke Alert patients?
  1. What does “TIA” stand for?
  1. What is a TIA?
  1. How can you differentiate a Stroke from a TIA in the field?
  1. List three key risk factors for Stroke.
  1. Explain how Stroke patients are particularly at risk for airway issues.

Lesson Sequence / Steps

Step One: Complete the A4L to determine what material you already understand.

Step Two: Review the summary and links below. Go back to the A4L and fill in any gaps in your understanding.

Step Three: (for students in initial EMT or Paramedic classes): Review your textbook materials and take the associated quizzes in the publisher’s online package.

•EMT Chapter 15 (AAOS Emerg. Care and Transport. of the Sick and Injured)

•Paramedic Chapter 2.11(Beebe & Myers Professional Paramedic) and ACLS textbook page 30 and Acute Stroke Case page 130.

From AAOS Text Chapter 15’s Stroke section / Summary with additional original notes by BCFPD EMS Education:

•The cerebrum, the largest part of the brain, is divided into right and left hemispheres, each controlling the opposite side of the body.

•Different parts of the brain control different functions. The front part of the cerebrum controls emotion and thought; the middle part controls touch and movement; and the back part of the cerebrum is involved with vision. In most people, speech is controlled on the left side of the brain, near the middle of the cerebrum.

•Many different disorders can cause brain or other neurologic symptoms. As a general rule, if the problem is primarily in the brain, only part of the brain will be affected. If the problem is in the heart or lungs, the whole brain will be affected.

•Stroke is a significant brain disorder because it is common and potentially treatable.

•Seizures and altered mental status are also common, and you must learn to recognize the signs and symptoms of each condition.

•Other causes of neurologic dysfunction include coma, infections, and tumors.

•Strokes occur when part of the blood flow to the brain is suddenly cut off; within minutes, brain cells begin to die.

oIschemic strokes comprise most (80% or more) of stroke causes.

oHemorrhagic strokes comprise the remainder.

oBoth are identical on assessment in the field. A CT (“CAT”) scan is needed to detect the “bleed”. Time is brain cells—-Stroke Alerts save brains.

•Signs and symptoms of stroke include receptive and/or expressive aphasia, slurred speech (dysarthria), muscle weakness or numbness on one side of the body, facial droop, and sometimes high blood pressure.

•Dysphasia can be receptive or expressive. Receptive dysphasia is difficulty in comprehension, whilst expressive dysphasia is difficulty in putting words together to make meaning. In reality there is usually considerable overlap of these conditions but a person who has pure dysarthria without dysphasia would be able to read and write as normal and to make meaningful gestures, provided that the necessary motor pathways are intact.

•Strictly speaking, the words anarthria and aphasia mean a total absence of ability to form speech or language but they are often used when dysarthria and dysphasia would be more correct.

•Hemiparesis is weakness on one side of the body. It is less severe than hemiplegia — the total paralysis of the arm, leg, and trunk on one side of the body.

•The elevated BP is usually not treated in the field (prior to CT evaluation).

•You should always perform at least three neurologic tests on patients you suspect of having a stroke: testing speech, facial movement, and arm movement.

oThe Cincinnati Pre-hospital Stroke Scale (CPSS) is highly predictive and is considered the standard of care in our system. Patients with 1 of these 3 findings as a new event have a 72% probability of an ischemic stroke. If all 3 findings are present the probability of an acute stroke is more than 85%

oTest for facial droop, slurred speech and one-sided weakness and then rule out hypoglycemia (common mimic).

•In a transient ischemic attack (TIA), normal body processes break up the blood clot, restoring blood flow and ending symptoms in less than 24 hours. However, patients experiencing a TIA are at high risk for a completed stroke.

oTIA cannot be differentiated from Stroke in the field—-patients present in the same manner.

•Because current treatments for stroke must be administered within 1 to 3 hours (and preferably within 2 hours) of the onset of symptoms to be most effective, you should provide prompt transport.

oSome treatment windows are larger depending on system capability. Stroke Centers save brains.

•Always notify the hospital as soon as possible that you are bringing in a patient with a possible stroke, so that staff there can prepare to test and treat the patient without delay.

oThe goal is to move to the CT Scanner as soon as possible. Prehospital care can reduce the time from arrival at the ER until the CT is performed. Patient registration, IV, blood samples, 12-lead EKG, serial vitals / CPSS / GCS.

•Watch this video screencast on Stroke:

•

•Here are some OPTIONAL but very informative links on Stroke:

!

!

Answer the same questions again to test your current knowledge. If you are applying for CEUs for this learning activity, you can anticipate that the material contained in these questions is key information that will be assessed on the proctored written learning assessment that you will take.

  1. Explain the two major types of Stroke and state which is more common.
  1. How can you differentiate between these two types of Stroke in the field?
  1. How can these two types of Stroke be differentiated in the hospital?
  1. Why is it important to determine which type of Stroke is happening to a patient?
  1. Name a very common and easily testable mimic of Stroke.
  1. List the three parts of the Stroke assessment in the Cincinnati Pre-hospital Stroke Scale (CPSS).
  1. Describe how you would perform the CPSS.
  1. Explain the purpose of a “Stroke Alert”.
  1. Why is the “last known well” time so important to the Stroke Team / hospital caregivers for the patient?
  1. Why is urgent transport important for Stroke Alert patients?
  1. What does “TIA” stand for?
  1. What is a TIA?
  1. How can you differentiate a Stroke from a TIA in the field?
  1. List three key risk factors for Stroke.
  1. Explain how Stroke patients are particularly at risk for airway issues.

Suggested Answers: STROKE

  1. Explain the two major types of Stroke and state which is more common.

Ischemic (obstructive) strokes comprise about 80-85% of strokes while hemorrhagic strokes make up the rest.

  1. How can you differentiate between these two types of Stroke in the field?you can’t
  1. How can these two types of Stroke be differentiated in the hospital?CT scan (CAT scan)
  1. Why is it important to determine which type of Stroke is happening to a patient?treatment for ischemic strokes may involve “clot buster” medications which would be harmful in hemorrhagic strokes
  1. Name a very common and easily testable mimic of Stroke.hypoglycemia
  1. List the three parts of the Stroke assessment in the Cincinnati Pre-hospital Stroke Scale (CPSS). slurred speech, facial droop, one-sided weakness
  1. Describe how you would perform the CPSS. have the patient speak, observe their facial symmetry and ask them to hold both arms in front of them while closing their eyes
  1. Explain the purpose of a “Stroke Alert”. to speed the patient’s access to CT scan for definitive diagnosis as well as to mobilize acute / critical care resources to rapidly address the stroke (“time is brain cells”)
  2. Why is the “last known well” time so important to the Stroke Team / hospital caregivers for the patient? stroke treatments are based, in part, on the length of time since the onset of symptoms
  1. Why is urgent transport important for Stroke Alert patients? “Time is Brain”
  1. What does “TIA” stand for? Transient Ischemic Attack
  1. What is a TIA? a temporary disruption to brain perfusion that appears to be a stroke but resolves within a few hours (< 24 hours)
  1. How can you differentiate a Stroke from a TIA in the field? you can’t
  1. List three key risk factors for Stroke. atrial fibrillation, hypertension, smoking, plus other cardiovascular disease risk factors
  1. Explain how Stroke patients are particularly at risk for airway issues.Facial muscle paralysis tends to produce poorly chewed food or food that is swallowed before the patient intended. General muscle weakness or paralysis in the face, jaw, throat tend to make upper airway obstruction more likely.

BCFPD EMS Education EMT Education Program