stroke

Oct 11, 2014

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STROKE. Presence Regional EMS System September 2013. “Grandpa had a stroke”. Not too long ago this statement meant death or disastrous disability for patients and families. In the 21 st century medical science has progressed in the understanding of STROKE,

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STROKE Presence Regional EMS System September 2013

“Grandpa had a stroke” • Not too long ago this statement meant death or disastrous disability for patients and families. • In the 21st century medical science has progressed in the understanding of STROKE, prevention and treatment

How big is the problem of STROKE?

Magnitude of the Problem • 795,000 Americans annually suffer a STROKE • 25% die • #3 killer of Americans • 25% of women have strokes before age 65 • #1 cause of long term disability

Stroke in the US • One case of stroke every 45 seconds • Results in devastating disability • 16% institutionalized in nursing homes • 31% assistance with Activities of Daily Living (bathing, dressing eating) • 20% assistance with walking • 30% depressed • Annual cost of $68 billion

New Advancements • The FDA has approved the same clot busting drugs (tPA thrombolytic) used in heart attacks to be used in brain attacks – stroke. • For a variety of reasons, only 2% of stroke victims are treated with thrombolytic medication • Aggressive treatment begins with assessment and intervention at point of patient contact

Before STROKE can be managed • Learn more about what strokes are and how they happen.

A very selfish organ • The brain requires 20 % of the total blood pumped by the heart. • No storage in the brain for either fuel or oxygen • Requires constant supply of oxygen and glucose.

Blood Supply to the Brain • Carotid arteries – anterior neck • Large • Frequently congested with plaque • Can be cleaned out surgically • Vertebral arteries • Pass through cervical vertebrae • Well protected • Not accessible for surgical cleaning

Circle of Willis • Both blood supplies (carotid and vertebral) join on the under surface of the brain. • Fail-safe mechanism in case of a blockage somewhere in circulation • BUT some hard corners in circle where debris can get caught and site of most cerebral aneurysms

What can go wrong??? • Disruption of blood flow to the brain • Plaque – build up of cholesterol in interior of blood vessel • Foreign debris– blood clot bubble of fluid air • Broken vessel

Ischemic STROKE • Blockage of blood flow to brain • Progressive Thrombus -- growing • Plaque deposit – similar to process in heart with coronary artery disease • Cerebral Emboli --Clot from somewhere else -- floating debris • Blood clot • Air bubble • Bubble of amniotic fluid • Bone marrow from a fracture

Hemorrhagic STROKE • Aneurysm – weakened area in artery • Congenital • Younger population younger than 40 years • Complain of “worst headache in my life” • Spontaneous Hypertensive Bleed • Due to BP > 200/100 • Malformed Artery • 50% younger than 30 years

Transient Ischemic Attack • “One Free Spin” • Looks like a stroke but,symptoms improve in 1-24 hours • Temporary disruption of blood flow to the brain –Like Unstable Angina of the brain • Warning sign (15% of strokes have TIA first) • Mimicked by low blood sugar (> blood sugar signs and symptoms go away) • 1 in 20 patients will have a true stroke in 3 months

Can STROKES be prevented? • Modifiable risk factors • High BP • Cigarette smoking • Alcohol intake • Uncontrolled Heart disease • Atrial fibrillation (creates mini clots) • Uncontrolled Diabetes • Carotid congestion

High blood cholesterol • Sedentary lifestyle • Obesity • Seasons– spring and fall • Stress

Risk Factors Unable to Control • Age • Gender • more women than men • Race • African American high risk • Prior strokes • Heredity • Sickle Cell Disease • Causes clot formation and strokes even in children

Signs and Symptoms of STROKE • Hemorrhagic • Sudden and dramatic • Violent explosive headache • “worst headache of my life” • Visual disturbance • Flashing lights, aura • Nausea and vomiting • Neck and back pain • Due to blood in sub-arachnoid space • Sensitivity to light • Weakness on one side • Can present like a migraine headache

Signs and Symptoms of STROKE • Ischemic Stroke • Harder to detect • Weakness in one side • Facial drooping • Numbness and tingling • Language disturbance • Visual disturbance

Left Brain Stroke • Right side paralysis • Speech and language disturbance • Behavioral changes • Swallowing problems

Right Brain Damage • Left side paralysis • Spatial perception • Where your limbs are in relation to the room • Coordination problems • Perception • Recognition of familiar objects

Primary Stroke Care • 180 minute window of time • Time is tissue • The longer the brain is without oxygen and glucose the more brain cells die Goal is to restore blood flow as soon as possible • Treatment is a system beginning with early recognition and continuing through rehabilitation

Goals of Primary STROKE Care • Rapid Recognition of STROKE Symptoms • Rapid access in to the medical system • Assessment • Treatment

Seven D’s of STROKE Care • Detection –of STROKE symptoms • Dispatch– of EMS/ MET Team • Delivery – to a facility prepared to manage STROKE • Door to treatment– rapid diagnosis and decision making • Data– CT Scan • Decision– Ischemic or Hemorrhagic, does the patient meet the criteria to receive thrombolytic drugs • Drug – thrombolytics when appropriate

EMS Has a Critical Role • Educate your community • At first signs of a possible STROKE call EMS • Many families wait to see if the patient gets better • Take patient to the hospital by car • “Don’t guess call EMS!!”

Use a “FAST” STROKE Assessment • Modification of Cincinnati Pre-Hospital Stroke Screen • Face • Arm • Speech • Time of onset

FACE • Look for Facial Droop • Have the patient smile or show his/her teeth • NORMAL Both sides of the face move equally • ABNORMAL One side of the patient’s face droops or does not move

ARMS • Motor Weakness: Look for arm drift by asking the patient to close eyes and lift arms • NORMAL- arms remain extended equally or drift downward equally • ABNORMAL – One arm drifts down compared to the other

Problem with gripping hands • Many elderly have arthritis in hands • Hurts to grip hands • May mimic weakness

SPEECH • Ask the patient to say “You can’t teach an old dog new tricks” • Lots of t’s, k’s and c’s • NORMAL –Phrase repeated clearly and plainly • ABNORMAL – Words slurred, abnormal or unable to speak

Abnormal Speech • Slurring of speech • Unable to think of words • Inappropriate words • Expressive aphasia – unable to speak words • Area of brain where words are created is damaged • Receptive aphasia – unable to understand words • Area where words are interpreted is damaged

TIME OF ONSET • The window of opportunity to effectively treat STROKE is 3 hours (180 minutes) • May be extended to 4 ½ hours in some cases • Need to know “ last known well”. • Difficult when • Patient lives alone • Woke up with symptoms

180 minutes • Don’t think of as 3 hours, but 180 minutes • Time gets eaten up fast • Short scene time • Take transport time into consideration

Assessing the Stroke Patient • Initial Assessment • General Impression • Airway Airway Airway!! • High-flow O2 • Circulation • HIGH PRIORITY TRANSPORT

Focused history and physical exam • Perform thorough neurologic exam. • FAST Stroke Screen • History of • Seizures • Headache • Nausea/vomiting • Neck pain • Obtain baseline set of vitals • Recheck Vital Signs frequently

Priorities of care • Conduct general assessment • Trauma – recent or within last month • Recent seizure • Could be a subdural hematoma • Cardiovascular – on heart medications • Does the patient have atrial fibrillation • Does the patient take blood thinners • Pulse oximetry > 94% • Blood sugar treat if able • Low blood sugars mimic a stroke • Pupils

Position • Protect potentially paralyzed parts

STROKE Check List • Securing A B Cs • Stroke identification • Use of FAST Screen • EKG monitoring if able • Oxygen saturation of > 94% • Management of blood glucose • IV access (ILS/ALS) • Blood specimens obtained (ILS/ALS) • Head of Bed elevated 15 degrees • Early communication with Physician • Urgent transport to CT Scan

Non Contrast CT of HeadWant a normal CT

Acute Hemorrhagic StrokeBlood shows up white

Sub Arachnoid BleedBlood in meninges due to aneurysm

Could this be anything other than a STROKE? • Transient Ischemic Attack • Hypoglycemia

Race Against Time

Goals of STROKE Care 2013 • Standardized assessments, vocabulary, protocols and goals • Door to treatment (with thrombolytics) goal is 60 minutes • Early identification of candidates • Direct transport to CT scan

NINDS** Recommended Goals • Door to doctor 10 minutes • Door to CT completion 25 minutes • Door to CT read 45 minutes • Door to treatment 60 minutes • Access to neurological expertise* 15 minutes • Access to neuro-surgical expertise* 120 minutes • Admit to monitored bed 180 minutes • * by phone or in person • ** National Institute of Neurological Diseases and Stroke

Case Study 1: 6:30 pm • You are called by a family member to assess a patient who is not acting right. • What could be the problem? • Keep an eye on the time you have 180 minutes

What could be the problem? • Seizure • Code • Myocardial infarction • Diabetic reaction • Medication reaction • Anxiety attack • STROKE

6:35 pm • Upon arrival, you find the patient, Mrs. Short, sitting in bed. She is confused, but responds to verbal stimuli. • What assessments do you need?

ABC/FAST • Airway and ventilations are adequate • Regular pulse and good perfusion • Speech is garbled • Unable to move her right arm and leg • Denies chest pain. • BP 195/105, pulse 90, respirations 18

The patient’s daughter reports that her mother felt fine a few minutes ago when suddenly her arm felt funny. She did not lose consciousness and did not have a seizure. • The woman did not complain of a headache, and has no history of seizures, diabetes, chest pain or palpitations.

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COMMENTS

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    The sooner a stroke victim gets to the hospital, the sooner they'll get lifesaving treatment. Stroke survivors have the best outcomes when they receive treatment in 4.5 hours or less. may improve the chances of getting better but only if they get help right away.

  2. Stroke Presentation - American Stroke Association">Preventing Stroke Presentation - American Stroke Association

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  3. Stroke Presentation - American Stroke Association">Preventing Stroke Presentation - American Stroke Association

    • Brain injury from stroke can affect any of the following functions: ability to move, feel, think and behave. • A stroke is a medical emergency. Immediate treatment may minimize the long -term effects of a stroke and even prevent death.

  4. PowerPoint Presentation">PowerPoint Presentation

    A stroke is a "brain attack" that happens when blOOd flow to the brain is blocked or a blOOd vessel ruptures. When this happens brain cells are deprived ot oxygen and begin to die.

  5. Stroke presentation | PPT - SlideShare">Stroke presentation | PPT - SlideShare

    Stroke is a leading cause of death and disability in the United States and worldwide. There are three main types of stroke: ischemic (caused by blockage), hemorrhagic (caused by bleeding), and transient ischemic attacks (TIAs or mini-strokes). Symptoms appear suddenly and without warning, and include numbness, confusion, trouble seeing or speaking.

  6. stroke | PPT - SlideShare">Management of stroke | PPT - SlideShare

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  8. PPT - STROKE PowerPoint Presentation, free download - ID:5390877">PPT - STROKE PowerPoint Presentation, free download - ID:5390877

    Stroke in the US • One case of stroke every 45 seconds • Results in devastating disability • 16% institutionalized in nursing homes • 31% assistance with Activities of Daily Living (bathing, dressing eating) • 20% assistance with walking • 30% depressed • Annual cost of $68 billion

  9. stroke | PPT - SlideShare">Pathophysiology stroke | PPT - SlideShare

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    Check out this medical presentation on Emergency Medical Services (EMS), which is titled "Stroke", to know about stroke, prehospital care, emergency management, and diagnostic approach.