Transcript Stroke December 2014

STROKE in the
st
21
Century
Presence Regional EMS System
December 2014
“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 women
 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 $58 billion

21st Century Management
The FDA has approved the same clot
busting drugs (tPA thrombolytic) used in
heart attacks to be used in brain attacks –
stroke.
 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 fat for storage
in the brain
 Requires constant
supply of oxygen and glucose.

Blood Supply to the Brain
Two pathways to get blood to brain
 Carotid arteries – anterior neck
 Vertebral arteries – through cervical
vertebrae

Good News + Bad News 
Carotid Arteries
Large +
 Anterior +
 Frequently occluded with plaque  Easily cleaned out with carotid
endarterectomy +

Good News + Bad News 
Vertebral Arteries
Smaller  Posterior  Imbedded in vertebrae of cervical spine +
 Not accessible for cleaning out –
 Stents available for occlusions +

Circle of Willis
Both blood supplies join on the under
surface of the brain.
 Shared circulation
 Fail-safe mechanism
in case of a blockage
somewhere in
circulation

Problem with Circle of Willis
Not a smooth circle
 Floating debris can get
caught in corners
 Site of most cerebral
aneurysms

What can go wrong???

Disruption of blood flow to the brain
Plaque
 Foreign debris
 Broken vessel

Ischemic STROKE

Progressive Thrombus


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)
 “worst headache in my life”


Spontaneous Hypertensive Bleed


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 --Angina of the brain
 Warning sign
 Mimicked by low blood sugar
 30% of patients will have a true stroke in 30
days

Can STROKES be prevented?

Modifiable risk factors
High BP
 Cigarette smoking
 Alcohol intake
 Uncontrolled Heart disease
 Atrial fibrillation
 Uncontrolled Diabetes
 Carotid congestion

High blood cholesterol
 Sedentary lifestyle
 Obesity
 Stress

Risk Factors Unable to Control
Age
 Gender – more female
 Race – more African American
 Prior strokes
 Heredity
 Sickle Cell Disease
 Seasons --more strokes in spring and fall

Signs and Symptoms of
STROKE

Hemorrhagic
Sudden and dramatic
 Violent explosive headache
 Visual disturbance
 Nausea and vomiting
 Neck and back pain
 Sensitivity to light
 Weakness on one side


Same signs and symptoms as new onset
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 Damage
Right side paralysis
 Speech and language disturbance
 Behavioral changes
 Swallowing problems

Right Brain Damage
Left side paralysis
 Spatial perception – able to locate items in
space
 Coordination
 Perception – what is that thing?

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 system
 Assessment
 Treatment

Seven D’s of STROKE Care
National Institute of Neurological Diseases and Stroke
Detection –of STROKE symptoms
 Dispatch– of EMS
 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

Drug – thrombolytic when appropriate
EMS Has a Critical Role
Educate your community
 At first signs of a possible STROKE call
EMS
 “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

SPEECH
Ask the patient to say “You can’t teach an
old dog new tricks”
 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
 Receptive aphasia – unable to understand
words

TIME OF ONSET

The window of opportunity to effectively
treat STROKE is 3 hours (180 minutes)

May be extended to 4 ½ hours
Need to know “ last known well”.
 Difficult when

Patient lives alone
 Woke up with symptoms

Assessing the Stroke Patient

Initial Assessment
General Impression – level of consciousness
 Airway Airway Airway!!
 High-flow O2
 Circulation
 HIGH PRIORITY!


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 medical assessment

Trauma – recent or within last month



Cardiovascular – on heart medications




Does the patient have atrial fibrillation
Does the patient take blood thinners
Pulse oximetry > 94%
Blood sugar treat if able


Recent seizure
Could be a subdural hematoma?
Low blood sugars mimic a stroke
Pupils
Position

Protect potentially paralyzed parts
Positioning
When possible keep supine
 Head elevated 30 degrees
 If put on side, put paralyzed side down
 Able to move and reach with unaffected
arm
 Keep affected arm slightly forward so that
weight is not on it

STROKE Check List











Stroke identification
Use of FAST Screen
Securing A B Cs
EKG monitoring if able
Oxygen saturation of > 94%
Management of blood glucose
IV access
Blood specimens obtained if able
Head of Bed elevated 30 degrees
Early communication with Physician
Urgent transport to CT Scan
Non Contrast CT of Head
No dye
 Normal
 No bleeds

Acute Hemorrhagic Stroke

Blood shows up white
Sub Arachnoid Bleed
Bleed between dura mater
and arachnoid mater

Could this be anything other
than a STROKE?

Transient Ischemic Attack

Hypoglycemia
Race Against Time
Goals of STROKE Care
21st Century

Standardized assessments, vocabulary,
protocols and goals
Everyone calls it the same thing
 Everyone does the same FAST assessment

Door of the ED to treatment goal is 60
minutes
 Early identification of candidates who
benefit from tPA
 Direct transport to CT scan

NINDS Recommended Goals
National Institute of Neurological Diseases and Stroke

ED Door to doctor
ED Door to CT completion
ED Door to CT read
ED Door to treatment
Access to neurological expertise*
Access to neuro-surgical expertise*
Admit to monitored bed

* by phone or in person






10 minutes
25 minutes
45 minutes
60 minutes
15 minutes
120 minutes
180 minutes
So

Get to an Emergency Department that has
a plan to deal with stroke.
2015 EMS Protocols

By-pass a non-designated hospital to
transport patient to a hospital designated
by Illinois as capable of managing stroke
Comprehensive Stroke Center
 Primary Stroke Center
 Acute Stroke Ready


If receiving hospital does not have a
working CT scanner – bypass for one that
does
Case Study 1: 6:30 pm

You are called by a family member to
assess a patient in who is not acting right.

What could be the problem?
What could be the problem?
Seizure
 Code
 Myocardial infarction
 Diabetic reaction
 Medication reaction
 Anxiety attack
 STROKE

6:35 pm

Upon arrival, you find a woman sitting in
bed. She is confused, but responds to
verbal stimuli.

What assessments do you need?
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.
6:43 pm

This patient, Mrs. Short, is 65 years old.
She has left sided facial drooping and right
arm and leg weakness. She can move the
right arm and leg slightly, but with great
difficulty. Her speech is slurred. All of
these signs and symptoms are new in the
last 10 minutes.
FAST

How does Mrs. Short fare on the FAST
Screen?
Face
 Arm
 Speech
 Time

Case 1 cont
Face -- left sided facial drooping
 Arm – right arm and leg weakness
 Speech – speech is slurred
 Time last known well -- unsure

HIGH PRIORITY
Determine precise time of onset of signs
and symptoms.
 If thrombolytic therapy is to be considered,
its infusion must begin within 3 hours of
the onset of symptoms.


Does Mrs. Short meet the criteria so far to
be on the Primary STROKE Care track to
receive thrombolytics (tPA)?

YES, transport immediately to ED
designated to treat stroke.
Case Study 2: 0635 Hours
70 year-old woman, Mrs. Black
 Awake with slight weakness and tingling
in her left side.
 Speech is hesitant and slightly slurred
 Vision seems to be normal
 No facial drooping
 Good eye contact

Case 2 cont.
Symptoms began 0615 per patient
 Speech was fine before that (spoke with
her husband at 066 speech clear)
 Blood sugar 50 mg/dl
 No emesis or seizure
 BP 150/90, Pulse 80, Respirations 16
 O2 sat 92%

FAST

How does Mrs. Black fare
on the FAST Screen?
Face
Arm
Speech
Time
Case 2 cont
Face -- no drooping
 Arm – slight weakness and tingling
 Speech -- Speech is hesitant and slightly
slurred
 Time known well -- 20 minutes ago

Case 2
Treat the blood sugar and reassess the
need for additional treatment
 Watch for choking if oral glucose
given!
 High priority transport to
a CT for acute STROKE

Case Study 3
Called to a home at 1400 hours
 80 year-old man, Mr. Schmidt
 Daughter found him 15 minutes ago
 Unknown down time
 Awake
 Drooping left side of face
 No movement of right arm and leg
 Speech too slurred to understand

Case 3 cont.
Blood sugar 200 mg/dl
 No evidence of seizure or emesis
 BP 180/100, pulse 72, respirations 15

FAST

How does Mr. Schmidt fare
on the FAST Screen?
Face
Arm
Speech
Time
Case 3 cont
Face --Drooping left side of face
 Arm – No movement of right arm and leg
 Speech – Speech too slurred to
understand
 Time known well – unknown, daughter
found him 15 minutes ago, but she had not
had contact with him since yesterday.
(She checks on him every day on her way
to work)

Case 3 Cont.
Time of onset = unknown
 Severe Headache = unknown
 Emesis = no
 Seizures = no
 Blood sugar = High OK

Case 3

Time window has closed. Not a candidate
for thrombolytic treatment. Transport to
ED for acute care.
Review
If doing this CE individually, please e-mail
your answers to:
[email protected]
 Use “December 2014 CE” in subject box.
 IDPH site code: 06-7100-E-1214
 You will receive an e-mail confirmation.
Print this confirmation for your records and
document in your PREMSS CE record
book.

Quiz

What are the 2 general types of stroke?



What condition is equivalent to “angina” of the
brain?


1.
2.
3.
What are 3 risk factors for stroke that can be
modified?



4.
5.
6.

What are 2 risk factors for stroke that cannot be
modified?



7.
8.
What are you measuring in a FAST Stroke
Screen?




9.
10.
11.
12.

In the 21st century, some patients suffering
from STROKE can be treated using what
type of medication?


13.
What is the time deadline that must be met
in order to use the aggressive medication
in the question above?

14.
Answers
1. Hemorrhagic stroke
2. Ischemic stroke
3. TIA (transient ischemic attack)
4. – 6. High BP






Cigarette smoking
Sedentary lifestyle
Obesity
Seasons
Stress
Alcohol intake
High blood cholesterol
Carotid Congestion
Uncontrolled diabetes
Atrial fibrillation
Uncontrolled heart disease
7.- 8.



9.
10.
11.
12.
Age
Gender
Race
prior strokes
heredity
Sickle cell disease
Face
Arm
Speech
Last known well
13. Clot busting drugs, thrombolytics, tPA
14. 3 hours (180 minutes)