Transcript Stroke June 2016 - Presence Health

STROKE
Presence Covenant Medical Center
June 2016
“Aunt Diane 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
New Advancements
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: (usually due to not
getting treatment in time)
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
Dual blood supplies
Carotid arteries – anterior neck
Vertebral arteries – through
cervical vertebrae
Circle of Willis
Both blood supplies join on the under surface of
the brain.
Fail-safe mechanism
in case of a blockage
somewhere in
circulation
Problems with Circle of Willis
Not a smooth circle
Debris gets caught in corners causing stroke
Aneurysms located
in Circle of Willis
What can go wrong???
Disruption of blood flow to the brain
– Plaque in vessel
– 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
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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
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High BP
Cigarette smoking
Alcohol intake
Uncontrolled Heart disease
Atrial fibrillation
Uncontrolled Diabetes
Carotid congestion
High blood cholesterol
Sedentary lifestyle
Obesity
Seasons
Stress
– More strokes in
fall and spring
Risk Factors Unable to Control
Age
Gender (more women)
Race
– More African American
Prior strokes
Heredity
Sickle Cell Disease
Signs and Symptoms of STROKE
Hemorrhagic
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Sudden and dramatic
Violent explosive headache
Visual disturbance
Nausea and vomiting
Neck and back pain
Sensitivity to light
Weakness on one side
Signs and symptoms similar to undiagnosed
migraine headache
Need CT scan to
differentiate
Signs and Symptoms of STROKE
Ischemic Stroke
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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
Coordination
Perception
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
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
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!!”
In 2015
56% of patients with stroke symptoms arrived at
the Emergency Departments in C-U by private
vehicle not EMS
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Delays in recognizing the stroke symptoms
Delays in getting access into the medical system
Delays in care
Eats up the time on the clock
Value of Calling EMS
Medical professionals at the patient’s door
Early communication with Emergency Physician
Initiation of Treatment Protocols
Stroke team waiting for the patient to arrive
Direct transport to CT scan
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
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General Impression
Airway Airway Airway!!
O2 to 94% oxygen saturation
Circulation
• Pulse
• Blood pressure
– HIGH PRIORITY transport
Focused history and physical exam
– Perform thorough neurologic exam.
• FAST Stroke Screen
• History of
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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
• Recent seizure
• Could it be a hidden head injury (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
Stroke identification
Use of FAST Screen
Securing A B Cs
EKG monitoring if able (12 lead)
Oxygen saturation of > 94%
Management of blood glucose
IV access
Blood specimens obtained if able
Head of Bed elevated 15 degrees
Early communication with Physician
Urgent transport to CT Scan on arrival
What are we looking for in CT Scan?
Non Contrast CT of Head
Acute Hemorrhagic Stroke
Sub Arachnoid Bleed
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
ED Door to treatment (tPA) goal is 60 minutes
Early identification of candidates
Direct transport to CT scan on arrival to ED
NINDS Recommended Goals
Door to doctor
Door to CT completion
Door to CT read
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
Case Study 1: 6:30 pm
You are called by a to assess a patient 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 on the
couch. 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?
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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, institute stroke order sets
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 according to her
husband
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
High priority transport to
a CT for acute STROKE
Case Study 3
Ambulance call 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.
Seems to see you
Looks only to left
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
Case 3 Cont.
Time of onset = unknown
Severe Headache = unknown
Emesis = no
Seizures = no
Blood sugar = OK
Case 3
Time window has closed. Not a candidate for
thrombolytic treatment. Transport to ED for
acute care.
Review
Answer the following questions as a group.
If doing this CE individually, please e-mail your answers to:
[email protected]
Use “June 2016 CE” in subject box.
You will receive an e-mail confirmation. Print this
confirmation for your records, and document the CE in your
PREMSS CE record book.
IDPH site code: 067100E1216
Quiz
What are the 2 general types of stroke?
– 1.
– 2.
What condition is equivalent to “angina” of the brain?
– 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?
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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
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Cigarette smoking
Sedentary lifestyle
Obesity
Seasons
Stress
Alcohol intake
High blood cholesterol
Carotid Congestion
Uncontrolled diabetes
Atrial fibrillation
Uncontrolled heart disease
7-8
– Age
– Gender
– Race
– 9.
– 10.
– 11.
– 12.
prior strokes
heredity
Sickle cell disease
Face
Arm
Speech
Last known well
13. Clot busting drugs, thrombolytics, tPA
14. 3 hours (180 minutes)
Race Against Time