Transcript diabetes symptom information

STROKE:
“BRAIN ATTACK”
Tom Beers
EMS Coordinator
Huron Hospital & Trauma Center
OBJECTIVES
• List at least 2 conditions that can
present with focal neurological signs
or mimic stroke.
• Recognize principles of prehospital
care.
• Identify the 3 components of the
Cincinnati Prehospital Stroke Scale.
OBJECTIVES
• Identify the time frame in which an
ischemic stroke patient can be
treated with fibrinolytic therapy.
• Appreciate the importance of rapid
transport and prearrival notification
of the ED.
• Documents stroke assessment
accurately on the run sheet.
STATISTICS
Stroke Facts:
• Each year, about 700,000 Americans suffer
a new or recurrent stroke.
- 500,000 are 1st attacks; 200,000 are
recurrent attacks.
• This means that a stroke occurs every 45
seconds.
• Stroke kills over 150,000 people/year.
• Stroke accounts for 1 of every 16 deaths.
• Stroke is the #3 cause of death behind
heart diseases and cancer.
STATISTICS
Stroke Facts:
• About every 3-4 minutes, someone
dies of a stroke.
• Of every 5 people who die from a
stroke, 2 are men and 3 are
women.
• For every 100,000 people in the US
(2004), about 50 people died of a
stroke.
STATISTICS
Stroke Facts:
• The stroke death rates/100,000
population for specific groups were:
- 48 for white males.
- 47 for white females.
- 74 for black males.
- 65 for black females.
STATISTICS
Stroke Facts:
• And finally, in 2007, Americans will
pay about $63 billion for strokerelated medical costs and disability!
STROKE/BRAIN ATTACK
• Sudden focal neurological deficit.
• Occurs when a blood vessel bringing
O2 and nutrients to the brain either
bursts or becomes clogged (blood clot
or other particle).
• Brain doesn’t get blood flow.
• No O2 – brain cells can’t function and
die within minutes.
STROKE/BRAIN ATTACK
• Part of the body controlled by these
brain cells is unable to function.
• Devastating effects of the stroke
are PERMANENT:
- Dead brain cells not replaced.
- Other brain cells may gradually take
on the function of the lost cells.
CLASSIFICATIONS
• Ischemic:
- Blood vessel supplying the brain is occluded –
disrupts blood flow to the brain.
- 85% of strokes are ischemic.
- Cerebral thrombosis (blood clots develop in the
brain artery itself)
- Cerebral embolism (clots develop elsewhere in
the body and migrate to the brain).
- Further classified by vascular supply or anatomic
location.
CLASSIFICATIONS
• Ischemic:
- Can use fibrinolytic drugs in ischemic
strokes.
* 3 hour window of time from symptom
onset to administration of
fibrinolytic.
- Must obtain a CT scan of the brain to
confirm that there is no hemorrhage
and that it is an ischemic stroke.
CEREBRAL INFARCTION
(Ischemic Stroke)
CLASSIFICATIONS
• Hemorrhagic:
- Due to rupture of an artery with
bleeding:
* Onto the surface of the brain
(subarachnoid hemorrhage)
* Into the parenchyma of the
brain (intracerebral hemorrhage)
- Bleeding disrupts blood supply to brain.
- Most common cause of SAH is an
aneurysm.
- Most common cause of intracerebral
hemorrhage is hypertension.
CLASSIFICATIONS
• Hemorrhagic:
• Fibrinolytic drugs CANNOT be used
with hemorrhagic strokes as they may
increase the amount of bleeding and
worsen the stroke.
• Symptoms are more severe and the pt
appears to be more ill with
hemorrhagic stroke.
• Deteriorate rapidly.
SUBARACHNOID
HEMORRHAGE
INTRACEREBRAL
HEMORRHAGE
TRANSIENT ISCHEMIC
ATTACKS (TIAs)
• Present like strokes.
• Resolve on their own within minutes
to hours.
• Warning sign of future stroke.
• Temporary condition – 10% chance of
stroke within 90 days after a TIA.
STROKE RISK FACTORS
Modifiable:
• High blood pressure
• Smoking
• TIAs
• Heart disease (Atrial fib, CHF, CAD)
• Diabetes
• Increased blood coagulation states
• High RBC count and Sickle Cell Anemia
• Carotid bruit
STROKE RISK FACTORS
Unmodifiable:
• Age (over 55)
• Gender (male)
• Race (African American)
• Prior stroke
• Heredity
SIGNS AND SYMPTOMS
• Sudden numbness or weakness of the face,
arm, or leg, especially on one side of the
body.
• Sudden confusion, trouble speaking, or
understanding.
• Sudden difficulty seeing in one or both
eyes.
• Sudden difficulty in walking, dizziness, loss
of balance or coordination.
• Sudden, severe headache with no known
cause.
CASE STUDY # 1
DIFFERENTIAL DIAGNOSIS
6:35
PM
• Upon arrival, you find an African-American
woman sitting on a bench. She is confused
but responsive to verbal stimuli.
• Summary clinical signs and symptoms:
- Regular heart rate and adequate
perfusion
- No evidence of ischemic chest pain
- Adequate airway and ventilation
- Right-sided paralysis
- Dysarthria
- Hypertension
DIFFERENTIAL DIAGNOSIS
1. What additional information do
you need?
2. What is your differential
diagnosis now?
DIFFERENTIAL DIAGNOSIS OF
FOCAL NEUROLOGICAL
DEFICIT
•Hemorrhagic stroke
•Ischemic stroke
•Craniocerebral/cervical
trauma
•Meningitis/encephalitis
•Hypertensive encephalopathy
DIFFERENTIAL DIAGNOSIS OF
FOCAL NEUROLOGICAL
DEFICIT
•
•
•
•
Intracranial mass
Seizure
Migraine
Metabolic problems, including
hypo/hyperglycemia, drug OD
What other information would be
helpful?
CASE DEVELOPMENT
The daughter reports that her mother felt
fine while shopping, then suddenly said her
arm felt funny. She then fell to the
ground. She did not hit her head or lose
consciousness. With further questioning
the daughter reveals that her mother did
not complain of a headache and had no
signs or history of seizures, diabetes,
chest pain, or palpitations.
What additional assessments may be helpful now?
CINCINNATI PREHOSPITAL
STROKE SCALE
• Facial droop (ask patient to show teeth
and smile)
• Arm drift (ask patient to extend arms,
palms up, with eyes closed)
• Speech (ask patient to say “You can’t
teach an old dog new tricks”)
Look for abnormalities!
CASE DEVELOPMENT
6:43
PM
• Patient demonstrates a right-sided
facial droop, right-arm weakness, and
slurred speech.
What is your conclusion from
your examination?
CASE DEVELOPMENT
1. What are your priorities of care?
2. Do you need further information?
Obtain as much information as
possible during transport; bring
the family member along if
possible.
SUMMARY OF PRIORITIES OF
PREHOSPITAL CARE OF PATIENTS
WITH POSSIBLE STROKE
• Assessment and support of
cardiorespiratory function and serum
glucose.
• Determination of precise time of onset of
signs and symptoms.
• Rapid transport to ED.
• Prearrival notification of ED.
• Assessment of neurological function.
• Rapid determination of essential medical
information.
CASE DEVELOPMENT
• The daughter states that her
mother’s symptoms developed
shortly before the call to EMS, but
she is not sure of the exact time.
How can you help clarify the
information?
CASE DEVELOPMENT
The daughter remembers that she and her
mother were walking past an electronics
store, and her mother stopped to watch
the weather on the local news program.
The weather report always airs at 6:20 PM.
1. What should you do with this
information?
2. What are appropriate assessment and
management priorities during transport?
CASE DEVELOPMENT
During transport the patient’s vital signs
are again obtained:
• HR = 92 (normal sinus rhythm)
• RR = 22min. and unlabored
• BP = 198/120 mm Hg
7:00 PM (40 minutes after onset)
Patient arrives in ED.
DOCUMENTATION
• ESSENTIAL TO DOCUMENT:
- Time of onset of symptoms and
witness(es) to validate sources.
* Establish the time of onset of
stroke signs and symptoms “Time Zero” – TIME IS BRAIN
TISSUE
* All assessments and therapies
can be related to that time.
* Three (3) hour window of time for
administration of thrombolytics for
ischemic strokes.
CASE STUDY #2
CASE STUDY #2
You are dispatched to the home of a
65-year-old Hispanic man who is c/o
weakness.
• What could be some causes of this
weakness?
- Hypoglycemia - GI bleeding
- Stroke
- Dehydration
- MI
- Infection
- Trauma
CASE STUDY #2
• You arrive on the scene and find a 65 year
old Hispanic man sitting on a chair in the
kitchen.
- Eyes closed
- Seems sleepy/drowsy, but responds
to your voice.
- Slow to answer questions.
- Slightly disoriented.
• No one else is home
• Need to continuously monitor his level of
consciousness.
CASE STUDY #2
• What would you do first?
a. Assess ABCs
b. Check VS
c. Check blood sugar and O2 sat
d. Obtain IV access
CASE STUDY #2
• ASSESS ABCs.
- Ensure patent airway
- Ensure adequate breathing
- Assess circulation
• What would you do next?
a. Check VS
b. Check blood sugar and O2 sat
c. Start IV
d. Examine pt
CASE STUDY #2
• CHECK VS
- HR: 104/min
- RR: 24/min
- BP: 118/60
• What is your next step?
a. Check blood sugar and O2 sat
b. Start IV
c. Obtain pt history
d. Examine pt
e. Transport
CASE STUDY #2
• OBTAIN PT HISTORY
- Pt states that he is weak.
- Answers questions appropriately.
- c/o lightheadedness.
- When asked about meds, he points to a list on
the table.
- Pt is wearing an ID bracelet for diabetes and end
stage renal disease.
- He is taking insulin, an antidepressant, and a
multivitamin.
• Try to find out when the pt last felt normal.
• If this is a possible stroke, try to find out the
exact time of symptom onset (In ischemic
stroke, 3 hour window of time for fibrinolytics).
CASE STUDY #2
• What should you do next?
a. Transport pt
b. Start IV.
c. Check blood sugar and O2 sat.
d. Examine pt.
CASE STUDY #2
• Examine pt.
- Diaphoretic, tachypneic, tachycardic
- Mildly confused; responds slowly.
- Focused neuro exam:
* Slurred speech
* Some weakness in the left arm
and leg
* No facial droop
CASE STUDY #2
• What should you do next?
a. Check blood sugar and O2 sat
b. Start IV
c. Call medical control
d. Transport
CASE STUDY #2
• Check blood sugar and O2 sat
- O2 sat – 96%
- Blood sugar: 42 mg/dl.
• Represents hypoglycemic reaction
- Give amp of D50
- Mental status improves
- Weakness disappears
• Hypoglycemia can present like a
stroke!
CASE STUDY #2
SUMMARY
•
•
•
•
ABCs
Check VS
Focused history and physical
Identify and treat other causes
- Check blood sugar and O2 sat
• Notify hospital
• Rapid transport
CASE STUDY #3
CASE STUDY #3
You are dispatched to see a 72-year-old
African American female. The family
describes her as being confused. On
arrival you find a 72-year-old female who:
• Is Obese.
• Can’t provide history.
• Has difficulty understanding questions.
• Has difficulty speaking
• Seems confused.
CASE STUDY #3
• What would you do first?
a. Assess ABCs.
b. Check VS.
c. Check blood sugar and O2 sat.
d. Start IV.
CASE STUDY #3
• Assess ABCs.
- Airway is open and patent.
- Breathing is adequate.
- Strong bilateral radial pulses palpated.
• What would you do next?
a. Check VS.
b. Check blood sugar and O2 sat.
c. Examine pt.
d. Obtain focused history.
CASE STUDY #3
• Check VS
- HR: 96/min
- RR: 18/min
- BP: 196/110
• What would you do next?
a. Check blood sugar and O2 sat.
b. Start IV.
c. Obtain history.
d. Examine pt.
CASE STUDY #3
• Obtain history
- Pt is struggling with questions.
* Difficulty understanding
* Cannot answer questions
* Words not understandable
• Son relates that his mother was eating
dinner 20 minutes ago when she began to
drool and food started to fall out of her
mouth.
CASE STUDY #3
• Find out when the symptoms started or when the
pt last seemed normal.
• Get a clear description of symptoms.
• Ask:
- How was the pt earlier today?
- Has this happened before?
- Has the pt had any recent trauma?
- Has there been any signs of seizure activity
before the onset of symptoms?
- History of HTN or diabetes?
- Is the pt taking any medications or does the pt
have any allergies?
- Have any other family members had a similar
illness?
- Ask about risk factors
* Does the pt have HTN, diabetes, smoke, etc.
CASE STUDY #3
• The son states that his mother has
HTN, diabetes, and smokes 1 pkg
cigarettes/day.
• What would you do next?
a. Start an IV.
b. Check blood sugar and O2 sat.
c. Focused neuro exam.
CASE STUDY #3
• Complete a focused neuro exam.
- Abrupt symptom onset with focal
deficits.
* Speech abnormality
* Subtle weakness of right arm
and leg
* PERL
- Which one of the above is not included in
the CPSS?
* Cincinnati Prehospital Stroke Scale
(CPSS): Facial droop, arm drift,
speech abnormalities.
CASE STUDY #3
• A normal CPSS does NOT rule out stroke.
• Possible causes of this pt’s symptoms:
- Ischemic stroke
- Hemorrhagic stroke
- TIA
- Head/neck trauma
- Hypoglycemia
- Seizure
- Migraine headache
- OD, toxic exposure
• TIA or stroke is likely due to multiple risk
factors – HTN, diabetes, smoking.
CASE STUDY #3
• What should you do next?
a. Check blood glucose and O2 sat.
b. Call medical control en route.
c. Transport.
• Check blood glucose and O2 sat.
- Blood glucose: 86; O2 sat: 97%.
• What should you do next?
a. Start IV.
b. Call Medical Control enroute.
c. Transport.
CASE STUDY #3
• Call medical control enroute.
- You report the VS as HR: 96; RR: 18; BP:
196/110; Blood glucose: 86; O2 sat: 97%.
- You relate the CPSS.
- You tell medical control that the symptoms
started about 20 minutes prior to your arrival.
- You ask for meds to decrease BP.
• Medical control asks you not to give any meds
for BP control.
- HTN can develop after an ischemic or
hemorrhagic stroke.
- Do NOT attempt to control it in the field.
- BP will decrease as pain, N/V, etc improve.
CASE STUDY #3
• Medical control tells you to:
- Monitor neuro status.
- Start IV of NS at KVO.
- Cardiac monitor.
- O2
• After arrival in the ED, the pt has a CT
scan done which shows no hemorrhage
and is diagnosed as an ischemic stroke.
• Fibrinolytics given and by that evening,
all symptoms resolved.
CASE STUDY #3
SUMMARY
• ABCs.
• Check VS.
• Focused history and physical.
- Verify focal neuro findings with CPSS.
• Check BS and O2 sat.
• Determine time of symptom onset.
• Notify medical control.
• Transport rapidly.
CASE STUDY #4
CASE STUDY #4
• You are dispatched to the home of a 52year-old African American male whose
wife called saying that her husband has
a severe headache.
• On arrival, you find him seated on the
couch.
• He appears to be uncomfortable.
• He is c/o a severe headache that came
on suddenly while he was mowing the
lawn.
CASE STUDY #4
• You check the ABCs:
- The pt is sitting on the couch with
his hands over his eyes.
- He is slow to answer questions.
- There is no airway obstruction and
his RR is 22/min.
- He has strong radial pulses
bilaterally.
CASE STUDY #4
• You then check his VS:
- HR: 110
- RR: 22
- BP: 210/120
• The focused history and physical show
the headache started suddenly while he
was mowing his lawn.
- States that he has never had a headache
like this before in his life.
- Pt has history of HTN – is on BP meds but
hasn’t taken them for 4 days because
he ran out.
CASE STUDY #4
• You next conduct a CPSS which
shows:
- Left sided upper extremity
weakness.
- Left facial droop.
- Slow speech.
• Remember that a normal CPSS does
not rule out a stroke!
CASE STUDY #4
• How do you lower BP in the field?
a. SL NTG
b. Morphine Sulfate 5 mg IV
c. Small (250cc) bolus NS
d. None of the above
DO NOT TREAT ELEVATED BP IN
THE FIELD!
CASE STUDY #4
• HTN after an ischemic or
hemorrhagic stroke is common and
will decrease once the pain,
anxiety, agitation, N/V, or
increased ICP are alleviated.
• Again, do not treat the increased
BP in the field!
CASE STUDY #4
SUMMARY
• Assess ABCs.
• Check VS.
• Do not treat HTN in the prehospital
setting.
• Complete the focused history and
physical.
• This pt had 3 risk factors for stroke:
- Male
- African American
- HTN
• Notify hospital and give report.
• Transport rapidly.
DOCUMENTATION
ESSENTIAL TO DOCUMENT:
• CINCINNATI PREHOSPITAL STROKE SCALE:
- Facial droop
- Arm drift
- Speech
• TIME OF SYMPTOM ONSET
• SEQUENTIAL VITAL SIGNS (several sets VS)
• ALERT THE ED TO POSSIBLE STROKE
PATIENT AS SOON AS YOU HAVE
COMPLETED THE PRE-HOSPITAL STROKE
CRITERIA.
• RAPID TRANSPORT TO THE
NEAREST APPROPRIATE HOSPITAL.