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STROKE

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Transport to ED for ... Clot busting drugs, thrombolytics, tPA 14 ... List Stroke identification Use of FAST Screen Securing A B Cs EKG monitoring if ... – PowerPoint PPT presentation

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Title: STROKE


1
STROKE
  • Presence Covenant Medical Center
  • June 2016

2
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

3
  • How big is the problem of STROKE?

4
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

5
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

6
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

7
Before STROKE can be managed
  • Learn more about what strokes are and how they
    happen.

8
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.

9
Blood Supply to the Brain
  • Dual blood supplies
  • Carotid arteries anterior neck
  • Vertebral arteries through
  • cervical vertebrae

10
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

11
Problems with Circle of Willis
  • Not a smooth circle
  • Debris gets caught in corners causing stroke
  • Aneurysms located
  • in Circle of Willis

12
What can go wrong???
  • Disruption of blood flow to the brain
  • Plaque in vessel
  • Foreign debris
  • Broken vessel

13
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

14
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

15
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

16
Can STROKES be prevented?
  • Modifiable risk factors
  • High BP
  • Cigarette smoking
  • Alcohol intake
  • Uncontrolled Heart disease
  • Atrial fibrillation
  • Uncontrolled Diabetes
  • Carotid congestion

17
  • High blood cholesterol
  • Sedentary lifestyle
  • Obesity
  • Seasons
  • Stress
  • More strokes in
  • fall and spring

18
Risk Factors Unable to Control
  • Age
  • Gender (more women)
  • Race
  • More African American
  • Prior strokes
  • Heredity
  • Sickle Cell Disease

19
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

20
  • Signs and symptoms similar to undiagnosed
    migraine headache
  • Need CT scan to
  • differentiate

21
Signs and Symptoms of STROKE
  • Ischemic Stroke
  • Harder to detect
  • Weakness in one side
  • Facial drooping
  • Numbness and tingling
  • Language disturbance
  • Visual disturbance

22
Left Brain Damage
  • Right side paralysis
  • Speech and language disturbance
  • Behavioral changes
  • Swallowing problems

23
Right Brain Damage
  • Left side paralysis
  • Spatial perception
  • Coordination
  • Perception

24
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

25
Goals of Primary STROKE Care
  • Rapid Recognition of STROKE Symptoms
  • Rapid access in to the system
  • Assessment
  • Treatment

26
Seven Ds 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

27
EMS Has a Critical Role
  • Educate your community
  • At first signs of a possible STROKE call EMS
  • Dont guess call EMS!!

28
In 2015
  • 56 of patients with stroke symptoms arrived at
    the Emergency Departments in C-U by private
    vehicle not EMS
  • Delays in recognizing the stroke symptoms
  • Delays in getting access into the medical system
  • Delays in care
  • Eats up the time on the clock

29
Value of Calling EMS
  • Medical professionals at the patients door
  • Early communication with Emergency Physician
  • Initiation of Treatment Protocols
  • Stroke team waiting for the patient to arrive
  • Direct transport to CT scan

30
Use a FAST STROKE Assessment
  • Modification of Cincinnati Pre-Hospital Stroke
    Screen
  • Face
  • Arm
  • Speech
  • Time of onset

31
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 patients face droops
  • or does not move

32
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

33
SPEECH
  • Ask the patient to say You cant teach an old
    dog new tricks
  • NORMAL Phrase repeated clearly and plainly
  • ABNORMAL Words slurred, abnormal or unable to
    speak

34
Abnormal Speech
  • Slurring of speech
  • Unable to think of words
  • Inappropriate words
  • Expressive aphasia unable to speak words
  • Receptive aphasia unable to understand words

35
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

36
Assessing the Stroke Patient
  • Initial Assessment
  • General Impression
  • Airway Airway Airway!!
  • O2 to 94 oxygen saturation
  • Circulation
  • Pulse
  • Blood pressure
  • HIGH PRIORITY transport

37
  • 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

38
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 gt 94
  • Blood sugar treat if able
  • Low blood sugars mimic a stroke
  • Pupils

39
Position
  • Protect potentially paralyzed parts

40
STROKE Check List
  • Stroke identification
  • Use of FAST Screen
  • Securing A B Cs
  • EKG monitoring if able (12 lead)
  • Oxygen saturation of gt 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

41
What are we looking for in CT Scan?
42
Non Contrast CT of Head
43
Acute Hemorrhagic Stroke
44
Sub Arachnoid Bleed
45
Could this be anything other than a STROKE?
  • Transient Ischemic Attack
  • Hypoglycemia

46
Race Against Time
47
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

48
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

49
Case Study 1 630 pm
  • You are called by a to assess a patient who is
    not acting right.
  • What could be the problem?

50
What could be the problem?
  • Seizure
  • Code
  • Myocardial infarction
  • Diabetic reaction
  • Medication reaction
  • Anxiety attack
  • STROKE

51
635 pm
  • Upon arrival, you find a woman sitting on the
    couch. She is confused, but responds to verbal
    stimuli.
  • What assessments do you need?

52
  • 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

53
  • The patients 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.

54
643 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.

55
FAST
  • How does Mrs. Short fare on the FAST Screen?
  • Face
  • Arm
  • Speech
  • Time

56
Case 1 cont
  • Face -- left sided facial drooping
  • Arm right arm and leg weakness
  • Speech speech is slurred
  • Time last known well -- unsure

57
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.

58
  • 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

59
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

60
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

61
FAST
  • How does Mrs. Black fare
  • on the FAST Screen?
  • Face
  • Arm
  • Speech
  • Time

62
Case 2 cont
  • Face -- no drooping
  • Arm slight weakness and tingling
  • Speech -- Speech is hesitant and slightly slurred
  • Time known well -- 20 minutes ago

63
Case 2
  • Treat the blood sugar and reassess the need for
    additional treatment
  • High priority transport to
  • a CT for acute STROKE

64
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

65
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

66
FAST
  • How does Mr. Schmidt fare
  • on the FAST Screen?
  • Face
  • Arm
  • Speech
  • Time

67
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

68
Case 3 Cont.
  • Time of onset unknown
  • Severe Headache unknown
  • Emesis no
  • Seizures no
  • Blood sugar OK

69
Case 3
  • Time window has closed. Not a candidate for
    thrombolytic treatment. Transport to ED for
    acute care.

70
Review
  • Answer the following questions as a group.
  • If doing this CE individually, please e-mail your
    answers to
  • shelley.peelman_at_presencehealth.org
  • 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

71
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.

72
  • 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.

73
  • 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.

74
Answers
  • 1. Hemorrhagic stroke
  • 2. Ischemic stroke
  • 3. TIA (transient ischemic attack)
  • 4. 6. High BP
  • Cigarette smoking High blood cholesterol
  • Sedentary lifestyle Carotid Congestion
  • Obesity Uncontrolled diabetes
  • Seasons Atrial fibrillation
  • Stress Uncontrolled heart disease
  • Alcohol intake

75
  • 7-8
  • Age prior strokes
  • Gender heredity
  • Race Sickle cell disease
  • 9. Face
  • 10. Arm
  • 11. Speech
  • 12. Last known well

76
  • 13. Clot busting drugs, thrombolytics, tPA
  • 14. 3 hours (180 minutes)

77
Race Against Time
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