Cerebral Vascular Accidents

1. Cerebral Vascular Accidents

2. Incidence • Stroke is the third leading cause of death in the United States • leading cause of brain injury in adults • Leading diagnosis from hospital to long-term care • New treatments may alter the outcome of stroke patients • TPA

3. Definition • Cerebral Vascular Accident (Stroke) • A neurological impairment caused by disruption of blood supply to a portion of the brain – an artery becomes blocked or ruptures • two different types of stroke • Ischemic • Hemorrhagic

4. Ischemic Stroke • Caused by a clot occluding a blood vessel in the brain • Slow onset of symptoms • Account for approximately 75% of strokes • Rarely immediately fatal • Cause classic stoke signs/symptoms

5. 2 Types of Ischemic Stroke • Thrombolitic – blood clot in vessel • Embolic – clot developed elsewhere in the body (usually the heart) and then migrates to the brain

6. Hemorrhagic Stroke • Caused by the rupture of a cerebral artery, causing bleeding on the surface of the brain, or directly in the brain tissue itself • Rapid onset of symptoms • Severity depends on location and size • Often fatal at onset

7. Modifiable Risk Factors

8. 1. HIGH BLOOD PRESSURE High blood pressure is one of the most important modifiable risk factors for both types of stroke Risk of hemorrhagic stroke greatly increases with elevated systolic pressure STROKE IS AN EMERGENCY

9. 2. CIGARETTE SMOKING • Can cause accelerated atherosclerosis and increased blood pressure • Cessation of cigarette smoking reduces risk of stroke STROKE IS AN EMERGENCY

10. 3. TIAs – Transient Ischemic Attack • Approximately 25% of patients presenting with a stroke have had a previous TIA • Treatment options include • Carotid Endarterectomy • Antiplatelet (ASA) • Anticoagulants (Coumadin) STROKE IS AN EMERGENCY

11. 4. HEART DISEASE • Heart disease significantly increases the risk of stroke. CAD and CHF double the risk of strokes • Prone to the formation of blood clots STROKE IS AN EMERGENCY!!!!

12. 5. DIABETES • Is associated with accelerated atherosclerosis STROKE IS AN EMERGENCY

13. 6. BLOOD DISORDERS • Hematological disorders which may produce hypercoagulatory conditions – as seen with sickle cell anemia

15. Unmodifiable Risk Factors 1. Age • Single most important risk factor in patients past 55 2. Gender • Men are at greater risk; however, more women live past the age of 65, and more women past 65 die from strokes than men

16. Unmodifiable Risk Factors 3. Race • African-Americans have more than twice the risk of death & disability • Generally have a greater number of risk factors • smoking, high blood pressure, sickle cell anemia, diabetes

17. Unmodifiable Risk Factors 4. Prior Stroke • risk is highest within the first 30 days after a stroke 5. Heredity • risk is greater for people with a family history of stroke

18. TRANSIENT ISCHEMIC ATTACK (TIA) Considered a TIA when the S/S of the stroke go away within 24 hours - commonly referred to as a “mini-stroke” • TIA is the most important forecaster of brain infarction • 5% develop actual CVA’s within 30 days STROKE IS AN EMERGENCY

19. Signs and Symptoms • Confusion • Rapid, bounding pulse • Dizziness • Difficulty breathing • Impaired Speech - Aphasia – patients knows what he/she wants to say but words come out wrong • Nausea Vomiting

20. Signs and Symptoms • Numbness or paralysis (one side of body) • Seizures • Loss of muscle tone on one side of the face – facial drooping • Unconsciousness • Headache (uncommon) • Loss of bowel or bladder control • Unequal pupils • Impaired vision

22. Patient Care • Goals for EMS providers: • Rapid recognition of stroke signs/symptoms • Support of vital functions • Rapid transport to an appropriate facility • Pre-arrival notification of receiving hospital

23. Patient Care Conscious Patient: • Reassure the patient. • Administer high concentration oxygen. • Transport in semi-fowlers position. Unconscious patient: • Provide high concentration oxygen. • Transport in the recovery position – lay them on the affected side.

24. Assessment of Patient • Chief Complaint • Initial Assessment • Assess and support airway, breathing, circulation • History of present illness • follow “Altered Mental Status” history • “Onset of Symptoms” very important • Cincinnati Stroke Assessment

25. Rapid Recognition • Physical Exam • Check for facial droop • ask patient to smile

26. Rapid Recognition • Physical Exam • Check for neurological disability • grip strength • arm drift • patient closes eyes, holds both arms out • normal - both arms move the same or not at all • abnormal - one arm does not move or one arm drifts down compared with the other

27. ARM DRIFT • Patient closes eyes and holds both arms out

28. Rapid Recognition • Check for speech abnormalities • Ask patient to say, “you can’t teach an old dog new tricks” or “the chicken wings taste great in Buffalo” • assess for slurred words, inappropriate words, or inability to speak

29. Rapid Transport • Load and Go Patients! • Be prepared to suction • Request ALS back-up • Rapid transport to an appropriate facility • MFG, KMH, ECMC, Buffalo Mercy, Sisters • Notify receiving hospital • Activation of the “Stroke Team”

30. Treatment... • Tissue Plasminogen Activator (TPA) • First approved therapy for ischemic stroke • Patients treated within 2 hours(NYS Protocol) of the onset of symptoms are at least 30% more likely to have minimal or no disability after 3 months • Stroke type must be confirmed by CAT scan prior to treatment • Increases our sense of urgency

33. NINDS RECOMMENDATIONS Time Dependent Treatment • Door to doctor 10 Minutes • Door to CT completion 25 Minutes • Door to CT read 45 Minutes • Door to treatment 60 Minutes STROKE IS AN EMERGENCY

34. The End

35. Acute Stroke Treatment Window Intravenous thrombolysis 3 hours Intra-arterial thrombolysis 6 hours Neuroradiological Intervention

36. Summary • Once CVA is suspected, patient is a “load and go” • Priorities include maintaining the ABC’s • ALS interventions enroute as needed • Prenotify receiving hospital

37. Overview • Review incidence of CVA’s • Review pathophysiology of CVA’s • Review risk factors for CVA’s • Discuss treatment of patients with possible CVA • Discuss in-hospital treatment options, how they effect EMS’s role

38. Modifiable Risk Factors • High blood pressure • Cigarette smoking • Previous TIA’s (ministrokes) • Heart Disease • prone to formation of blood clots • Diabetes • Sickle Cell Anemia

39. Signs/Symptoms - Hemorrhagic Stroke • Severe Headache • occurs suddenly, often during exertion • often radiates to the neck or face • Loss of Consciousness • Severe headache with a transient loss of consciousness is particularly alarming.

40. Signs/Symptoms - Hemorrhagic Stroke • Nausea/vomiting • Neck pain • Intolerance of noise or light • Altered mental status • Focal neurological deficits with associated nausea, vomiting, headache, and loss of consciousness

41. Signs/SymptomsIschemic Stroke & TIA • Signs/symptoms of a stroke will persist; TIA signs/symptoms last a few minutes to several hours. • Unilateral Paralysis • weakness, clumsiness or heaviness involving one side of the face and extremities on the opposite side of the body • Numbness • sensory loss, tingling, or abnormal sensation, most commonly involving the face and hand

42. Signs/SymptomsIschemic Stroke & TIA • Language Disturbances • trouble selecting correct words, incomprehensible or nonsense speech, trouble understanding other’s speech • Visual Disturbances • blurred or indistinct vision in one side of the field of vision in both eyes

43. Signs/SymptomsIschemic Stroke & TIA • Monocular Blindness • painless loss of part or all vision in one eye • Vertigo • sense of spinning or whirling • Ataxia • poor balance, stumbling gait, staggering, uncoordinated with one side of the body

44. Support & Treatment • Maintain ABC’s • Hemorrhagic stroke patients may present with coma, inability to maintain airway, vomiting, seizures • Be prepared to suction, ALS back-up • Assisting ventilation • Do not hyperventilate unless patient presents with Herniation Syndrome