STROKE

1. STROKE Presence Regional EMS System September 2013

2. “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

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 Americans • 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 $68 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. • For a variety of reasons, only 2% of stroke victims are treated with thrombolytic medication • 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 storage in the brain for either fuel or oxygen • Requires constant supply of oxygen and glucose.

9. Blood Supply to the Brain • Carotid arteries – anterior neck • Large • Frequently congested with plaque • Can be cleaned out surgically • Vertebral arteries • Pass through cervical vertebrae • Well protected • Not accessible for surgical cleaning

10. Circle of Willis • Both blood supplies (carotid and vertebral) join on the under surface of the brain. • Fail-safe mechanism in case of a blockage somewhere in circulation • BUT some hard corners in circle where debris can get caught and site of most cerebral aneurysms

11. What can go wrong??? • Disruption of blood flow to the brain • Plaque – build up of cholesterol in interior of blood vessel • Foreign debris– blood clot bubble of fluid air • Broken vessel

12. Ischemic STROKE • Blockage of blood flow to brain • Progressive Thrombus -- growing • 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

13. Hemorrhagic STROKE • Aneurysm – weakened area in artery • Congenital • Younger population younger than 40 years • Complain of “worst headache in my life” • Spontaneous Hypertensive Bleed • Due to BP > 200/100 • Malformed Artery • 50% younger than 30 years

14. 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 –Like Unstable Angina of the brain • Warning sign (15% of strokes have TIA first) • Mimicked by low blood sugar (> blood sugar signs and symptoms go away) • 1 in 20 patients will have a true stroke in 3 months

15. Can STROKES be prevented? • Modifiable risk factors • High BP • Cigarette smoking • Alcohol intake • Uncontrolled Heart disease • Atrial fibrillation (creates mini clots) • Uncontrolled Diabetes • Carotid congestion

16. High blood cholesterol • Sedentary lifestyle • Obesity • Seasons– spring and fall • Stress

17. Risk Factors Unable to Control • Age • Gender • more women than men • Race • African American high risk • Prior strokes • Heredity • Sickle Cell Disease • Causes clot formation and strokes even in children

18. Signs and Symptoms of STROKE • Hemorrhagic • Sudden and dramatic • Violent explosive headache • “worst headache of my life” • Visual disturbance • Flashing lights, aura • Nausea and vomiting • Neck and back pain • Due to blood in sub-arachnoid space • Sensitivity to light • Weakness on one side • Can present like a migraine headache

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

20. Left Brain Stroke • Right side paralysis • Speech and language disturbance • Behavioral changes • Swallowing problems

21. Right Brain Damage • Left side paralysis • Spatial perception • Where your limbs are in relation to the room • Coordination problems • Perception • Recognition of familiar objects

22. 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

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

24. 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 to receive thrombolytic drugs • Drug – thrombolytics when appropriate

25. EMS Has a Critical Role • Educate your community • At first signs of a possible STROKE call EMS • Many families wait to see if the patient gets better • Take patient to the hospital by car • “Don’t guess call EMS!!”

26. Use a “FAST” STROKE Assessment • Modification of Cincinnati Pre-Hospital Stroke Screen • Face • Arm • Speech • Time of onset

27. 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

28. 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

29. Problem with gripping hands • Many elderly have arthritis in hands • Hurts to grip hands • May mimic weakness

30. SPEECH • Ask the patient to say “You can’t teach an old dog new tricks” • Lots of t’s, k’s and c’s • NORMAL –Phrase repeated clearly and plainly • ABNORMAL – Words slurred, abnormal or unable to speak

31. Abnormal Speech • Slurring of speech • Unable to think of words • Inappropriate words • Expressive aphasia – unable to speak words • Area of brain where words are created is damaged • Receptive aphasia – unable to understand words • Area where words are interpreted is damaged

32. TIME OF ONSET • The window of opportunity to effectively treat STROKE is 3 hours (180 minutes) • May be extended to 4 ½ hours in some cases • Need to know “ last known well”. • Difficult when • Patient lives alone • Woke up with symptoms

33. 180 minutes • Don’t think of as 3 hours, but 180 minutes • Time gets eaten up fast • Short scene time • Take transport time into consideration

34. Assessing the Stroke Patient • Initial Assessment • General Impression • Airway Airway Airway!! • High-flow O2 • Circulation • HIGH PRIORITY TRANSPORT

35. 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

36. Priorities of care • Conduct general assessment • Trauma – recent or within last month • Recent seizure • Could be a 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

37. Position • Protect potentially paralyzed parts

38. STROKE Check List • Securing A B Cs • Stroke identification • Use of FAST Screen • EKG monitoring if able • Oxygen saturation of > 94% • Management of blood glucose • IV access (ILS/ALS) • Blood specimens obtained (ILS/ALS) • Head of Bed elevated 15 degrees • Early communication with Physician • Urgent transport to CT Scan

39. Non Contrast CT of HeadWant a normal CT

40. Acute Hemorrhagic StrokeBlood shows up white

41. Sub Arachnoid BleedBlood in meninges due to aneurysm

42. Could this be anything other than a STROKE? • Transient Ischemic Attack • Hypoglycemia

43. Race Against Time

44. Goals of STROKE Care 2013 • Standardized assessments, vocabulary, protocols and goals • Door to treatment (with thrombolytics) goal is 60 minutes • Early identification of candidates • Direct transport to CT scan

45. 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 • ** National Institute of Neurological Diseases and Stroke

46. Case Study 1: 6:30 pm • You are called by a family member to assess a patient who is not acting right. • What could be the problem? • Keep an eye on the time you have 180 minutes

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

48. 6:35 pm • Upon arrival, you find the patient, Mrs. Short, sitting in bed. She is confused, but responds to verbal stimuli. • What assessments do you need?

49. ABC/FAST • 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

50. 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.