Acute Ischemic Stroke

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					STROKE: FAST Approach

 Provena Covenant Medical Center
         November 2011
      ―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
    big is the problem of
 How
    Magnitude of the Problem
 795,000 Americans annually suffer a
 25% die
 #3 killer of women
 25% of women have strokes before age
 #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 –
 Only 2% of stroke victims are treated with
  thrombolytic medication
 Aggressive treatment begins with
  assessment and intervention at point of
  patient contact
       Before STROKE can be
   Learn more about what strokes are and
    how they happen.
         A very selfish organ
 The brain requires
  20 % of
  the total blood
   by the heart.
 No fat for storage
   in the brain
 Requires constant
  supply of oxygen and glucose.
        Blood Supply to the Brain
   Carotid arteries – anterior neck
     Very large
     Can be cleaned out if
    Get occluded with arthrosclerosis
 Vertebral arteries –
through cervical vertebrae
     Smaller
     Well protected by vertebrae
     Can’t clean out surgically
            Circle of Willis
 Both blood supplies join on the under
  surface of the brain.
 Fail-safe mechanism
  in case of a blockage
  somewhere in
   Problem with Circle of Willis
     Multiple sharp corners
      where blood clots could
      get caught
     Area where brain
      aneurysms are typically
        What can go wrong???
   Disruption of blood flow to the brain
     Plaque – build up arthrosclerosis
     Foreign debris – blood clot, fat, air bubble
     Broken vessel -- aneurysm
               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
          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
Can STROKES be prevented?
   Modifiable risk factors
     High BP
     Cigarette smoking
     Alcohol intake
     Uncontrolled Heart disease
     Atrial fibrillation
     Uncontrolled Diabetes
     Carotid congestion
 High blood cholesterol
 Sedentary lifestyle
 Obesity
 Seasons
 Stress
 Risk Factors Unable to Control
 Age
 Gender
 Race
 Prior strokes
 Heredity
 Sickle Cell Disease
        Signs and Symptoms of
   Hemorrhagic
     Sudden and dramatic
     Violent explosive headache
     Visual disturbance
     Nausea and vomiting
     Neck and back pain
     Sensitivity to light
     Weakness on one side
What else does this sound like?
     Violent explosive headache
     Visual disturbance
     Nausea and vomiting
     Neck and back pain
     Sensitivity to light

   Signs and symptoms similar to a migraine
        Signs and Symptoms of
   Ischemic Stroke
     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—
       anger, depression
   Swallowing problems—
      Patients choke easily
     Nothing to eat or drink
    till assessed for choking risk
            Right Brain Damage
 Left side paralysis
 Spatial perception –
       Unable to locate objects
 Coordination
 Perception –
       Unable to recognize or name
        familiar objects
             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 medical system
 Assessment
 Treatment
     Seven D’s of STROKE Care
 Detection –of STROKE symptoms
 Dispatch– of EMS
 Delivery – to a facility prepared to manage STROKE
 Door to treatment– rapid diagnosis and decision
 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
 ―Don’t guess call EMS!!”
        Use a ―FAST‖ STROKE
   Modification of Cincinnati Pre-Hospital
    Stroke Screen
Time       of onset
   Print off a copy of the attached PDF file of
    the PREMSS FAST form
   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
 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
 Assessment of arms using hand grips
 Many older people have painful arthritic
 This may make hand
  grips artificially weak
 Ask the patient to say “You can’t teach an
  old dog new tricks”
 NORMAL –Phrase repeated clearly and
 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
     Able to understand speech
     Knows what to say
     Unable to put words together
     Able to speak clearly if speaking from memory
         Able to sing familiar songs ―Happy Birthday to you‖
         Say to family ―I love you‖
   Receptive aphasia – unable to understand
     People sound like they are speaking ―Martian‖
     Patient is able to speak clearly
              TIME OF ONSET
   The window of opportunity to effectively
    treat STROKE is 3 hours (180 minutes)

       May be extended to 4 ½ hours if invasive
        neurology available
             Last Known Well
   Need to know ― last known well‖.
     Last time face was normal
     Last time able to move normally
     Last time able to speak

   Difficult when
     Patient lives alone
     Patient woke up with symptoms
        Assessing the Stroke Patient

   Initial Assessment
     General Impression
     Airway Airway Airway!!
     High-flow O2
     Breathing
     Circulation
    Focused History and Physical
   Neurological Exam
     FAST Form
     History of: (looking for bleeding aneurysm)
         Seizures
         Headache
         Nausea/Vomiting
         Neck   Pain
   Baseline set of Vital Signs
       Recheck every 5-10 minutes
                     Priorities of care
   Conduct general medical 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
   Protect potentially paralyzed parts
            STROKE Check List
   Stroke identification
   Use of FAST Screen
   Securing A B Cs
   EKG monitoring (if able)
   Oxygen saturation of > 94%
   Management of blood glucose
   IV access (if able)
   Blood specimens obtained (if able)
   Head of Bed elevated 15 degrees
   Early communication with Medical Control
   Urgent transport to CT Scan at hospital
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 2011
   Standardized assessments, vocabulary,
    protocols and goals
     EMS
     Hospital

 Direct transport to CT scan
 Early identification of candidates
 Door to treatment goal is 60 minutes
    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
        Case Study 1: 6:30 pm
   You are called for 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
                  6:35 pm
   Upon arrival, you find a middle aged
    woman sitting in bed. She is confused,
    but responds to verbal stimuli.

   What assessments do you need?
             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
   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.
                   6:45 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 20 minutes.
   How does Mrs. Short fare on the FAST
     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, Proceed to a hospital ready to
    manage an acute STROKE
    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
            Case 2 cont.
 Symptoms began 0615 per patient’s
 Speech was fine before that
 Blood sugar 50 mg/dl
 No emesis or seizure
 BP 150/90, Pulse 80, Respirations 16
 O2 sat 92%
   How does Mrs. Black fare
    on the FAST Screen?
              Case 2 cont

 Face -- no drooping
 Arm – slight weakness and tingling
 Speech -- Speech is hesitant and slightly
 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
   How does Mr. Schmidt fare
    on the FAST Screen?
             Case 3 cont

 Face --Drooping left side of face
 Arm – No movement of right arm and leg
 Speech – Speech too slurred to
 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 = unknown
 Blood sugar = OK
                  Case 3
   Time window has closed. Not a candidate
    for thrombolytic treatment. Transport to
    ED for acute care.
   Answer the following questions as a group.
   If doing this CE individually, please e-mail your
    answers to:
   Use ―November 2011 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.
What do you know about stroke?
   What are the 2 general types of stroke?
       1.
       2.

   What condition is equivalent to ―angina‖ of the
       3.
   What are 3 risk factors for stroke that can be
       4.
       5.
       6.
   What are 2 risk factors for stroke that cannot be
       7.
       8.
   What are you measuring in a FAST Stroke
       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.
   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
   7-8
       Age          prior strokes
       Gender       heredity
       Race         Sickle cell disease

     9.  Face
     10. Arm
     11. Speech
     12. Last known well
 13. Clot busting drugs, thrombolytics, tPA
 14. 3 hours (180 minutes)

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