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

How

big is the problem of

STROKE?

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

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
stroke.
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

managed

Learn

more about what strokes are and

how they happen.

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.

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
Cant 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
circulation

 Problem
Multiple

with Circle of Willis

sharp corners
where blood clots could
get caught
Area where brain
aneurysms are typically
located

What can go wrong???

Disruption
Plaque

of blood flow to the brain

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
days

Can STROKES be prevented?

Modifiable
High

risk factors

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

STROKE

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

headache.

Signs and Symptoms of

STROKE

Ischemic
Harder

Stroke

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
Patients

problems

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 Ds 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
making
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
EMS
Dont guess call EMS!!

Use a FAST STROKE

Assessment

Modification

of Cincinnati Pre-Hospital
Stroke Screen

Face
Arm
Speech
Time

of onset

 Print

off a copy of the attached PDF file of

the PREMSS FAST form

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

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

Avoid
Assessment

of arms using hand grips

Many older people have painful arthritic
hands
This may make hand
grips artificially weak

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

Abnormal Speech
Slurring

of speech
Unable to think of words
Inappropriate words

 Expressive

aphasia unable to speak

words
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

words
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 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
HIGH PRIORITY

Focused History and Physical

Neurological

Exam

FAST

Form
History of: (looking for bleeding aneurysm)
Seizures
Headache
Nausea/Vomiting
Neck

Baseline

Pain

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

Pupils

blood sugars mimic a stroke

Position
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
Door to CT completion
Door to CT read
Door to treatment
Access to neurological expertise*
Access to neuro-surgical expertise*
Admit to monitored bed

* by phone or in person

10 minutes
25 minutes
45 minutes
60 minutes
15 minutes
120 minutes
180 minutes

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
STROKE

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

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.

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.

FAST
How

does Mrs. Short fare on the FAST

Screen?
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 patients

husband
Speech was fine before that
Blood sugar 50 mg/dl
No emesis or seizure
BP 150/90, Pulse 80, Respirations 16
O2 sat 92%

FAST
How

does Mrs. Black fare

on the FAST Screen?
Face
Arm
Speech
Time

Case 2 cont
Face

-- no drooping
Arm slight weakness and tingling
Speech -- Speech is hesitant and slightly
slurred
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

FAST
How

does Mr. Schmidt fare

on the FAST Screen?
Face
Arm
Speech
Time

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

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.

Review
Answer

the following questions as a group.

If doing this CE individually, please e-mail your
answers to:
shelley.peelman@provena.org
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?

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.

 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.

 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.

Answers
1.

Hemorrhagic stroke
2. Ischemic stroke
3. TIA (transient ischemic attack)
4. 6. High BP

Cigarette smoking
Sedentary lifestyle
Obesity
Seasons
Stress
Alcohol intake

High blood cholesterol

Carotid Congestion
Uncontrolled diabetes
Atrial fibrillation
Uncontrolled heart disease

 7-8

Age
Gender
Race

9.
10.
11.
12.

prior strokes
heredity
Sickle cell disease

Face
Arm
Speech
Last known well

 13.

Clot busting drugs, thrombolytics, tPA

14. 3 hours (180 minutes)