STROKE

Presence Covenant Medical Center

June 2016
 “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
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: (usually due to not
getting treatment in time)
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

Dual blood supplies

Carotid arteries – anterior neck
Vertebral arteries – through
cervical vertebrae
 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
 Problems with Circle of Willis

Not a smooth circle

Debris gets caught in corners causing stroke
Aneurysms located
in Circle of Willis
 What can go wrong???

Disruption of blood flow to the brain

– Plaque in vessel
– Foreign debris
– Broken vessel
 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 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
– More strokes in
fall and spring
 Risk Factors Unable to Control

Age
Gender (more women)
Race
– More African American
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
 Signs and symptoms similar to undiagnosed
migraine headache
Need CT scan to
differentiate
 Signs and Symptoms of STROKE

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
Swallowing problems
 Right Brain Damage

Left side paralysis

Spatial perception
Coordination
Perception
 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 system
Assessment
Treatment
 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
Drug – thrombolytic when appropriate
 EMS Has a Critical Role

Educate your community

At first signs of a possible STROKE call EMS
“Don’t guess call EMS!!”
 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
 Value of Calling EMS

Medical professionals at the patient’s door

Early communication with Emergency Physician
Initiation of Treatment Protocols
Stroke team waiting for the patient to arrive
Direct transport to CT scan
 Use a “FAST” STROKE Assessment

Modification of Cincinnati Pre-Hospital Stroke

Screen
Face
Arm
Speech
Time of onset
 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
 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
 SPEECH

Ask the patient to say “You can’t 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
Receptive aphasia – unable to understand words
 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
 Assessing the Stroke Patient

Initial Assessment
– General Impression
– Airway Airway Airway!!
– O2 to 94% oxygen saturation
– Circulation
• Pulse
• Blood pressure
– HIGH PRIORITY transport
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
 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 > 94%
– Blood sugar treat if able
• Low blood sugars mimic a stroke
– Pupils
 Position

Protect potentially paralyzed parts

 STROKE Check List
Stroke identification
Use of FAST Screen
Securing A B Cs
EKG monitoring if able (12 lead)
Oxygen saturation of > 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
What are we looking for in CT Scan?
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
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
 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 by a to assess 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 woman sitting on the

couch. She is confused, but responds to verbal
stimuli.

What assessments do you need?

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.
 6:43 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.
 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, institute stroke order sets

 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
 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%
 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 = no
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@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
 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 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)
Race Against Time