STROKE
CODE STROKE AND THE PCT
“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
CVA
 How
big is the problem of
STROKE?
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

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

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
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 storage
in the brain for
either fuel or oxygen
 Requires constant
supply of oxygen and glucose.

Blood Supply to the Brain

Carotid arteries – anterior neck



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Large
Frequently congested
with plaque
Can be cleaned out surgically
Vertebral arteries



Pass through cervical vertebrae
Well protected
Not accessible for
surgical cleaning
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

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

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
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
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
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

Can STROKES be prevented?
High blood cholesterol
 Sedentary lifestyle
 Obesity
 Seasons– spring and fall
 Stress

Risk Factors Unable to Control


Age
Gender


Race

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more women than men
African American high risk
Prior strokes
Heredity
Sickle Cell Disease

Causes clot formation and
strokes even in children
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
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 Stroke
Right side paralysis
 Speech and language disturbance
 Behavioral changes
 Swallowing problems

Right Brain Damage
Left side paralysis
 Spatial perception


Where your limbs
are in relation to the room
Coordination problems
 Perception

Recognition of 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/ 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
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!!”
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


Problem with gripping hands
Many elderly have arthritis in hands
 Hurts to grip hands
 May mimic weakness

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

Abnormal Speech

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

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
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

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

Assessing the Stroke Patient

Initial Assessment
General Impression
 Airway Airway Airway!!
 High-flow O2
 Circulation
 HIGH PRIORITY TRANSPORT

Assessing the Stroke Patient

Focused history and physical exam

Perform thorough neurologic exam.
 FAST
Stroke Screen
 History of



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
Seizures
Headache
Nausea/vomiting
Neck pain
Obtain baseline set of vitals
 Recheck
Vital Signs frequently
Priorities of care

Conduct general assessment

Trauma – recent or within last month


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Cardiovascular – on heart medications




Does the patient have atrial fibrillation
Does the patient take blood thinners
Pulse oximetry > 94%
Blood sugar treat if able


Recent seizure
Could be a subdural hematoma
Low blood sugars mimic a stroke
Pupils
Position

Protect potentially paralyzed parts
STROKE Check List
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Securing A B Cs
Stroke identification
Use of FAST Screen
EKG monitoring if able
Oxygen saturation of > 94%
Management of blood glucose
IV access
Blood specimens obtained
Head of Bed elevated 15 degrees
Early communication with Physician
Urgent transport to CT Scan
Non Contrast CT of Head
Want a normal CT
Acute Hemorrhagic Stroke
Blood shows up white
Sub Arachnoid Bleed
Blood in meninges due to
aneurysm
Could this be anything other
than a STROKE?

Transient Ischemic Attack

Hypoglycemia
Race Against Time
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

NINDS** Recommended Goals
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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
10 minutes
25 minutes
45 minutes
60 minutes
15 minutes
120 minutes
180 minutes
* by phone or in person
** National Institute of Neurological Diseases and Stroke
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
What could be the problem?
Seizure
 Code
 Myocardial infarction
 Diabetic reaction
 Medication reaction
 Anxiety attack
 STROKE

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?
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

ABC/FAST

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 – within 20 minutes

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.

HIGH PRIORITY

Does Mrs. Short meet the criteria so far to
be on the Primary STROKE Care track to
receive thrombolytics (tPA)?

YES, Proceed with Stroke protocol
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
 No facial drooping
 Good eye contact

Case 2 cont.
Symptoms began 0615 per patient
 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
BUT blood sugar is low!
 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.
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

Time window has closed. Not a candidate
for thrombolytic treatment. Transport to
ED for acute care.
Quiz

What are the 2 general types of stroke?



What condition is equivalent to “angina” of the
brain?


1.
2.
3.
What are 3 risk factors for stroke that can be
modified?



4.
5.
6.
Quiz

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.
QUIZ

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


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
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Cigarette smoking
Sedentary lifestyle
Obesity
Seasons
Stress
Alcohol intake
High blood cholesterol
Carotid Congestion
Uncontrolled diabetes
Atrial fibrillation
Uncontrolled heart disease
Answers

7-8



Age
Gender
Race
 9.
prior strokes
heredity
Sickle cell disease
Face
 10. Arm
 11. Speech
 12. Last known well
Answers
13. Clot busting drugs, thrombolytics, tPA
 14. 3 hours (180 minutes)
