Stroke

1. Stroke Martin Community College EMT � Basic Class 2009 Lori Hardison EMT - Paramedic

2. STROKE Emergency Stroke Care: Myth: It doesn�t make a difference Fact: It does! (Just like with a AMI) Better field management Decreased time to ED treatment Problem: Prehospital and hospital personnel must be on the same page Solution: Lead the way

3. STROKE Major Learning Goals: All Health care professionals Early treatment may result in a marked reduction in risk of disability Identify the 5 main stroke syndromes Perform focused evaluation to identify stroke, its location, and severity, and t-PA contraindications

4. STROKE In the United States -1/3 die - 1/3 disabled - 1/3 no or minimal disability Stroke is preventable and treatable

5. Stroke It is important for the EMT to recognize that a pt may be having a stroke. Provide emergency care, begin rapid transport, and notify the receiving medical facility. (communication w/ED) Strokes can lead to comprise airway and inadequate breathing. The EMT should continuously monitor the pt airway and breathing, be prepared to intervene if necessary.

6. STROKE Major Stroke Syndromes: Left Hemisphere Right Hemisphere Brainstem Cerebellum Hemorrhage

7. Stroke The ability to be alert and aware of your surroundings, to speak, feel, and move are all functions of the brain and nervous system. Neurologic deficit is defined as any deficiency in the functioning of the brain or nervous system. Altered mental status slurred or absent speech, paralysis, weakness, and numbness are all signs and symptoms of neurologic deficit.

8. Stroke Remember the pt central nervous system is made up of brain and spinal cord. You must look for sign and symptoms of both traumatic and medical conditions that may be affecting the brain. Care for the pt with a non traumatic brain injury, or a stroke, is a medical injury to the brain that is not related to trauma

9. Stroke Time is critical factor in the emergency care of stroke. Early and prompt recognition of stroke, rapid transport, and notification of the receiving facility are key elements of EMS management of the stroke pt. Early recognition of a stroke leads to early transport and treatment in the emergency department.

10. Stroke Drugs are now available that may be administered to certain stroke pt�s that may reduce or even reverse the consequences of the stroke by breaking up the clot causing the obstruction. Drugs must be administered within 3 hours from the first sign or symptom of the onset of the stroke.

11. Stroke Pt must be delivered to the emergency department at least within 2 hours from the onset of the signs and symptoms of the stroke to allow the emergency department to gather all information and make a decision whether the pt meets the requirements for the medication.

12. Stroke The time of onset of a stroke is commonly defined as the last time the pt was seen neurologically intact. Meaning without any neurologic deficit such as numbness, weakness, paralysis, slurred or stuttering speech, and cognitive problems.

13. Stroke Remember not all pt will exhibit the same symptoms. Example: some pt may have only a simple numbness or tingling in their hands, stuttering or trouble speaking, dizziness, loss of balance, and difficulty understanding. These are vital to recognize as possible indicators of stroke.

14. Stroke The 7 �Ds�, which address the issue of time as a critical factor in reducing permanent disability and death in the stroke patient, are: Detection Dispatch Delivery door, Data Decision drug

15. Stroke The first three of the �Ds� are the responsibility of the general public and emergency medical services. Detection is the recognition of the signs and symptoms of a stroke either by the pt, family or emergency medical responders Dispatch is responsible for recognizing the signs and symptoms described by the caller

16. Stroke Delivery involves the prompt assessment, emergency care and transport of the stroke pt. The last four of the �Ds� are for the emergency department.

17. Stroke A stroke is caused by a sudden brain dysfunction due to blood vessel problem. Stroke is also referred to as a brain attack

18. Stroke Stroke is known as CVA, or cerebrovascular accident. Two types of stroke: Ischemic (80%) Ischemic stroke is very similar to a heart attack, it is due to an inadequate amount of blood being delivered to a portion of the brain caused by a blood clot obstructing the cerebral artery.

19. STROKE Ischemic Stroke: Most common cause: thromboembolism A blood clot forms in the vascular system, travels up, and plugs a cerebral artery Possible sources of clot: Heart Large artery (to brain) Small artery ( in brain) Blood itself

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21. Stroke Two subtypes of ischemic stoke: Thrombotic stroke � from a clot that forms in a cerebral artery Embolic stroke � material carried to and lodging in the cerebral circulation from another area of the body.

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24. STROKE Second type of stroke: Hemorrhagic Stroke (20%) Blood vessel rupture within skull (cranium) not due to trauma Intracerebral (12%) or subarachnoid (8%)

25. STROKE Most common cause aneurysm rupture Other causes: Vessel malformation Tumor Bleeding abnormalities

26. Stroke Hemorrhagic stroke is due to rupture of a vessel in the brain that allows blood to leak and collect in or around the brain tissue (subarachnoid). Bleeding within the brain is called intracerebral. Chronic hypertension is a common risk factor for hemorrhagic stroke.

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28. Stroke It is difficult to distinguish between the two types of strokes, ischemic and hemorrhagic in the field. The primary difference is that the pt suffering from an ischemic stroke can receive the drug, fibrinolytic, to break up the clot and restore perfusion to the area of the brain that was not receiving an adequate supply of blood.

29. Stroke Hemorrhagic stroke pt cannot receive a fibrinolytic drug because it may increase the amount of bleeding within the brain and worsen the stroke and may lead to the pt death.

30. Stroke Stroke most often affect the elderly who have a history of atherosclerosis (fat deposit in the arteries), heart disease, or hypertension. S&S of stroke associated with the specific area of the brain that has been affected by disruption in the blood flow. It most commonly involves the areas that control speech, sensation, and muscle function.

31. Stroke The onset of S&S is usually sudden and may be accompanied by a seizure, headache, or the inability to swallow (dysphagia)

32. STROKE Dysphagia � inability to swallow Dyspnea � experiencing difficulty in breathing.

33. Stroke Paralysis is a very common sign in the stroke pt. Other common signs are: Facial droop � there is a loss of facial expression on one side and the facial features droop downward. Monoplegia � paralysis of one extremity on one side of the body Hemiplegia � paralysis of both extremities on one side of the body

34. Stroke Why does this happen this way? Because the nerve on one side of the brain cross over to the other side, the damage is usually noticeable on the side opposite the affected area.

35. STROKE Example: if a stroke occurs on the left side of the brain, the damage is noticeable on the right side of the body.

36. Stroke An unusual occurrence is paralysis from a stroke affecting both extremities on both sides of the body If both sides of the body is affected usually the face will be paralyzed on one side and the extremities will be weak or paralyzed on the opposite side

37. Stroke Paralysis is one factor that will help you distinguish stroke from a spinal injury. Spinal injury will frequently cause paralysis to both legs (paraplegia) or to all four extremities (quadriplegia) In stroke pt carefully monitor because the weakness may progress to complete paralysis.

38. Stroke In pt suspected of a stroke alterations in mental status commonly range from simple confusion or dizziness to complete unresponsiveness. The speech of the pt maybe slurred (dysphasia), or completely absent (aphasia).

39. Stroke Pt may also speak clearly, uttering nonsensical words (fluent aphasia). Also they may experience double or blurred vision, loss of vision in one eye, or loss of a visual field.

40. Stroke Transient Ischemic Attack: (TIA) Most S&S are the same as a pt experiencing a stroke. Key difference is that the S&S of a TIA typically disappear within 10-15 minutes but almost always within 1 hour of the onset of the S&S.

41. STROKE TIA (TRANSIENT ISCHEMIC ATTACK) Decrease stroke risk with proper therapy

42. STROKE Ischemic Stroke Risk Factors Non modifiable: Advanced age Male gender Family history of MI or early stroke

43. STROKE Ischemic Stoke Risk Factors Modifiable: Hypertension Diabetes mellitus Hypercholesterolemia Cigarette smoking Prior stroke / TIA Carotid disease, heart disease Hypercoagulable Cocaine, excessive alcohol

44. Stroke TIA always resolves within 24 hours without causing any permanent neurologic disability. Ischemia refers to an oxygen deficit in the tissues affects the brain and causes the stroke like signs and symptoms to appear.

45. Stroke Remember a transient ischemia stroke last no longer than 15 minutes and will almost always resolve within one hour from the onset. Approximately 30% of pt who suffer a TIA will eventually have a stroke.

46. Stroke TIAs are important to recognize and report. Although this incident is very frightening for pt�s, some may refuse emergency care and transportation to a medical facility because the signs and symptoms have disappeared.

47. Stroke You must encourage the pt to seek medical attention, also explain all risk if the pt refuses medical care. Medical care for a pt suffering a TIA is the same as a pt suffering a stroke

48. STROKE Time is Brain: save the Penumbra Penumbra is zone of reversible ischemia around core of irreversible infarction- salvageable in first few hours after ischemia stroke onset.

49. STROKE PENUMBRA

50. STROKE Penumbra is damaged by: Seizure Hypotension Hyperglycemia Fever

51. Stroke Medical care: scene size up Look for any signs that would make you suspect that the pt head or spine has been injured. Scan the scene for drugs, alcohol, or drug paraphernalia, prescription and illegal drugs. Which may cause altered function. Look for evidence of amphetamines, cocaine, and other stimulants, since they relate to nontrauma brain injury in young adults,

52. Stroke Noted how the pt was found, and how the pt was dressed. Why would you need to concerned on how the pt is dressed is important?

53. Stroke Many strokes occur at night and the pt awakens with neurologic deficits Also most stroke pt have a bucket or ice packs near them. Due to nausea, vomiting or headache

54. Stroke Initial assessment: Immediately inspect the pt�s airway and suction any vomitus and secretions. If spinal injury is suspected, perform a jaw thrust maneuver to open the airway.

55. Stroke Pt with altered neurologic status may not be able to control his own airway. The muscles supporting the tongue relax or become paralyzed, the support of both the tongue and epiglottis is lost.

56. Stroke Focused history and physical exam The pt is unresponsive, you will perform a physical exam and obtain baseline vital signs before you obtaining the SAMPLE history. Responsive pt, you will take the history before performing the physical exam and obtaining vital signs.

57. Stroke Remember that paralysis or loss of speech is frightening to the pt. It is extremely important that you remain calm and confident and continuously reassure the pt.

58. Stroke Suspect a stroke in any pt with sudden weakness of the face, hand, arm or leg; trouble speaking or stuttering; difficulty seeing in one or both eyes; problem walking or a loss of balance or coordination; confusion; dizziness; or a sudden severe headache

59. Stroke Pt with loss of motor or sensory function, speech difficulties, or an altered mental status may be suffering from a head injury. It is extremely important to inspect and palpate the head for possible trauma

60. Stroke Physical exam: Inspect � facial droop Listen � garbled sounds or slurring of speech Note the pt ability to follower command When assessing the extremities, reduction in the sensory and motor function When performing a neurologic examination on responsive pt

61. Stroke Cincinnati Prehospital Stroke Scale: Facial droop � show teeth or make a smile Arm drift � pt close eyes and hold both arm straight out for 10 seconds Abnormal speech � have pt repeat � you can�t teach old dogs new tricks.�

62. Stroke Los Angeles Prehospital Stroke Screen (LAPSS): Takes in consideration other possible causes of altered mental status, such as Hypoglycemia Hyperglycemia Seizures

63. Stroke LAPSS: Age greater than 45 years History of seizure or epilepsy Duration of symptoms Wheel chair or bedridden status of pt Blood glucose level Asymmetry of strength is assessed by testing facial smile or grimace, grip, and arm strength

64. STROKE MENDS: Miami Emergency Neurologic Deficit Mental Status Level of Consciousness (AVPU) Speech: �You can�t teach an old dog new tricks� Questions (age, month) Commands (close , open eyes)

65. STROKE MENDS: Miami Emergency Neurologic Deficit Cranial Nerves Facial Droop (show teeth or smile) Visual Fields (four quadrants) Horizontal Gaze (side to side)

66. STROKE MENDS: Miami Emergency Neurologic Deficit Limbs: Motor � Arm Drift (close eyes � hold out arms) Leg Drift (open eyes � lift each leg separately Sensory � Arm, Leg (close eyes & touch, pinch) Coordination � Arm, Leg (finger- nose, heel � shin)

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68. Stroke Keep in mind that any one of the following physical exam findings is strongly suggestive of a stroke: Facial � droop of one side of the face when the pt is asked to smile or show his teeth

69. STROKE One arm does not move or one arm drifts downward when the pt�s arms are extended outward for 10 seconds with his eyes closed The pt slurs his words, uses wrong words, or is unable to speak when asked to repeat the phase Weak or no grip on one side of the body when asked to squeeze your fingers.

70. Stroke Answers to the following questions will guide you in your emergency care of the pt: When did the symptoms begin? Is there any recent history of trauma to the head? Does the pt have a history of previous stroke? Was there any seizure activity noted prior to your arrival?

71. Stroke What was the pt doing at the time of onset of the signs and symptoms? Does the pt have a history of diabetes? Has the pt complained of a headache? A stiff neck? Has the pt complained of dizziness, nausea, vomiting or weakness? Has the pt experienced any slurred speech?

72. Stroke Following information will be helpful to the hospital staff who is receiving the pt: Does the pt take any oral anticoagulant drugs? Does the pt have a history of HTN? Has the pt taken amphetamines, cocaine, or some other stimulant drug?

73. STROKE Was the onset of signs and symptoms gradual or sudden? Did the signs and symptoms get progressively worse or better? Did the paralysis or weakness affect one part of the body first and then progress to other areas? Does the pt have a history of atrial fibrillation or irregular heart beat?

74. Stroke The three most common findings are facial droop, arm drift, and speech disturbances and others include: Altered mental status Sudden onset of paralysis Numbness Speech disturbances Loss of control of the bladder or bowel Unequal pupils Deterioration or loss of vision Eyes turned away from the side that is paralyzed

75. STROKE Nausea and vomiting Sudden onset of severe headache Seizure activity Stiff neck Sensory or receptive aphasia In coordination Poor balance Hearing loss Light or sound sensitivity Vertigo dizziness

76. Stroke In some types of stroke, it is important to realize that the signs and symptoms may progress and the pt�s condition may continue to deteriorate. This is particular true of the mental status, speech disturbance, numbness, weakness, and paralysis

77. Stroke Emergency Medical Care: Maintain a patent airway Suction secretions and vomitus Be prepared to assist ventilation Maintain oxygen therapy � 15 LPM via NRB Position the patient � left lateral recumbent Check the blood glucose level Protect any paralyzed extremities Rapid transport

78. Stroke Do not delay transport to perform detailed physical exam Perform an ongoing assessment every 5 minutes