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How
Stroke in the US
One case of stroke every 45 seconds
Results in devastating disability
New Advancements
Large
Frequently congested
with plaque
Can be cleaned out surgically
Vertebral arteries
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
Ischemic STROKE
Blood clot
Air bubble
Bubble of amniotic fluid
Bone marrow from
a fracture
Hemorrhagic STROKE
Malformed Artery
Age
Gender
Race
Prior strokes
Heredity
Sickle Cell Disease
Hemorrhagic
Visual disturbance
Sensitivity to light
Weakness on one side
Can present like a migraine headache
Ischemic Stroke
Harder to detect
Weakness in one side
Facial drooping
Numbness and tingling
Language disturbance
Visual disturbance
Coordination problems
Perception
Recognition of familiar
objects
Time is tissue
The longer the brain is without
oxygen and glucose the more
brain cells die
making
Data CT Scan
Decision Ischemic or Hemorrhagic, does the patient
Face
Arm
Speech
Time
of onset
FACE
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
Abnormal Speech
Slurring of speech
Unable to think of words
Inappropriate words
Expressive aphasia unable to speak words
TIME OF ONSET
180 minutes
Dont think of as 3 hours, but 180 minutes
Time gets eaten up fast
Short scene time
Take transport time into consideration
Initial Assessment
General Impression
Airway Airway Airway!!
High-flow O2
Circulation
HIGH PRIORITY TRANSPORT
Stroke Screen
History of
Seizures
Headache
Nausea/vomiting
Neck pain
Priorities of care
Recent seizure
Could be a subdural hematoma
Pupils
Position
Securing A B Cs
Stroke identification
Use of FAST Screen
EKG monitoring if able
Oxygen saturation of > 94%
Management of blood glucose
IV access (ILS/ALS)
Blood specimens obtained (ILS/ALS)
Head of Bed elevated 15 degrees
Early communication with Physician
Urgent transport to CT Scan
Hypoglycemia
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
6:35 pm
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
6:43 pm
FAST
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.
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
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
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
Quiz
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
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
7-8
Age
Gender
Race
9.
prior strokes
heredity
Sickle cell disease
Face
10. Arm
11. Speech
12. Last known well