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How
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
New Advancements
The
Learn
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.
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
Problem
Multiple
sharp corners
where blood clots could
get caught
Area where brain
aneurysms are typically
located
build up arthrosclerosis
Foreign debris blood clot, fat, air bubble
Broken vessel -- aneurysm
Ischemic STROKE
Progressive Thrombus
Plaque
Cerebral
clot
Air bubble
Bubble of amniotic fluid
Bone marrow from
a fracture
Hemorrhagic STROKE
Aneurysm
Congenital
Younger
Hypertensive Bleed
BP 200/100
Malformed Artery
50%
Free Spin
Looks
risk factors
BP
Cigarette smoking
Alcohol intake
Uncontrolled Heart disease
Atrial fibrillation
Uncontrolled Diabetes
Carotid congestion
High
blood cholesterol
Sedentary lifestyle
Obesity
Seasons
Stress
strokes
Heredity
Sickle Cell Disease
Hemorrhagic
Sudden
and dramatic
Violent explosive headache
Visual disturbance
Nausea and vomiting
Neck and back pain
Sensitivity to light
Weakness on one side
explosive headache
Visual disturbance
Nausea and vomiting
Neck and back pain
Sensitivity to light
Signs
Ischemic
Harder
Stroke
to detect
Weakness in one side
Facial drooping
Numbness and tingling
Language disturbance
Visual disturbance
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
side paralysis
Spatial perception
Unable
to locate objects
Coordination
Perception
Unable
to recognize or name
familiar objects
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
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
your community
At first signs of a possible STROKE call
EMS
Dont guess call EMS!!
Modification
of Cincinnati Pre-Hospital
Stroke Screen
Face
Arm
Speech
Time
of onset
FACE
Look
Have
ARMS
Motor
Avoid
Assessment
SPEECH
Ask
Abnormal Speech
Slurring
of speech
Unable to think of words
Inappropriate words
Expressive
words
Able
to understand speech
Knows what to say
Unable to put words together
Able to speak clearly if speaking from memory
Able
Receptive
words
People
TIME OF ONSET
The
Last
when
Patient
lives alone
Patient woke up with symptoms
Initial Assessment
General
Impression
Airway Airway Airway!!
High-flow O2
Breathing
Circulation
HIGH PRIORITY
Exam
FAST
Form
History of: (looking for bleeding aneurysm)
Seizures
Headache
Nausea/Vomiting
Neck
Baseline
Pain
Recheck
Priorities of care
Conduct
Trauma
Recent
seizure
Could be a subdural hematoma
Cardiovascular
on heart medications
Does
Pupils
Position
Protect
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
Ischemic Attack
Hypoglycemia
assessments, vocabulary,
protocols and goals
EMS
Hospital
Direct
transport to CT scan
Early identification of candidates
Door to treatment goal is 60 minutes
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
What
infarction
Diabetic reaction
Medication reaction
Anxiety attack
STROKE
6:35 pm
Upon
What
ABC --FAST
Airway
The
The
6:45 pm
This
FAST
How
Case 1 cont
Face
HIGH PRIORITY
Determine
Does
YES,
Case 2 cont.
Symptoms
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
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
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
Case 3 cont
Face
Case 3 Cont.
Time
of onset = unknown
Severe Headache = unknown
Emesis = no
Seizures = unknown
Blood sugar = OK
Case 3
Time
Review
Answer
Quiz
What
1.
2.
What
3.
What
What
What
In
What
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.
10.
11.
12.
prior strokes
heredity
Sickle cell disease
Face
Arm
Speech
Last known well
13.