Stroke 2006 Debate Optimizing ED Stroke Patient Care: Clinical Questions.
Stroke for cont ed
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Transcript of Stroke for cont ed
Stroke in the United States
Over 780,000 people suffer a stroke in the US each year
By 2020, expected that 1,000,000 Americans will suffer a stroke each year
168,000 deaths per year
Stroke in the United States
Someone has a stroke every 45 seconds
1/3 die, 1/3 become disabled, 1/3 recover
5,800,000 stroke survivors in the US today
3rd leading cause of death – WRONG!!!!
Stroke is now the 5th leading cause of death because of the recognition of signs/symptoms of stroke and early treatment. YOU played a role in decreasing this as a cause of death in the United States!
Emergency Stroke Care
It is a myth that there is not much that can be done for stroke victims
Progress in stroke management has led to:
Improved patient outcomes
Shorter length of hospitalizations and rehabilitations
Decreased referral to nursing homes
Sooner and more frequent return to the work force
Decrease in the incidence of recurrent stroke
Walk vs Cane vs Wheelchair
Pre-Hospital Care
Pre-Hospital care does count!
Responsibilities include obtaining accurate history of symptoms, basic data, physical exam including CPSS, communication with ALS ambulance and notification of the receiving hospital of “stroke code”
Strokes should be looked at with as high a priority as an MI
Ischemic Stroke
Accounts for 80% of all strokes
Most caused by a blood clot that forms in the heart or vascular system and travels up to the brain and plugs an artery
Ischemic Stroke
Most common source of blood clot:
Heart – due to atrial fibrillation, poor ventricular function, or other structural abnormalities
Large arteries like the carotid arteries
Small arteries in the brain damaged by atherosclerosis or other damage
Blood – due to clotting disorders or abnormalities
Hemorrhagic Stroke
Accounts for about 20% of all strokes
Due to blood vessel rupture within the skull not due to trauma
Intracerebral or subarachnoid
Intracerebral Hemorrhage
Defined as bleeding into the brain tissue
Most common cause is chronic hypertension
Other causes include vessel malformation, tumor, and bleeding abnormalities.
Subarachnoid Hemorrhage
Occurs when a blood vessel ruptures and blood spills into the subarachnoid space – between the pia mater and arachnoid membrane
Most common cause is rupture of an aneurysm
Other non-traumatic causes include vessel malformation, tumor, bleeding abnormalities.
Transient Ischemic Attack (TIA)
Ischemic stroke that completely resolves (1 hour)
“Angina” of the brain
Most common cause is thromboembolism
Most patients will go on to have a stroke or recurrent event within 3 months
Transient Ischemic Attack
Among TIA patients who go to ED
5% have stroke w/in 2 days
10% have stroke w/in 3 months
25% have recurrent “event” w/in 3 months
Who is not listed above?!!!
Ischemic Stroke Risk Factors - Nonmodifiable
Advanced age
Male gender
Race (Blacks have nearly 2x risk of first-ever stroke)
Family history of MI or early stroke
Ischemic Stroke Risk Factors - Modifiable
HTN
DM
Hypercholesterolemia
Cigarette smoking
Prior stroke/TIA
Carotid disease, heard disease (a. fib.)
Hypercoagulable states
Cocaine, excessive alchohol
Time is Brain!!!
When a blood vessel is occluded, there is a core of irreversible damage
The penumbra constitutes the zone of reversible ischemia which is salvageable in the first few hours
The most effective agent in saving the penumbra at this time is t-PA
If t-PA is given within 3 hours (even 4.5 hours), the risk of disability is reduced by 30%
The sooner t-PA is given, the better the outcome
The goal for hospitals is to administer TPA within 60 minutes of diagnosing a TPA stroke candidate.
Major Divisions of the Brain
Cerebral cortex (Gray matter) is the computer center of the brain. It consists of nerve cells that control complex functions such as language, mathematics, artistic ability, etc.
Cerebral subcortex (White matter) is composed of nerve fibers that connect the cerebral cortex to the brain stem
Brainstem connects cerebrum and the spinal cord. It contains the cranial nerves to the face and head
Cerebellum coordinates movement
Major Stroke Syndromes
Based on location in the brain
1. Left Hemisphere
2. Right Hemisphere
3. Brainstem
4. Cerebellum
5. Possible Hemorrhage
Left Hemisphere
Controls the movement and sensation of right side of the body
Stroke in Left Hemisphere results in:
o Aphasia
o Right visual field deficit
o Left gaze deviation/preference
o Right hemiparesis
o Right hemisensory loss
Right Hemisphere
Controls the movement and sensation of the left side of the body. It also controls perceptual and spatial abilities.
Stroke in Right Hemisphere results in:
o Left hemi-inattention or neglect
o Left visual field deficit
o Right gaze deviation/preference
o Left hemiparesis
o Left hemisensory losss
Speech should be Fine!
Brainstem
Strokes that occur in the brain stem can be especially devastating due to the compact nature of the area.
Stroke in the Brainstem results in: Eye movement abnormalities – diplopia, dysconjugate gaze,
gaze deviation
Nausea, vomiting, vertigo and tinnitus
Dysarthria – difficulty making speech due to weakness of the muscles of oropharynx
Dysphagia –difficulty swallowing due to weakness of the muscles of the oropharynx
Decreased consciousness
Abnormalities of respirations, pulse, blood pressure possible
Cerebellum
Controls balance and coordination
Strokes in the Cerebellum results in:
Ataxia or dyscoordination
Patients usually have imbalance and walk with a wide-based gait
Hemorrhagic
Cranium is a hard container enclosing brain
Meninges are 3–layered cloth-like coverings of brain and spinal cord
Hemorrhagic stroke suddenly increases intracanialpressure
Hemorrhagic stroke can cause:
Headache
Nausea/vomiting
Decreased level of consciousness
Hemorrhagic
Symptoms suggestive of subarachnoid hemorrhage not usually found with intracerebral hemorrrhage or ischemic stroke:
Intolerance to light
Neck stiffness/pain
Symptoms suggestive of intracerebral hemorrhage:
Focal signs such as hemiparesis (similar to ischemic stroke)
Stroke Mimics
Hypoglycemia – 12.5 g vs 25 g of Dextrose
Posticial state after seizure
Migraine
Tumors
Abscess
Subdural hematoma
CT Scan
Needed for all patients presenting with stroke or stroke symptoms
Necessary prior to administration of thrombolyticsfor stroke
7 D’s: Chain of Survival and Recovery
Detection: stroke onset
Dispatch: EMS activation and response
Delivery: prehospital care to hospital
Door: ED triage
Data: ED evaluation, CT scan
Decision: potential therapies
Drug: therapy – t-PA within 4.5 hours (new treatment options as well)
Pre-Hospital Stroke Care Principles
First do no harm – avoid having glucose, avoid treating hypertension, avoid causing aspiration pneumonia
Report to ED – details of symptom onset, neurologic exam, witness information
Glucose
The rule: Do NOT give glucose-containing solutions to acute stroke patients
Hyperglycemia can worsen patient outcomes, and decreases t-PA efficacy
The exception: Hypoglycemic by fingerstick
(60 dl/mg)
Aspiration Pneumonia
Dysphagia, or difficulty swallowing is a major stroke complication and a poor prognostic sign.
1/3 of patients with dysphagia develop aspiration pneumonia – major cause of morbitdity and mortality
Keep all acute stroke patients NPO and elevate the head of the bed 30◦, turn to side if vomiting.
Oxygen
Goal is to maintain normal oxygen saturations (95%)
Routine use of oxygen has not been shown to of benefit in patients who are not hypoxic
Current recommendations is to give low-flow (2-4L/min).
On-Scene Care
Stroke history and symptom onset
Perform Stroke exam
Prevent aspiration
Prevent hypoxia
Do not delay transport!
En Route Care
Transport urgently
Obtain IV access
Glucose if level less than 60
Screen for t-PA contraindications
Notify ED of possible stroke patient
t-PA Contraindications
Symptom onset more than 4.5 hours
Head trauma or seizure at onset
Recent surgery, hemorrhage, or AMI
Any history of intracranial hemorrhage
Minor or resolving stroke
Sustained BP > 185/110
Mend Exam – Mental Status
Level of Consciousness
Speech (CPSS)
Questions – age and month
Commands – open and close eyes
Aphasia – wrong or inappropriate words
Dysarthria – Slurred Speech
MEND Exam - Limbs
Motor – Arm Drift (CPSS)
Motor – Leg Drift
Sensory – Arm and Leg
Coordination – Arm and Leg
Information for ED
Basic Data – Age, Gender, Chief Complaint
Symptom Onset – Last time without symptoms, Head trauma, Severe headache, Seizure
Supplemental Information – Recent surgery, trauma, MI, Medications, allergies, BP, Glucose, Witness name, contact info
Neurologic Exam – Consciousness, Speech/language, Visual fields, motor strength