Cerebral Vascular Accidents

Cerebral Vascular Accidents

Incidence

Stroke is the third leading cause of death in the United Stateso leading cause of brain injury in adultso Leading diagnosis from hospital to long-

term careNew treatments may alter the outcome of

stroke patientso TPA

Definition

Cerebral Vascular Accident (Stroke)A neurological impairment caused by

disruption of blood supply to a portion of the brain – an artery becomes blocked or ruptures

two different types of stroke1. Ischemic2. Hemorrhagic

Ischemic StrokeCaused by a clot occluding a blood

vessel in the brainSlow onset of symptomsAccount for approximately 75% of

strokesRarely immediately fatalCause classic stoke

signs/symptoms

2 Types of Ischemic Stroke

1. Thrombolitic – blood clot in vessel

2. Embolic – clot developed elsewhere in the body (usually the heart) and then migrates to the brain

Hemorrhagic Stroke

Caused by the rupture of a cerebral artery, causing bleeding on the surface of the brain, or directly in the brain tissue itself

Rapid onset of symptomsSeverity depends on location and

sizeOften fatal at onset

1. HIGH BLOOD PRESSURE

a. High blood pressure is one of the most important modifiable risk factors for both types of stroke

b. Risk of hemorrhagic stroke greatly increases with elevated systolic pressure

STROKE IS AN EMERGENCYSTROKE IS AN EMERGENCY

2. CIGARETTE SMOKING

a. Can cause accelerated atherosclerosis and increased blood pressure

b. Cessation of cigarette smoking reduces risk of stroke

STROKE IS AN EMERGENCYSTROKE IS AN EMERGENCY

3. TIAs – Transient Ischemic Attack

a. Approximately 25% of patients presenting with a stroke have had a previous TIA

b. Treatment options include Carotid Endarterectomy Antiplatelet (ASA) Anticoagulants (Coumadin)

STROKE IS AN EMERGENCYSTROKE IS AN EMERGENCY

4. HEART DISEASE

a. Heart disease significantly increases the risk of stroke. CAD and CHF double the risk of strokes

b. Prone to the formation of blood clots

STROKE IS AN EMERGENCY!!!!STROKE IS AN EMERGENCY!!!!

5. DIABETES

a.Is associated with accelerated atherosclerosis

STROKE IS AN EMERGENCYSTROKE IS AN EMERGENCY

6. BLOOD DISORDERS

a. Hematological disorders which may produce hypercoagulatory conditions – as seen with sickle cell anemia

Unmodifiable Risk Factors

1. Age Single most important risk factor in

patients past 55

2. Gender Men are at greater risk; however, more

women live past the age of 65, and more women past 65 die from strokes than men

Unmodifiable Risk Factors

3. Race African-Americans have more than

twice the risk of death & disability Generally have a greater number of risk

factorssmoking, high blood pressure, sickle cell

anemia, diabetes

Unmodifiable Risk Factors

4. Prior Stroke risk is highest within the first 30 days

after a stroke

5. Heredity risk is greater for people with a family

history of stroke

TRANSIENT ISCHEMIC ATTACK (TIA)

Considered a TIA when the S/S of the stroke go away within 24 hours - commonly referred to as a “mini-stroke”

TIA is the most important forecaster of brain infarction

5% develop actual CVA’s within 30 days

STROKE IS AN EMERGENCYSTROKE IS AN EMERGENCY

Signs and Symptoms

1. Confusion2. Rapid, bounding pulse3. Dizziness4. Difficulty breathing5. Impaired Speech - Aphasia –

patients knows what he/she wants to say but words come out wrong

6. Nausea Vomiting

Signs and Symptoms7. Numbness or paralysis (one side of

body)8. Seizures9. Loss of muscle tone on one side of the

face – facial drooping10.Unconsciousness11.Headache (uncommon)12.Loss of bowel or bladder control13.Unequal pupils14.Impaired vision

Patient Care

Goals for EMS providers:oRapid recognition of stroke

signs/symptomso Support of vital functionsoRapid transport to an appropriate facilityo Pre-arrival notification of receiving

hospital

Patient Care

Conscious Patient:1.Reassure the patient. 2.Administer high concentration

oxygen.3.Transport in semi-fowlers position.

Unconscious patient:1.Provide high concentration oxygen.2.Transport in the recovery position –

lay them on the affected side.

Assessment of Patiento Chief Complainto Initial Assessment

Assess and support airway, breathing, circulation

o History of present illnessfollow “Altered Mental Status” history“Onset of Symptoms” very

importantCincinnati Stroke Assessment

Rapid Recognition

Physical ExamCheck for facial droop

ask patient to smile

Rapid Recognition

Physical ExamCheck for neurological disability• grip strength• arm drift

• patient closes eyes, holds both arms out• normal - both arms move the same or not at all• abnormal - one arm does not move or one arm

drifts down compared with the other

ARM DRIFT

Patient closes eyes and holds both arms out

Rapid Recognition

Check for speech abnormalities• Ask patient to say, “you can’t teach an old

dog new tricks” or “the chicken wings taste great in Buffalo”• assess for slurred words, inappropriate

words, or inability to speak

Rapid Transport

Load and Go Patients!Be prepared to suctionRequest ALS back-upRapid transport to an appropriate

facilityoMFG, KMH, ECMC, Buffalo Mercy, Sisters

Notify receiving hospitalo Activation of the “Stroke Team”

Treatment...

Tissue Plasminogen Activator (TPA)o First approved therapy for ischemic strokeo Patients treated within 2 hours (NYS Protocol)

of the onset of symptoms are at least 30% more likely to have minimal or no disability after 3 months

o Stroke type must be confirmed by CAT scan prior to treatment

o Increases our sense of urgency

NINDS RECOMMENDATIONS

Time Dependent Treatment

Door to doctor 10 MinutesDoor to CT completion 25 MinutesDoor to CT read 45 MinutesDoor to treatment 60 Minutes

STROKE IS AN EMERGENCYSTROKE IS AN EMERGENCY

Acute Stroke Treatment Window

Intravenous thrombolysis 3 hours

Intra-arterial thrombolysis 6 hours

Neuroradiological Intervention

Intravenous thrombolysis 3 hours

Intra-arterial thrombolysis 6 hours

Neuroradiological Intervention

Summary

Once CVA is suspected, patient is a “load and go”

Priorities include maintaining the ABC’s

ALS interventions enroute as neededPrenotify receiving hospital

Overview

Review incidence of CVA’sReview pathophysiology of CVA’sReview risk factors for CVA’sDiscuss treatment of patients with

possible CVADiscuss in-hospital treatment

options, how they effect EMS’s role

Modifiable Risk Factors

High blood pressureCigarette smokingPrevious TIA’s (ministrokes)Heart Disease

prone to formation of blood clotsDiabetesSickle Cell Anemia

Signs/Symptoms - Hemorrhagic Stroke

Severe Headache occurs suddenly, often during exertion often radiates to the neck or face

Loss of ConsciousnessSevere headache with a transient

loss of consciousness is particularly alarming.

Signs/Symptoms - Hemorrhagic Stroke

Nausea/vomitingNeck painIntolerance of noise or lightAltered mental status Focal neurological deficits with

associated nausea, vomiting, headache, and loss of consciousness

Signs/SymptomsIschemic Stroke & TIA

Signs/symptoms of a stroke will persist; TIA signs/symptoms last a few minutes to several hours.

Unilateral Paralysis weakness, clumsiness or heaviness involving

one side of the face and extremities on the opposite side of the body

Numbness sensory loss, tingling, or abnormal sensation,

most commonly involving the face and hand

Signs/SymptomsIschemic Stroke & TIA

Language Disturbances trouble selecting correct words,

incomprehensible or nonsense speech, trouble understanding other’s speech

Visual Disturbances blurred or indistinct vision in one side of the

field of vision in both eyes

Signs/SymptomsIschemic Stroke & TIA

Monocular Blindness painless loss of part or all vision in one eye

Vertigo sense of spinning or whirling

Ataxia poor balance, stumbling gait, staggering,

uncoordinated with one side of the body

Support & Treatment

Maintain ABC’s Hemorrhagic stroke patients may

present with coma, inability to maintain airway, vomiting, seizures

Be prepared to suction, ALS back-upAssisting ventilation

Do not hyperventilate unless patient presents with Herniation Syndrome