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Cerebral Vascular Accidents. Incidence. Stroke is the third leading cause of death in the United States leading cause of brain injury in adults Leading diagnosis from hospital to long-term care New treatments may alter the outcome of stroke patients TPA. Definition. - PowerPoint PPT Presentation
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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