STROKE: FAST ApproachSTROKE: FAST Approach

Provena Covenant Medical CenterProvena Covenant Medical Center

November 2011November 2011

““Grandpa had a stroke”Grandpa had a stroke”

Not too long ago this statement meant Not too long ago this statement meant death or disastrous disability for patients death or disastrous disability for patients and families. and families.

In the 21In the 21stst century medical science has century medical science has progressed in the understanding of progressed in the understanding of STROKE, prevention STROKE, prevention

and treatmentand treatment

How big is the problem of How big is the problem of STROKE?STROKE?

Magnitude of the ProblemMagnitude of the Problem

795,000 Americans annually suffer a 795,000 Americans annually suffer a STROKESTROKE

25% die25% die#3 killer of women#3 killer of women25% of women have strokes before age 25% of women have strokes before age

6565#1 cause of long term disability#1 cause of long term disability

Stroke in the USStroke in the US

One case of stroke every 45 secondsOne case of stroke every 45 secondsResults in devastating disabilityResults in devastating disability

16% institutionalized in nursing homes16% institutionalized in nursing homes31% assistance with Activities of Daily Living 31% assistance with Activities of Daily Living

(bathing, dressing eating)(bathing, dressing eating)20% assistance with walking20% assistance with walking30% depressed30% depressedAnnual cost of $58 billionAnnual cost of $58 billion

New AdvancementsNew Advancements

The FDA has approved the same clot The FDA has approved the same clot busting drugs (tPA thrombolytic) used in busting drugs (tPA thrombolytic) used in heart attacks to be used in brain attacks – heart attacks to be used in brain attacks – stroke.stroke.

Only 2% of stroke victims are treated with Only 2% of stroke victims are treated with thrombolytic medicationthrombolytic medication

Aggressive treatment begins with Aggressive treatment begins with assessment and intervention at point of assessment and intervention at point of patient contactpatient contact

Before STROKE can be Before STROKE can be managedmanaged

Learn more about what strokes are and Learn more about what strokes are and how they happen.how they happen.

A very selfish organA very selfish organ

The brain requires The brain requires 20 % of 20 % of the total bloodthe total blood pumped pumped by the heart.by the heart. No fat for storage No fat for storage in the brainin the brain Requires constant Requires constant supply of oxygen and glucose.supply of oxygen and glucose.

Blood Supply to the BrainBlood Supply to the Brain

Carotid arteries – anterior neckCarotid arteries – anterior neckVery largeVery largeCan be cleaned out if Can be cleaned out if Get occluded with arthrosclerosisGet occluded with arthrosclerosis

Vertebral arteries – Vertebral arteries – through cervical vertebraethrough cervical vertebrae

SmallerSmallerWell protected by vertebraeWell protected by vertebraeCan’t clean out surgicallyCan’t clean out surgically

Circle of WillisCircle of Willis

Both blood supplies join on the under Both blood supplies join on the under surface of the brain.surface of the brain.

Fail-safe mechanismFail-safe mechanism

in case of a blockagein case of a blockage

somewhere in somewhere in

circulationcirculation

Problem with Circle of WillisMultiple sharp corners

where blood clots could

get caughtArea where brain

aneurysms are typically

located

What can go wrong???What can go wrong???

Disruption of blood flow to the brainDisruption of blood flow to the brainPlaque – build up arthrosclerosisPlaque – build up arthrosclerosisForeign debris – blood clot, fat, air bubbleForeign debris – blood clot, fat, air bubbleBroken vessel -- aneurysmBroken vessel -- aneurysm

Ischemic STROKEIschemic STROKE

Progressive ThrombusProgressive Thrombus Plaque deposit – similar to process in heart with Plaque deposit – similar to process in heart with

coronary artery diseasecoronary artery disease

Cerebral Emboli --Clot from somewhere else -- Cerebral Emboli --Clot from somewhere else -- floating debrisfloating debris Blood clotBlood clot Air bubbleAir bubble Bubble of amniotic fluidBubble of amniotic fluid Bone marrow fromBone marrow from

a fracturea fracture

Hemorrhagic Hemorrhagic STROKESTROKE

Aneurysm – weakened area in arteryAneurysm – weakened area in arteryCongenitalCongenitalYounger population younger than 40 yearsYounger population younger than 40 years ““worst headache in my life”worst headache in my life”

Spontaneous Hypertensive BleedSpontaneous Hypertensive BleedBP 200/100BP 200/100

Malformed ArteryMalformed Artery50% younger than 30 years50% younger than 30 years

Transient Ischemic AttackTransient Ischemic Attack

““One Free Spin”One Free Spin”Looks like a stroke but, symptoms improve in Looks like a stroke but, symptoms improve in

1-24 hours1-24 hoursTemporary disruption of blood flow to the Temporary disruption of blood flow to the

brain --Angina of the brainbrain --Angina of the brainWarning signWarning signMimicked by low blood sugarMimicked by low blood sugar30% of patients will have a true stroke in 30 30% of patients will have a true stroke in 30

daysdays

Can STROKES be prevented?Can STROKES be prevented?

Modifiable risk factorsModifiable risk factorsHigh BPHigh BPCigarette smokingCigarette smokingAlcohol intakeAlcohol intakeUncontrolled Heart diseaseUncontrolled Heart diseaseAtrial fibrillationAtrial fibrillationUncontrolled DiabetesUncontrolled DiabetesCarotid congestionCarotid congestion

High blood cholesterolHigh blood cholesterolSedentary lifestyleSedentary lifestyleObesityObesitySeasonsSeasonsStressStress

Risk Factors Unable to ControlRisk Factors Unable to Control

AgeAgeGenderGenderRaceRacePrior strokesPrior strokesHeredityHereditySickle Cell DiseaseSickle Cell Disease

Signs and Symptoms of Signs and Symptoms of STROKESTROKE

HemorrhagicHemorrhagicSudden and dramaticSudden and dramaticViolent explosive headacheViolent explosive headacheVisual disturbanceVisual disturbanceNausea and vomitingNausea and vomitingNeck and back painNeck and back painSensitivity to lightSensitivity to lightWeakness on one sideWeakness on one side

What else does this sound like?

Violent explosive headacheViolent explosive headacheVisual disturbanceVisual disturbanceNausea and vomitingNausea and vomitingNeck and back painNeck and back painSensitivity to lightSensitivity to light

Signs and symptoms similar to a migraine headache.

Signs and Symptoms of Signs and Symptoms of STROKESTROKE

Ischemic StrokeIschemic StrokeHarder to detectHarder to detectWeakness in one sideWeakness in one sideFacial droopingFacial droopingNumbness and tinglingNumbness and tinglingLanguage disturbanceLanguage disturbanceVisual disturbanceVisual disturbance

Left Brain DamageLeft Brain Damage

Right side paralysisRight side paralysisSpeech and language disturbanceSpeech and language disturbanceBehavioral changes—Behavioral changes—

anger, depressionanger, depressionSwallowing problems—Swallowing problems—

Patients choke easilyPatients choke easilyNothing to eat or drink Nothing to eat or drink

till assessed for choking risktill assessed for choking risk

Right Brain DamageRight Brain Damage

Left side paralysisLeft side paralysisSpatial perception –Spatial perception –

Unable to locate objects Unable to locate objects CoordinationCoordinationPerception – Perception –

Unable to recognize or name Unable to recognize or name

familiar objectsfamiliar objects

Primary Stroke CarePrimary Stroke Care

180 minute window of time180 minute window of time Time is tissueTime is tissue The longer the brain is withoutThe longer the brain is without oxygen and glucose the more oxygen and glucose the more brain cells diebrain cells die

Goal is to restore blood flow as Goal is to restore blood flow as soon as possiblesoon as possible

Treatment is a system beginning with early Treatment is a system beginning with early recognition and continuing through rehabilitationrecognition and continuing through rehabilitation

Goals of Primary STROKE CareGoals of Primary STROKE Care

Rapid Recognition of STROKE SymptomsRapid Recognition of STROKE SymptomsRapid access in to the medical systemRapid access in to the medical systemAssessmentAssessmentTreatmentTreatment

Seven D’s of STROKE CareSeven D’s of STROKE Care

Detection –Detection –of STROKE symptomsof STROKE symptoms

Dispatch–Dispatch– of EMS of EMS

DeliveryDelivery – to a facility prepared to manage STROKE – to a facility prepared to manage STROKE

Door to treatment– Door to treatment– rapid diagnosis and decision rapid diagnosis and decision makingmaking

Data–Data– CT Scan CT Scan

Decision–Decision– Ischemic or Hemorrhagic, does the patient Ischemic or Hemorrhagic, does the patient meet the criteriameet the criteria

Drug –Drug – thrombolytic when appropriate thrombolytic when appropriate

EMS Has a Critical RoleEMS Has a Critical Role

Educate your communityEducate your communityAt first signs of a possible STROKE call At first signs of a possible STROKE call

EMS EMS ““Don’t guess call EMS!!”Don’t guess call EMS!!”

Use a “Use a “FASTFAST” STROKE ” STROKE AssessmentAssessment

Modification of Cincinnati Pre-Hospital Modification of Cincinnati Pre-Hospital Stroke ScreenStroke Screen

FaceFaceArmArmSpeechSpeechTime of onsetTime of onset

Print off a copy of the attached PDF file of the PREMSS FAST form

FACEFACE

Look for Facial DroopLook for Facial DroopHave the patient smile or show his/her teethHave the patient smile or show his/her teethNORMALNORMAL Both sides of the Both sides of the

face move equally face move equally ABNORMALABNORMAL One side of One side of

the patient’s face droops the patient’s face droops

or does not moveor does not move

ARMSARMS

Motor Weakness: Look for arm drift by asking Motor Weakness: Look for arm drift by asking the patient to close eyes and lift armsthe patient to close eyes and lift arms

NORMAL- arms remain NORMAL- arms remain

extended equally or drift extended equally or drift

downward equallydownward equally ABNORMAL – One arm ABNORMAL – One arm

drifts down compared drifts down compared

to the otherto the other

Avoid

Assessment of arms using hand gripsMany older people have painful arthritic

handsThis may make hand

grips artificially weak

SPEECHSPEECH

Ask the patient to say Ask the patient to say “You can’t teach an “You can’t teach an old dog new tricks”old dog new tricks”

NORMAL –Phrase repeated clearly and NORMAL –Phrase repeated clearly and plainlyplainly

ABNORMAL – Words slurred, abnormal or ABNORMAL – Words slurred, abnormal or unable to speakunable to speak

Abnormal SpeechAbnormal Speech

Slurring of speechSlurring of speechUnable to think of wordsUnable to think of words Inappropriate wordsInappropriate words

Expressive aphasia – unable to speak Expressive aphasia – unable to speak wordswordsAble to understand speechAble to understand speechKnows what to sayKnows what to sayUnable to put words togetherUnable to put words togetherAble to speak clearlyAble to speak clearly if speaking from memory if speaking from memory

Able to sing familiar songs “Happy Birthday to you”Able to sing familiar songs “Happy Birthday to you”Say to family “I love you”Say to family “I love you”

Receptive aphasia – unable to understand Receptive aphasia – unable to understand wordswordsPeople sound like they are speaking “Martian”Patient is able to speak clearly

TIME OF ONSETTIME OF ONSET

The window of opportunity to effectively The window of opportunity to effectively treat STROKE is 3 hours (180 minutes)treat STROKE is 3 hours (180 minutes)

May be extended to 4 ½ hours if invasive May be extended to 4 ½ hours if invasive neurology availableneurology available

Last Known Well

Need to know “ last known well”.Need to know “ last known well”.Last time face was normalLast time face was normalLast time able to move normallyLast time able to move normallyLast time able to speakLast time able to speak

Difficult whenDifficult whenPatient lives alonePatient lives alonePatient woke up with symptomsPatient woke up with symptoms

Assessing the Stroke PatientAssessing the Stroke Patient

Initial AssessmentInitial AssessmentGeneral ImpressionGeneral ImpressionAirway Airway Airway!!Airway Airway Airway!!High-flow O2High-flow O2BreathingBreathingCirculationCirculationHIGH PRIORITYHIGH PRIORITY

Focused History and Physical

Neurological ExamFAST FormHistory of: (looking for bleeding aneurysm)

SeizuresHeadacheNausea/VomitingNeck Pain

Baseline set of Vital SignsRecheck every 5-10 minutes

Priorities of carePriorities of care

Conduct general medical assessmentConduct general medical assessment Trauma – recent or within last monthTrauma – recent or within last month

Recent seizureRecent seizure Could be a subdural hematomaCould be a subdural hematoma

Cardiovascular – on heart medicationsCardiovascular – on heart medications Does the patient have atrial fibrillationDoes the patient have atrial fibrillation Does the patient take blood thinnersDoes the patient take blood thinners

Pulse oximetry > 94% Pulse oximetry > 94% Blood sugar treat if ableBlood sugar treat if able

Low blood sugars mimic a strokeLow blood sugars mimic a stroke PupilsPupils

PositionPosition

Protect potentially paralyzed partsProtect potentially paralyzed parts

STROKE Check ListSTROKE Check List Stroke identificationStroke identification Use of FAST ScreenUse of FAST Screen Securing A B CsSecuring A B Cs EKG monitoring (if able)EKG monitoring (if able) Oxygen saturation of > 94%Oxygen saturation of > 94% Management of blood glucoseManagement of blood glucose IV access (if able)IV access (if able) Blood specimens obtained (if able)Blood specimens obtained (if able) Head of Bed elevated 15 degreesHead of Bed elevated 15 degrees Early communication with Medical ControlEarly communication with Medical Control Urgent transport to CT Scan at hospitalUrgent transport to CT Scan at hospital

Non Contrast CT of HeadNon Contrast CT of Head

Acute Hemorrhagic StrokeAcute Hemorrhagic Stroke

Sub Arachnoid BleedSub Arachnoid Bleed

Could this be anything other Could this be anything other than a STROKE?than a STROKE?

Transient Ischemic AttackTransient Ischemic Attack

HypoglycemiaHypoglycemia

Race Against TimeRace Against Time

Goals of STROKE Care 2011Goals of STROKE Care 2011

Standardized assessments, vocabulary, Standardized assessments, vocabulary, protocols and goalsprotocols and goalsEMSEMSHospitalHospital

Direct transport to CT scan Direct transport to CT scan Early identification of candidates Early identification of candidates Door to treatment goal is 60 minutesDoor to treatment goal is 60 minutes

NINDS Recommended GoalsNINDS Recommended Goals

Door to doctorDoor to doctor 10 minutes10 minutes Door to CT completionDoor to CT completion 25 minutes25 minutes Door to CT readDoor to CT read 45 minutes45 minutes Door to treatmentDoor to treatment 60 minutes60 minutes Access to neurological expertise*Access to neurological expertise* 15 minutes15 minutes Access to neuro-surgical expertise*Access to neuro-surgical expertise* 120 minutes120 minutes Admit to monitored bedAdmit to monitored bed 180 minutes180 minutes

* by phone or in person* by phone or in person

Case Study 1: 6:30 pmCase Study 1: 6:30 pm

You are called for a patient who is not You are called for a patient who is not acting right.acting right.

What could be the problem?What could be the problem?

What could be the problem?What could be the problem?

SeizureSeizureCodeCodeMyocardial infarctionMyocardial infarctionDiabetic reactionDiabetic reactionMedication reactionMedication reactionAnxiety attackAnxiety attackSTROKESTROKE

6:35 pm6:35 pm

Upon arrival, you find a middle aged Upon arrival, you find a middle aged woman sitting in bed. She is confused, woman sitting in bed. She is confused, but responds to verbal stimuli. but responds to verbal stimuli.

What assessments do you need?What assessments do you need?

ABC --FASTABC --FAST

Airway and ventilations are adequateAirway and ventilations are adequateRegular pulse and good perfusionRegular pulse and good perfusionSpeech is garbledSpeech is garbledUnable to move her right arm and legUnable to move her right arm and legDenies chest pain.Denies chest pain.BP 195/105, pulse 90, respirations 18BP 195/105, pulse 90, respirations 18

The patient’s daughter reports that her mother The patient’s daughter reports that her mother felt fine a few minutes ago when suddenly her felt fine a few minutes ago when suddenly her arm felt funny. She did not lose consciousness arm felt funny. She did not lose consciousness and did not have a seizure.and did not have a seizure.

The woman did not complain of a headache, and The woman did not complain of a headache, and has no history of seizures, diabetes, chest pain has no history of seizures, diabetes, chest pain or palpitations.or palpitations.

6:45 pm6:45 pm

This patient, Mrs. Short, is 65 years old. This patient, Mrs. Short, is 65 years old. She has left sided facial drooping and right She has left sided facial drooping and right arm and leg weakness. She can move the arm and leg weakness. She can move the right arm and leg slightly, but with great right arm and leg slightly, but with great difficulty. Her speech is slurred. All of difficulty. Her speech is slurred. All of these signs and symptoms are new in the these signs and symptoms are new in the last 20 minutes.last 20 minutes.

FASTFAST

How does Mrs. Short fare on the FAST How does Mrs. Short fare on the FAST Screen?Screen?FaceFaceArmArmSpeechSpeechTimeTime

Case 1 contCase 1 cont

Face -- left sided facial drooping Face -- left sided facial drooping Arm – right arm and leg weaknessArm – right arm and leg weaknessSpeech – speech is slurredSpeech – speech is slurredTime last known well -- unsureTime last known well -- unsure

HIGH PRIORITYHIGH PRIORITY

Determine precise time of onset of signs Determine precise time of onset of signs and symptoms.and symptoms.

If thrombolytic therapy is to be considered, If thrombolytic therapy is to be considered, its its infusioninfusion must begin within 3 hours of must begin within 3 hours of the onset of symptoms.the onset of symptoms.

Does Mrs. Short meet the criteria so far to Does Mrs. Short meet the criteria so far to be on the Primary STROKE Care track to be on the Primary STROKE Care track to receive thrombolytics (tPA)?receive thrombolytics (tPA)?

YES, Proceed to a hospital ready to YES, Proceed to a hospital ready to manage an acute STROKEmanage an acute STROKE

Case Study 2: 0635 HoursCase Study 2: 0635 Hours

70 year-old woman, Mrs. Black70 year-old woman, Mrs. Black Awake with slight weakness and tingling Awake with slight weakness and tingling

in her left side. in her left side. Speech is hesitant and slightly slurredSpeech is hesitant and slightly slurredVision seems to be normalVision seems to be normalNo facial droopingNo facial drooping

Case 2 cont.Case 2 cont.

Symptoms began 0615 per patient’s Symptoms began 0615 per patient’s husbandhusband

Speech was fine before thatSpeech was fine before thatBlood sugar 50 mg/dlBlood sugar 50 mg/dlNo emesis or seizureNo emesis or seizureBP 150/90, Pulse 80, Respirations 16BP 150/90, Pulse 80, Respirations 16O2 sat 92%O2 sat 92%

FASTFAST

How does Mrs. Black fareHow does Mrs. Black fare

on the FAST Screen?on the FAST Screen?

FaceFace

ArmArm

SpeechSpeech

TimeTime

Case 2 contCase 2 cont

Face -- no droopingFace -- no droopingArm – slight weakness and tinglingArm – slight weakness and tinglingSpeech -- Speech is hesitant and slightly Speech -- Speech is hesitant and slightly

slurredslurredTime known well -- 20 minutes agoTime known well -- 20 minutes ago

Case 2Case 2

Treat the blood sugar and reassess the Treat the blood sugar and reassess the need for additional treatmentneed for additional treatment

High priority transport toHigh priority transport to

a CT for acute STROKEa CT for acute STROKE

Case Study 3Case Study 3

Ambulance call at 1400 hoursAmbulance call at 1400 hours80 year-old man, Mr. Schmidt80 year-old man, Mr. SchmidtDaughter found him 15 minutes agoDaughter found him 15 minutes agoUnknown down timeUnknown down timeAwakeAwakeDrooping left side of faceDrooping left side of faceNo movement of right arm and legNo movement of right arm and legSpeech too slurred to understandSpeech too slurred to understand

Case 3 cont.Case 3 cont.

Seems to see youSeems to see youLooks only to leftLooks only to leftBlood sugar 200 mg/dlBlood sugar 200 mg/dlNo evidence of seizure or emesisNo evidence of seizure or emesisBP 180/100, pulse 72, respirations 15BP 180/100, pulse 72, respirations 15

FASTFAST

How does Mr. Schmidt fareHow does Mr. Schmidt fare

on the FAST Screen?on the FAST Screen?

FaceFace

ArmArm

SpeechSpeech

TimeTime

Case 3 contCase 3 cont

Face --Drooping left side of faceFace --Drooping left side of faceArm – No movement of right arm and legArm – No movement of right arm and legSpeech – Speech too slurred to Speech – Speech too slurred to

understandunderstandTime known well – unknown, daughter Time known well – unknown, daughter

found him 15 minutes ago, but she had not found him 15 minutes ago, but she had not had contact with him since yesterdayhad contact with him since yesterday

Case 3 Cont.Case 3 Cont.

Time of onset = unknownTime of onset = unknownSevere Headache = unknownSevere Headache = unknownEmesis = noEmesis = noSeizures = unknownSeizures = unknownBlood sugar = OKBlood sugar = OK

Case 3Case 3

Time window has closed. Not a candidate Time window has closed. Not a candidate for thrombolytic treatment. Transport to for thrombolytic treatment. Transport to ED for acute care.ED for acute care.

Review

Answer the following questions as a group. If doing this CE individually, please e-mail your

answers to:

shelley.peelman@provena.org Use “November 2011 CE” in subject box. You will receive an e-mail confirmation. Print

this confirmation for your records, and document the CE in your PREMSS CE record book.

What do you know about stroke?

QuizQuiz

What are the 2 general types of stroke?What are the 2 general types of stroke? 1.1. 2.2.

What condition is equivalent to “angina” of the brain?What condition is equivalent to “angina” of the brain? 3.3.

What are 3 risk factors for stroke that can be What are 3 risk factors for stroke that can be modified?modified? 4.4. 5.5. 6.6.

What are 2 risk factors for stroke that cannot be What are 2 risk factors for stroke that cannot be modified?modified? 7.7. 8.8.

What are you measuring in a FAST Stroke What are you measuring in a FAST Stroke Screen?Screen? 9.9. 10.10. 11.11. 12.12.

In the 21In the 21stst century, some patients suffering century, some patients suffering from STROKE can be treated using what from STROKE can be treated using what type of medication?type of medication?13.13.

What is the time deadline that must be met What is the time deadline that must be met in order to use the aggressive medication in order to use the aggressive medication in the question above?in the question above?14.14.

AnswersAnswers

1. Hemorrhagic stroke1. Hemorrhagic stroke 2. Ischemic stroke2. Ischemic stroke 3. TIA (transient ischemic attack)3. TIA (transient ischemic attack) 4. – 6. 4. – 6. High BPHigh BP

Cigarette smoking Cigarette smoking High blood cholesterolHigh blood cholesterol Sedentary lifestyleSedentary lifestyle Carotid CongestionCarotid Congestion ObesityObesity Uncontrolled diabetesUncontrolled diabetes SeasonsSeasons Atrial fibrillationAtrial fibrillation StressStress Uncontrolled heart diseaseUncontrolled heart disease Alcohol intakeAlcohol intake

7-8 7-8 AgeAge prior strokesprior strokes GenderGender heredityheredity RaceRace Sickle cell diseaseSickle cell disease

9. Face9. Face10. Arm10. Arm11. Speech11. Speech12. Last known well12. Last known well

13. Clot busting drugs, thrombolytics, tPA13. Clot busting drugs, thrombolytics, tPA14. 3 hours (180 minutes)14. 3 hours (180 minutes)