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Stroke PowerPoint ALS-ILS-BLS
Stroke PowerPoint ALS-ILS-BLS
Stroke PowerPoint ALS-ILS-BLS
Stroke PowerPoint ALS-ILS-BLS
Stroke PowerPoint ALS-ILS-BLS
Stroke PowerPoint ALS-ILS-BLS
Stroke PowerPoint ALS-ILS-BLS
Stroke PowerPoint ALS-ILS-BLS
Stroke PowerPoint ALS-ILS-BLS
Stroke PowerPoint ALS-ILS-BLS
Stroke PowerPoint ALS-ILS-BLS
Stroke PowerPoint ALS-ILS-BLS
Stroke PowerPoint ALS-ILS-BLS
Stroke PowerPoint ALS-ILS-BLS
Stroke PowerPoint ALS-ILS-BLS
Stroke PowerPoint ALS-ILS-BLS
Stroke PowerPoint ALS-ILS-BLS
Stroke PowerPoint ALS-ILS-BLS
Stroke PowerPoint ALS-ILS-BLS
Stroke PowerPoint ALS-ILS-BLS
Stroke PowerPoint ALS-ILS-BLS
Stroke PowerPoint ALS-ILS-BLS
Stroke PowerPoint ALS-ILS-BLS
Stroke PowerPoint ALS-ILS-BLS
Stroke PowerPoint ALS-ILS-BLS
Stroke PowerPoint ALS-ILS-BLS
Stroke PowerPoint ALS-ILS-BLS
Stroke PowerPoint ALS-ILS-BLS
Stroke PowerPoint ALS-ILS-BLS
Stroke PowerPoint ALS-ILS-BLS
Stroke PowerPoint ALS-ILS-BLS
Stroke PowerPoint ALS-ILS-BLS
Stroke PowerPoint ALS-ILS-BLS
Stroke PowerPoint ALS-ILS-BLS
Stroke PowerPoint ALS-ILS-BLS
Stroke PowerPoint ALS-ILS-BLS
Stroke PowerPoint ALS-ILS-BLS
Stroke PowerPoint ALS-ILS-BLS
Stroke PowerPoint ALS-ILS-BLS
Stroke PowerPoint ALS-ILS-BLS
Stroke PowerPoint ALS-ILS-BLS
Stroke PowerPoint ALS-ILS-BLS
Stroke PowerPoint ALS-ILS-BLS
Stroke PowerPoint ALS-ILS-BLS
Stroke PowerPoint ALS-ILS-BLS
Stroke PowerPoint ALS-ILS-BLS
Stroke PowerPoint ALS-ILS-BLS
Stroke PowerPoint ALS-ILS-BLS
Stroke PowerPoint ALS-ILS-BLS
Stroke PowerPoint ALS-ILS-BLS
Stroke PowerPoint ALS-ILS-BLS
Stroke PowerPoint ALS-ILS-BLS
Stroke PowerPoint ALS-ILS-BLS
Stroke PowerPoint ALS-ILS-BLS
Stroke PowerPoint ALS-ILS-BLS
Stroke PowerPoint ALS-ILS-BLS
Stroke PowerPoint ALS-ILS-BLS
Stroke PowerPoint ALS-ILS-BLS
Stroke PowerPoint ALS-ILS-BLS
Stroke PowerPoint ALS-ILS-BLS
Stroke PowerPoint ALS-ILS-BLS
Stroke PowerPoint ALS-ILS-BLS
Stroke PowerPoint ALS-ILS-BLS
Stroke PowerPoint ALS-ILS-BLS
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Stroke PowerPoint ALS-ILS-BLS

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  • Hypercoagulable states – pregnancy, sickle cell anemia, etc.
  • Transcript

    • 1. StrokeStroke Continuing EducationContinuing Education EMS Region 7EMS Region 7 May 2010May 2010
    • 2. MENINGES 1) Dura Mater 2) Arachnoid 3) Pia Mater
    • 3. Epidural Hemorrhage Subdural Hemorrhage Dura Mater creates Potential Space * Epidural space * Subdural space
    • 4. CEREBRAL CORTEX
    • 5. FRONTAL LOBE  Personality  Behavior  Voluntary motor function  Motor speech (Broca’s), Left side dominent  Intellectual functions, problem solving  Judgment; good/bad, right/wrong Called the “MOM” portion of the Brain
    • 6. PARIETAL LOBE  Primary sensory lobe; pain, pressure, vibration, touch  Localization of stimuli  Object recognition  Position sense  Sensory association
    • 7. TEMPORAL LOBE  Primary auditory lobe  Long term memory  Emotions  Cognitive speech (Wernicke’s); organize language, understand and respond to verbal input  Uncus discriminates smells
    • 8. OCCIPITAL LOBE  Processing visual input
    • 9. INTRACRANIAL DYNAMICS  Three substances in the cranial vault  Brain 80%  Blood 12%  CSF 8% MONRO-KELLIE DOCTRINE If one of these substances increase, then one or both of the other must therefore decrease to maintain normal pressure within the cranial vault
    • 10. BLOOD SUPPLYBLOOD SUPPLY  The Brain:The Brain:  Needs constant supply of O2 andNeeds constant supply of O2 and glucoseglucose  Receives 15% of cardiac outputReceives 15% of cardiac output  Consumes 20% of inspired O2Consumes 20% of inspired O2  Perfused by the Circle of WillisPerfused by the Circle of Willis
    • 11. Not that Willis…..Not that Willis….. THE CIRCLE OF WILLIS !THE CIRCLE OF WILLIS !
    • 12. THE CIRCLE OF WILLISTHE CIRCLE OF WILLIS  The brain’s own arterial circulatory system  Connected to the aorta by the carotid arteries
    • 13.  Stroke is no accident!  CVA is now called Stroke or “Brain Attack”  Carries the same urgency as AMI
    • 14. STROKE DEFINED  Sudden, catastrophic event causing focal neuro impairment due to interruption of cerebral blood flow  Most often caused by an occlusion or rupture of an artery that supplies a specific part of the brain
    • 15. BRAIN ATTACK / ISCHEMICBRAIN ATTACK / ISCHEMIC STROKESTROKE  Caused by anything that decreasesCaused by anything that decreases blood flow to the brainblood flow to the brain  Thrombus /embolus (A-fib,Thrombus /embolus (A-fib, hypercoagulable state, etc)hypercoagulable state, etc)  Carotid artery plaquesCarotid artery plaques  VasospasmVasospasm  Hypotension with carotid arteryHypotension with carotid artery stenosisstenosis
    • 16. Ischemia  Can result from:  Vascular injuries  Secondary vascular spasm  Increased intracranial pressure  Focal or more global infarcts can result
    • 17.  No characteristic clinical picture  May range from a TIA to infarction of a major portion of the ipsilateral (on the same side) hemisphere  If adequate intracranial collateral circulation is present, may see no signs or symptoms  Neurological symptoms may include: monoparesis to hemiparesis with or without a defect in vision impairment of speech or language transient monocular blindness
    • 18.  Most occlusions in the first portion of this artery are due to emboli and typically produce a neurological deficit  Opportunity for collateral circulation is restricted  Neurological symptoms: hemiplegia (paralysis of one side of the body) hemisensory deficit hemianopsia (blindness in 1/2 of the visual field) aphasia (if infarct is in the dominant hemisphere)
    • 19.  Neurological symptoms may include: weakness of the opposite leg with or without sensory involvement apraxia (particularly of gait) possible cognitive impairment
    • 20.  Neurological symptoms may include: severe vertigo, nausea, vomiting, dysphagia, ipsilateral cerebellar ataxia decreased pain and temperature loss of 2 point discrimination diplopia, visual field loss, gaze palsies
    • 21.  Neurological symptoms may include: Alterations in LOC, delerium and coma possible hemisensory disturbances visual disturbances with possible blindness Visual agnosia-lack of recognition or understanding of visual objects or loss of color Amenesia Loss of motor function possible
    • 22. STROKE STATISTICS  Stroke occurs every 40 seconds  3rd leading cause of mortality  143,00 deaths annually  Death due to stroke every 3-4 minutes  4.8 million stroke survivors  Leading cause of serious long tern disability  Life time cost of an ischemic stroke is $140,000  Strides in prevention are off set by aging population  80% of strokes are preventable!!!
    • 23. TIA STATISTICS  200,000-500,000 Per Year  Prevalence increases with age  Half of those with TIA’s fail to report it  15% of strokes are preceded by a TIA  Following TIA  12% of patients experience a stroke within the next 30 days  3-17% have a stroke within 90 days  25% die with in 1 year
    • 24. STROKE AWARENESS:SURVEY  38% aware of 5 stroke signs and would call 911  Stroke pts:  55% able to identify 1 stroke warning sign!  60% able to identify 1 stroke risk factor!  Huge public education need
    • 25. Interrupted supply O2 and glucose causing anaerobic metabolism and increasing cellular waste (toxins) causing cell membrane dysfunction causing cellular swelling and pressure on the cells which causes cellular ischemia and death EFFECT OF STROKE ON BRAIN CELLS
    • 26.  Age  >55 risk doubles every decade  Gender  Male more common  Female higher death rate  Heredity  Relative with stroke increased risk  Prior stroke/TIA  25-40% chance of stroke in 5 years  Prior MI  Race  Increased in Hispanic/Asian/Pacific Islander  African American 2x higher rate than whites STROKE RISK FACTORS: NON MODIFIABLE
    • 27. STROKE RISK FACTORS: MODIFIABLE  HTN  >140/90  Most important risk factor  Most common cause of stroke  Increased risk 4-6 times  Improved treatment may be responsible for decreased stroke deaths  High Cholesterol  Clogs arteries  107 million in US
    • 28. STROKE RISK FACTORS: MODIFIABLE  Atrial Fibrillation  Pooling blood promotes clots  Increases risk by 6 times  15% stroke patients have A-Fib  Diabetes  Most have other risk factors as well  2/3 die from stroke or heart disease  Increases risk 2-4 times
    • 29. STROKE RISK FACTORS: MODIFIABLE  Tobacco  Damages vessel walls  Accelerates arterial stenosis  Increases CV workload  Increases BP  Increasing clotting factors  Doubles risk  Alcohol  Heavy use related to stroke  >2/day may increase risk by 50%  Leads to HTN
    • 30. STROKE RISK FACTORS: MODIFIABLE  Obesity  Strains entire cardiovascular system  Likely to have DM, HTN and high cholesterol
    • 31. NEURO ASSESSEMENT BASELINE ASSESSMENT IS OF GREAT IMPORTANCE TO DETERMINE THE HISTORY OF THE PRESENT ILLNESS AND TO ACT AS A GUIDE FOR FURTHER SERIAL ASSESSMENTS
    • 32. ASSESSMENT: SYMPTOMS/CHIEF COMPLAINT  Headache of unknown cause  AMS/Sudden confusion  Photophobia, visual deficits  Stiff neck  Weakness/paralysis  Sensory loss face, arm or leg  Vertigo, dizziness,syncope,ataxia  Trouble speaking or understanding  Seizure
    • 33. ASSESSMENT: CINCINNATI STROKE SCALE  3 Components  Facial (Smile)  Arm drift-Unilateral weakness  Speech- abnormal speech pattern  Takes less than 1 minute  Reliability  1 finding= 72%  3 findings = 85%  However, patients can be having a stroke despite a normal CSS  Correct documentation
    • 34. CSS: ARM DRIFT  Weakness  Clumsiness  Heaviness  Documentation – in narrative or use built-in Zoll categories  Normal  Drift  Can’t resist gravity  No effort  No movement
    • 35. CSS: SPEECH  Speech  Ask the patient to repeat a simple sentence  The sky is blue  You can’t teach an old dog new tricks  Assess  Ability to form words  Abnormal pattern  Articulation  Hoarseness  Phonation  Rate
    • 36. CCS: SMILE  Facial Symmetry  Smile/Grimace  Show teeth  Does he have a deficit?
    • 37. BELL’S PALSY vs. STROKE  Bell’s Palsy  Total hemiparesis of face  Stroke  Can wrinkle both sides of forehead but has lower facial weakness
    • 38. STROKE: ABNORMAL PRESENTATIONS  Weakness  Quick neuro exam  Negative suspect ACS obtain a 12 lead  Positive Consider Stroke  Syncope  Hx of seizures  Exam  GCS  ECG  Trauma
    • 39. STROKE: ABNORMAL PRESENTATIONS  AMS  Scene size up  Differential diagnosis  AEIOUTIPS  Other  Visual disturbances  Hoarseness  “Heavy” sensation  Cranial nerve S/S
    • 40. STROKE: ABNORMAL PRESENTATIONS  Strong trend for misdiagnosis <35  50% of those were diagnosed as inner ear disorder  Women  AMS (most common)  Meaning confusion  Disorientation  Loss of consciousness  Delays in triage, exam and imaging
    • 41.  Lessons learned in Trauma and Cardiac care can be applied to Stroke care:  Patients need definitive treatment in the hospital  Outcomes greatly improved with early access to emergency care IT’S NEURO TIME!!IT’S NEURO TIME!!
    • 42. STROKE CHAIN OF SURVIVAL  Goal  Minimize brain injury and maximize recovery  Rapid  Recognition and reaction  EMS Dispatch  EMS transport and pre arrival notification  Diagnosis and treatment
    • 43. 7 D’s OF STROKE CARE POTENTIAL POINTS OF DELAY  Detection  Dispatch  Delivery with advance notification  Door  Data  Decision  Drug/Monitoring
    • 44. EMS PREHOSPITAL STROKE CARE  ID stroke symptoms  Transport to a Stroke Center  Medical Center pre arrival notification  Safest most efficient method of transport  Manage the life threats  Perform targeted neuro assessment  ID/treat other causes of symptoms  Establish time of symptom onset
    • 45. OVERVIEW STROKE CARE  Prehospital  Identify signs  CSS/assessment  Time of onset  Check glucose  Support ABC’s  Oxygen  Monitor  Transport  Alert hospital
    • 46.  Glucose checkGlucose check  Limit IV attempts to 2Limit IV attempts to 2  Neuro Exam (GCS, Stroke Scale, Pupils)Neuro Exam (GCS, Stroke Scale, Pupils)  Note TIME OF ONSET OF SYMPTOMS!Note TIME OF ONSET OF SYMPTOMS!  Protect patient from injury/aspirationProtect patient from injury/aspiration  Be attuned to subtle changes/ongoingBe attuned to subtle changes/ongoing assessmentassessment MINIMIZE SCENE TIME, BUTMINIMIZE SCENE TIME, BUT ENSURE …ENSURE …
    • 47. OVERVIEW STROKE CARE  What does the ED do?  ABC’s  O2  IV access  12 lead  Labs  Detailed neuro exam  CT, MRI  Stroke Team
    • 48. Clot busters • tPA Clot removal device • MERCI TREATMENTS FOR ISCHEMICTREATMENTS FOR ISCHEMIC STROKESTROKE
    • 49. OVERVIEW STROKE CARE  IV tPA  Time: 3 hrs (5/09: up to 4.5 hr)  Administered in ED  Class I for qualified pts  Good outcomes only if given in window  ICU admit w/ close monitoring  Intra-arterial tPA  Med directly to thrombus  Class I up to 6 hrs k  Qualified interventionalist at specialty center  Beneficial up to 6+ hr of onset
    • 50.  Interventional Therapy  • "MERCI" procedure  Mechanical Embolus Removal in Cerebral Intervention  Removes thrombus from vessel  Useful when tPA contraindicated
    • 51. TRANSPORTTRANSPORT CONSIDERATIONSCONSIDERATIONS Time is Brain!Time is Brain! Stroke Centers?Stroke Centers? Aero medical?Aero medical?
    • 52.  Benefit of stroke centers is also rehab  Swallow evaluation  65% have dysphagia  Rehab needs assessment  Begin rehab  Placement  long term, inpatient, outpatient, home
    • 53. EMS PLAYS INTEGRAL ROLE INEMS PLAYS INTEGRAL ROLE IN STROKE CARE!STROKE CARE! Early access to hospital care isEarly access to hospital care is crucial to optimizing patientcrucial to optimizing patient outcomeoutcome Taking care of stroke victims Worrying about becoming stroke victims
    • 54. Assessment and Evaluation  Prehospital management of the head-injured patient is determined by:  Mechanism and severity of injury  Patient's level of consciousness  Associated injuries  Airway and ventilation  Circulation  Neurological examination  Fluid therapy  Drug therapy
    • 55. AVOID TUNNEL VISION!AVOID TUNNEL VISION!  Form a list of differentialForm a list of differential diagnoses for EACH patient.diagnoses for EACH patient.  What are some reasons whyWhat are some reasons why people have alterations in theirpeople have alterations in their mental status?mental status?  Psychiatric causes should always be thePsychiatric causes should always be the last explanation,last explanation, even if the patient haseven if the patient has a previous history of psychologicala previous history of psychological illness.illness.
    • 56. Brand New Stroke SMO for 2010 – learn it, love it, live it!
    • 57. Code 38 SUSPECTED STROKE Perform Cincinnati Pre-Hospital Stroke Scale* Identify patients last “known normal” If Stroke scale positive and “last known normal” < 3 hours, transport to the nearest most appropriate facility. Do not delay scene time. Initiate rapid transport. Effective 05/01/10 ALS INITIAL MEDICAL CARE *Cincinnati Prehospital Stroke Scale Facial Droop (Have the patient show teeth or smile) •Normal – Both sides of face move equally well •Abnormal – One side of face does not move as well as the other side Arm Drift (Patient closes eyes and holds both arms straight out for 10 seconds) •Normal – Both arms move the same or both arms do not move at all (other findings, such as pronator grip, may be helpful) •Abnormal – One arm does not move or one arm drifts down compared with the other Speech (Have the patient say, “You can’t teach an old dog new tricks.”) •Normal – Patient uses correct words with no slurring •Abnormal – Patient slurs words, uses inappropriate words, or is unable to speak Blood Glucose GO TO CODE 32 12 Lead EKG Other SMO CODE’s as indicated: Coma of Unknown Origin Seizures < 60 or > 400
    • 58. QUESTIONS Thank You for Your Attention

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