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Chapter 17 : Acute Stroke

Stroke is one of the leading causes of death in the United States. Approximately 700,000 people suffer from stroke every year in the US and 1 in 15 deaths are stroke related. Early detection of stroke is vital as IV fibrinolytic treatment needs to be administered within 3 hours of the onset of symptoms.  Understanding the signs and symptoms of stroke and speed of response is vital in not only saving a life, but also maintaining quality of life of an individual.  Stroke occurs due to insufficient blood supply to the parts of the brain.

There are 2 major types of strokes:

  1. Ischemic stroke which accounts for 85% of all stroke cases and is caused by blockage of an artery in the brain.
  2. Hemorrhagic stroke (includes intracerebral & subarachnoid) occurs less often and is caused by rupture of a blood vessel in the brain.

Adequate stroke care involves reducing brain injury and increasing chance of patient’s survival and recovery.  According to the American Heart Association there are 8D’s of stroke care which are important in diagnosis and treatment of a stroke.

Detection: Rapid recognition of stroke symptoms
Dispatch: early activation and dispatch of EMS by 911
Delivery: Rapid EMS identification, management, and transport
Door: appropriate triage to stroke center
Data: Rapid triage, evaluation, and management within ED
Decision: Stroke expertise and therapy selection
Drug: Fibrinolytic therapy, intra-arterial strategies
Disposition: Rapid admission to the stroke unit or critical care unit

Reference: American Heart Association.  Advanced Cardiac Life Support (ACLS) Student Provider Manuel.  Dallas: American Heart Association, 2011. Print

Stroke Chain of Survival

Brain injury and risk of death will be reduced if the chain of survival is used:

  • Quick identification and reaction to the signs of stroke
  • Quick EMS dispatch
  • Quick transport by EMS and notification prior to arrival to the hospital
  • Quick diagnosis and treatment upon arrival of the patient to the hospital

The Cincinnati Prehospital Stroke Scale from strokecenter.org shows ways in recognizing signs and symptoms of a stroke.
chapter14-2-scaled-1-scaled
chapter14-3-scaled-1-scaled

Facial Droop

  • Normal: Both sides of face move equally
  • Abnormal: One side of face does not move at all

Arm Drift

  • Normal: Both arms move equally or not at all
  • Abnormal: One arm drifts compared

Speech

  • Normal: Patient uses correct words with no slurring
  • Abnormal: Slurred or inappropriate words or mute

If any 1 of these 3 is abnormal, the probability of a stroke is 72%.  The presence of all 3 findings indicates that the probability of stroke is >85%

The following is an algorithm showing management of acute stroke:

Treatment of Stroke Patients Goals
  • Quick general assessment in 10 minutes
  • Quick neurological assessment in 25 minutes
  • CT scan on head in 25 minutes
  • Quick interpretation of CT Scan in 45 minutes
  • Fibrinolytic therapy in 60 minutes of ED arrival
  • Fibrinoloytic therapy in 3 hours of onset
  • Admitted to a monitored bed in 3 hours of onset
CT scan Interpretation

The purpose of the CT scan is to differentiate between ischemic and hemorrhagic stroke. The most common type is a non-contrast CT scan for the acute stroke patient. Treatments for hemorrhagic and ischemic stroke are:

  • Fibrinolytic therapy may be considered for non-hemorrhagic stroke patients with no additional signs or symptoms
  • For hemorrhagic stroke patients consider a consult from neurologists or neurosurgeon as they do not quality for fibrinolytics
  • A patient who is qualified for fibrinolytic therapy will be assessed for fibrinolytic therapy
  • If no hemorrhaging on CT and does not qualify for fibrinolytic therapy, they should be given aspirin
Fibrinolytic Therapy

The NINDS protocol and criteria show tPA is the first line treatment within 3 hours of the onset of symptoms for patients who have acute ischemic stroke. The AHA guidelines recommend IV tPA administration for patients with acute ischemic stroke. To qualify a patient for fibrinolytic therapy a checklist must be applied.

Fibrinolytic Therapy Checklist
Inclusion Criteria (all below should be YES)Exclusion Criteria (all below should be NO)Relative Contraindications/Precautions
Patient is 18 years or older?Intracranial hemorrhage on non-contrast head CT?Symptoms are not major and improve quickly and spontaneously
Dx of ischemic stroke with neurologic deficit?Presentation of patient shows subarachnoid hemorrhage even with normal CT?14 days since major surgery or trauma
Time of system onset – less than 3 hours?Multilobar Infarction on CT (hypodensity greater than 1/3 of cerebral hemisphere)?Current GI or Urinary tract hemorrhage (approx. 21 days)
All ABOVE SHOULD BE YESHistory of intracranial hemorrhage?Current acute Myocardial infarction (in approx.. 3 months)
 Hypertension: SBP > 185 mmHg or DBP > 110 mm Hg on repeated measurements?Postmyocardial infarction pericarditis
 Arteriovenous malformation, neoplasm, or aneurysm?Abnormal blood glucose level (400 mg/dl [22.2 mmmol/L])
 Witnessed seizure at stroke onset?THESE ARE ALL CONTRAINDICATIONS/PRECAUTIONS
 Active internal bleeding or acute trauma (fracture)? 
 

Acute bleeding diathesis, including

  • Platelet count less than 100,000 mm3
  • Heparin received within 48 hours with an aPTT greater than upper limit of normal
  • Current use of anticoagulant with INR >1.7 or prothrombin time PT >12 seconds?
 
 History of intracranial or intraspinal surgery, serious head trauma or previous stroke within past 3 months? 
 Arterial puncture at a noncompressible site within past 7 days? 
 ALL ABOVE SHOULD BE NO! 
Learning Outcomes:

You have completed Chapter XVII. Now you should be able to:

  1. Understand the 8Ds of stoke care
  2. Apply the Adult Stroke Algorithm
  3. Recognize the signs and symptoms of stroke
  4. Understand the checklist of fibrinolytic therapy
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