STROKESTROKE

CODE STROKE AND THE PCT CODE STROKE AND THE PCT

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

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

In the 21In the 21stst century medical century medical

science has progressed in science has progressed in

the understanding of STROKE, the understanding of STROKE,

prevention and treatmentprevention and treatment

CVACVA

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 Americans#3 killer of Americans25% of women have strokes 25% of women have strokes

before age 65before age 65#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 $68 billionAnnual cost of $68 billion

New AdvancementsNew Advancements

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

For a variety of reasons, only 2% of stroke For a variety of reasons, only 2% of stroke victims are treated with thrombolytic medicationvictims are treated with thrombolytic medication

Aggressive treatment begins with assessment Aggressive treatment begins with assessment and intervention at point of patient contactand intervention at point of patient 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 storage No storage in the brain for in the brain for either fuel or oxygeneither fuel or oxygen 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 neck LargeLarge Frequently congested Frequently congested with plaquewith plaque Can be cleaned out surgicallyCan be cleaned out surgically

Vertebral arteries Vertebral arteries Pass through cervical vertebraePass through cervical vertebrae Well protectedWell protected Not accessible for Not accessible for surgical cleaningsurgical cleaning

Circle of WillisCircle of Willis

Both blood supplies (carotid and vertebral) join Both blood supplies (carotid and vertebral) join on the under surface of the brain.on the under surface of the brain.

Fail-safe mechanismFail-safe mechanism in case of a blockagein case of a blockage somewhere in somewhere in circulationcirculation BUT some hard corners in BUT some hard corners in circle where debris can get circle where debris can get caught and site of mostcaught and site of most cerebral aneurysms cerebral aneurysms

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

Disruption of blood flow to the brainDisruption of blood flow to the brainPlaque – build up of cholesterol in interior of Plaque – build up of cholesterol in interior of

blood vesselblood vesselForeign debris– Foreign debris–

blood clotblood clot

bubble of fluidbubble of fluid

airairBroken vesselBroken vessel

Ischemic STROKEIschemic STROKE

Blockage of blood flow to brainBlockage of blood flow to brain Progressive Thrombus -- growingProgressive Thrombus -- growing

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 artery CongenitalCongenital Younger population younger than 40 yearsYounger population younger than 40 years Complain of “worst headache in my lifeComplain of “worst headache in my life””

Spontaneous Hypertensive BleedSpontaneous Hypertensive Bleed Due to BP > 200/100Due to BP > 200/100

Malformed ArteryMalformed Artery 50% 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 Looks like a stroke but,symptoms improve in 1-24 hoursimprove in 1-24 hours

Temporary disruption of blood flow to the Temporary disruption of blood flow to the brain –Like Unstable Angina of the brainbrain –Like Unstable Angina of the brain

Warning sign (15% of strokes have TIA Warning sign (15% of strokes have TIA first)first)

Mimicked by low blood sugar (> blood Mimicked by low blood sugar (> blood sugar signs and symptoms go away)sugar signs and symptoms go away)

1 in 20 patients will have a true stroke in 1 in 20 patients will have a true stroke in 3 months3 months

Can STROKES be prevented?Can STROKES be prevented?

Modifiable risk factorsModifiable risk factorsHigh BPHigh BPCigarette smokingCigarette smokingAlcohol intakeAlcohol intakeUncontrolled Heart diseaseUncontrolled Heart diseaseAtrial fibrillation Atrial fibrillation (creates mini clots)(creates mini clots)Uncontrolled DiabetesUncontrolled DiabetesCarotid congestionCarotid congestion

Can STROKES be prevented?Can STROKES be prevented?

High blood cholesterolHigh blood cholesterolSedentary lifestyleSedentary lifestyleObesityObesitySeasons– spring and fallSeasons– spring and fallStressStress

Risk Factors Unable to ControlRisk Factors Unable to Control

AgeAge GenderGender

more women than menmore women than men Race Race

African American high riskAfrican American high risk Prior strokesPrior strokes HeredityHeredity Sickle Cell DiseaseSickle Cell Disease

Causes clot formation and Causes clot formation and strokes even in childrenstrokes even in children

Signs and Symptoms of Signs and Symptoms of STROKESTROKE

HemorrhagicHemorrhagic Sudden and dramaticSudden and dramatic Violent explosive headache Violent explosive headache

““worst headache of my life”worst headache of my life” Visual disturbanceVisual disturbance

Flashing lights, auraFlashing lights, aura Nausea and vomitingNausea and vomiting Neck and back painNeck and back pain

Due to blood in sub-arachnoid spaceDue to blood in sub-arachnoid space Sensitivity to lightSensitivity to light Weakness on one sideWeakness on one side Can present like a migraine headacheCan present like 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 StrokeLeft Brain Stroke

Right side paralysisRight side paralysisSpeech and language disturbanceSpeech and language disturbanceBehavioral changesBehavioral changesSwallowing problemsSwallowing problems

Right Brain DamageRight Brain Damage

Left side paralysisLeft side paralysisSpatial perceptionSpatial perception

Where your limbs Where your limbs

are in relation to the roomare in relation to the roomCoordination problemsCoordination problemsPerceptionPerception

Recognition of familiarRecognition of familiar

objects 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/ MET Team of EMS/ MET Team

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 criteria to receive thrombolytic drugsmeet the criteria to receive thrombolytic drugs

Drug –Drug – thrombolytics when appropriate thrombolytics 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 Many families wait to see if the patient gets Many families wait to see if the patient gets

betterbetterTake patient to the hospital by carTake patient to the hospital by car

““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

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

Problem with gripping handsProblem with gripping handsMany elderly have arthritis in handsMany elderly have arthritis in handsHurts to grip handsHurts to grip handsMay mimic weaknessMay mimic weakness

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”Lots of tLots of t’s, ’s, k’s and c’sk’s and c’s

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 speech Unable to think of wordsUnable to think of words Inappropriate wordsInappropriate words Expressive aphasia – unable to speak words Expressive aphasia – unable to speak words

Area of brain where words are created is damagedArea of brain where words are created is damaged

Receptive aphasia – unable to understand Receptive aphasia – unable to understand wordswords Area where words are interpreted is damagedArea where words are interpreted is damaged

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 in some casesMay be extended to 4 ½ hours in some cases

Need to know “ last known well”.Need to know “ last known well”.Difficult whenDifficult when

Patient lives alonePatient lives aloneWoke up with symptomsWoke up with symptoms

180 minutes180 minutes

Don’t think of as 3 hours, but 180 minutesDon’t think of as 3 hours, but 180 minutesTime gets eaten up fastTime gets eaten up fastShort scene time Short scene time Take transport time into considerationTake transport time into consideration

Assessing the Stroke PatientAssessing the Stroke Patient

Initial AssessmentInitial AssessmentGeneral ImpressionGeneral ImpressionAirway Airway Airway!!Airway Airway Airway!!High-flow O2High-flow O2CirculationCirculationHIGH PRIORITY TRANSPORTHIGH PRIORITY TRANSPORT

Assessing the Stroke PatientAssessing the Stroke Patient

Focused history and physical examFocused history and physical examPerform thorough neurologic exam.Perform thorough neurologic exam.

FAST Stroke ScreenFAST Stroke ScreenHistory of History of

SeizuresSeizures HeadacheHeadache Nausea/vomitingNausea/vomiting Neck painNeck pain

Obtain baseline set of vitalsObtain baseline set of vitalsRecheck Vital Signs frequentlyRecheck Vital Signs frequently

Priorities of carePriorities of care

Conduct general assessmentConduct general 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 Securing A B CsSecuring A B Cs Stroke identificationStroke identification Use of FAST ScreenUse of FAST Screen EKG monitoring if ableEKG monitoring if able Oxygen saturation of > 94%Oxygen saturation of > 94% Management of blood glucoseManagement of blood glucose IV access IV access Blood specimens obtained Blood specimens obtained Head of Bed elevated 15 degreesHead of Bed elevated 15 degrees Early communication with PhysicianEarly communication with Physician Urgent transport to CT ScanUrgent transport to CT Scan

Non Contrast CT of HeadNon Contrast CT of HeadWant a normal CT Want a normal CT

Acute Hemorrhagic StrokeAcute Hemorrhagic StrokeBlood shows up whiteBlood shows up white

Sub Arachnoid BleedSub Arachnoid BleedBlood in meninges due to Blood in meninges due to

aneurysmaneurysm

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 2013Goals of STROKE Care 2013

Standardized assessments, vocabulary, Standardized assessments, vocabulary, protocols and goalsprotocols and goals

Door to treatment (with thrombolytics) Door to treatment (with thrombolytics) goal is 60 minutesgoal is 60 minutes

Early identification of candidates Early identification of candidates Direct transport to CT scanDirect transport to CT scan

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 ** National Institute of Neurological Diseases and Stroke** National Institute of Neurological Diseases and Stroke

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

You are called by a family member to You are called by a family member to assess a patient who is not acting right.assess a patient who is not acting right.

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

Keep an eye on the timeKeep an eye on the time

you have 180 minutesyou have 180 minutes

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 the patient, Mrs. Upon arrival, you find the patient, Mrs. Short, sitting in bed. She is confused, but Short, sitting in bed. She is confused, but responds to verbal stimuli. 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

ABC/FASTABC/FAST

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.

6:43 pm6:43 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 10 minutes.last 10 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 – within 20 minutesTime last known well – within 20 minutes

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.

HIGH PRIORITYHIGH PRIORITY

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 with Stroke protocolYES, Proceed with Stroke protocol

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 slurredNo facial droopingNo facial droopingGood eye contactGood eye contact

Case 2 cont.Case 2 cont.

Symptoms began 0615 per patientSymptoms began 0615 per patientSpeech 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

BUT blood sugar is low!BUT blood sugar is low!Treat the blood sugar and reassess the Treat the blood sugar and reassess the

need for additional treatmentneed for additional treatmentHigh 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.

Blood 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 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.

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.

QuizQuiz

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.

QUIZQUIZ

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

AnswersAnswers

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

AnswersAnswers

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