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Description : Check out this medical presentation on Emergency Medical Services (EMS), which is titled "Stroke", to know about stroke, prehospital care, emergency management, and diagnostic approach.

Tags : Emergency Medical Services, EMS, Stroke, prehospital care, emergency management, diagnostic approach

Published on : Aug 10, 2021 | Views : 4920 | Downloads : 15

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Slide 1-

Stroke Matthew Simmons, MD Sept. 2013 Matthew.simmons@usd.edu
Slide 2-

TIA: Definition “A transient episode of neurologic dysfunction caused by focal brain, spinal cord, or retinal ischemia without acute infarction.” Note: Duration usually less than 60 minutes.
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Stroke: New Definitions CNS infarction: Brain, spinal cord, or retinal cell death due to ischemia. Based on: Pathological, imaging, or other objective evidence Clinical evidence Symptoms greater than 24 hours (or until death) Other etiologies excluded Ischemic stroke: Clinical neurologic dysfunction with evidence as above Silent CNS infarction: Evidence limited to imaging or neuropathological findings.
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Stroke Definitions (cont.) Intracerebral hemorrhage Stroke caused by intracerebral hemorrhage Silent cerebral hemorrhage Subarachnoid hemorrhage Stroke caused by subarachnoid hemorrhage Stroke caused by cerebral sinus thrombosis: can be ischemic or hemorrhagic Stroke not otherwise specified
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Stroke: Outline 1. Prehospital care 2. Emergency management 3. Diagnostic approach 4. Subacute care Prevent complications Rehabilitation Secondary prevention
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Stroke: Prehospital care Primary prevention Public awareness/use 911 Emergency medical services (EMS) Hospital stroke care: Acute Stoke-Ready Hospital Primary Stroke Center Comprehensive Stroke Center Telemedicine
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Stroke: EMS Checklist ABC’s/ Establish time of symptom onset Oxygen/ NPO/ Check Glucometer Cardiac monitoring IV access (if no delay in transport) Rapid transport; alert receiving ED Avoid dextrose solutions; use Normal Saline
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Stroke: Emergency Management ABC’s and recheck H & P Labs: CMP, CBC, PT/PTT, TROPONIN (toxicology, Beta HCG, and HIV if indicated) Imaging: CT (“gold standard”) or MRI Cardiac Monitoring/EKG Normothermia; avoid hyper/hypoglycemia Cerebral ischemia pathway Cerebral hemorrhage pathway R/O Stroke Mimics.
Slide 9-

Common Acute Stroke Mimics Postictal deficits (Todd paralysis) Hypoglycemia Complicated migraine Mass lesions (i.e. tumor, subdural) Conversion reaction (psychogenic) Hypertensive encephalopathy Others: Subarachnoid hemorrhage, peripheral vestibulopathy, Bell’s Palsy, reactivation of old stroke.
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Stroke mimic goals Identify stroke mimics with 97% accuracy. Means that less than 3% of patients who are diagnosed with acute stroke will have a stroke mimic that might be treated with thrombolytics.
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Stroke Imaging: CT/MRI CT MRI Hemorrhage and Gradient Echo (GRE) Diffusion-weighted images (DWI) and apparent diffusion coefficient (ADC) Map Note non ischemic causes of diffusion restriction: Inflammation, infection, tumors, post seizure, etc. Vascular territories Time related changes
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CT scan: Cerebral Hemorrhage
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Stroke: Cerebral Hemorrhage Pathway Additional diagnostics: toxicology?, angiography, LP (if needed for R/O SAH) Treatment Supportive care (similar to ischemic stroke/TBI) Anticoagulant reversal BP Management per guidelines Neurosurgery consultation
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CT scan: Acute Ischemia
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Stroke: Acute Cerebral ischemia pathway Systemic rtPA per protocol (save penumbra) If no rtPA, then antiplatelet agent; NOT heparin Acute BP management per protocol If rtPA: <185/110; post rtPA <180/105 If no rtPA: <220/130 Endovascular thrombolytic or clot retrieval Admit to appropriate stroke unit Initiate diagnostic workup
Slide 16-

Stroke: Cerebral ischemia diagnostics Major etiologies: Atherothromboembolic disease Artery to artery embolus (most common) Stenosis/occlusion with distal hypoperfusion Small vessel disease Arteriosclerosis (fibrinoid necrosis) Microatheromatous Cardioembolic (including “paradoxical embolus?”) Hypotension (with or without stenosis) Idiopathic/Cryptogenic (20-30%) Misc.
Slide 17-

Cryoptogenic Stroke: Current Issues Patent Foramen Ovale Closure vs. medical treatment Studies on going Atrial Fibrillation Prolonged monitoring 20-50 days 12-25% intermittent AFib “Wake up stroke” 3X risk of new AFib
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Stroke: Cerebral ischemia diagnostic tests MRI with diffusion Extra labs: Lipids; others (i.e. “thrombo”) Echocardiogram with agitated saline Sometimes TEE Vascular imaging Ultrasound (extracranial) MRA (intracranial/extracranial) CTA (intracranial/extracranial)
Slide 19-

Dizziness, R face/L body numb; dysphagia
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Right body numbness
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Aphasia
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Left hemiplegia and neglect
Slide 23-

MRI with ADC Map: Acute Ischemia
Slide 24-

Stroke Imaging: Vascular studies Carotid/vertebral ultrasound Angiograms including cervical and intracranial vessels: CT angiograms (CTA) MRI angiograms (MRA) Conventional angiogram (endovascular) Also venograms New options: CT or MR Perfusion
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MR Angiogram: Normal Intracranial Study
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MR Angiogram: Normal Cervical Study
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MR Angiogram: Occluded Right Internal Carotid
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VTE prophylaxis by day 2 Stroke education provided Rehabilitation needs assessed Quality Metrics In-patient Ischemic Antithrombotic therapy initiated by day 2 VTE prophylaxis by day 2 Anticoagulation at discharge for a fib/flutter TPA considered for patients arriving within window Lipid panel assessed and RX statins for LDL>100 Discharged on antithrombotic Stroke education provided Rehabilitation needs assessed In-patient Hemorrhagic
Slide 29-

Stroke: Subacute care Major goals: Reduce complications Manage co morbidities Maximize recovery/rehabilitation Secondary prevention
Slide 30-

Subacute Stroke care: reduce complications IMPORTANT: USE STROKE ORDER SET! Follow evidence based guidelines: Dysphagia screening Cardiac monitoring Avoid fever; avoid hyperglycemia (>140) VTE prophylaxis Stress ulcer prophylaxis Rehab program/mobilization
Slide 31-

Cardiac Cerebral edema, hemorrhage, hydrocephalus Pulmonary/ Sleep apnea Mental status change/delirium Infections Depression Bowel/bladder Subacute Stroke Care: Reduce Complications
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Secondary Stroke Prevention Risk factor management Anticoagulants Antiplatelet agents Surgery
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Stroke: Risk factor management Lifestyle Non-DM HTN: Diuretic; Diuretic &ACEI DM with HTN: ACEI or Angiotension Rec Blocker Glucose control Statins: LDL<100 or <70 (high risk patients)
Slide 34-

Stroke: Anticoagulants Cardiac source of embolus Some hyper thrombotic states? Venous sinus thrombosis Major arterial dissection Few others?
Slide 35-

Stroke: Antiplatelet agents For atherothomboembolic and small vessel disease Aspirin Clopidogrel Note nonresponders/drug-drug interactions (PPI) Platelet function tests? Dipyridamole/aspirin New agents?
Slide 36-

Periprocedural management of antithrombotic medications For Dental procedures: Can continue ASA or Warfarin. ASA probably OK for invasive ocular anethesia, cataract surgery, derm procedures, US guided prostate biopsy, spinal/epidural procedures, and carpal tunnel surgery. Warfarin probably ok for most derm procedures.
Slide 37-

Secondary Stroke Prevention: Surgery Carotid endarterectomy Angioplasty/stenting Cardiac surgery
Slide 38-

Questions? Dr. Matthew Simmons matthew.simmons@usd.edu Kathy Hill, RN, MSN Rapid City Regional Hospital Stroke Coordinator khill@regionalhealth.com 605-719-4374