slumping, slurring and slipping away: stroke assessment

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  • 1. Slumping, Slurring and Slipping Away: Stroke Assessment Laurie A. Romig, MD, FACEP Medical Director Pinellas County (FL) EMS

2. Caution! This discussion relates only to nontraumatic neurological problems! 3. Prehospital Stroke Care

  • MYTH :It doesnt make a difference
  • FACT :It does! (as with AMI)
    • Better field management can help to limit stroke deficit
    • Rapid transport to the right facility is an important component of the overall treatment strategy
  • CHALLENGE:Not all areas have the appropriate infrastructure in place (i.e., Stroke Centers)

4. Prehospital Stroke Care

  • Use the FAST-G #exam and history to determine hospital destination
  • Use the MEND* checklist to refine field impression
  • Evaluation and treatment criteria are based on latest AHA/ASA guidelines

# Pinellas County adaptation of Cincinnati Stroke Scale *Miami Emergency Neurologic Deficit (includes Cincinnati Stroke Scale elements) 5. Stroke Facts and Rationale for Acute Care 6. Stroke in the United States

  • Affects > 700,000 persons per year
    • 1/3 die, 1/3 become disabled, 1/3 recover
  • Third leading cause of death
  • Leading cause of long-term disability
  • Costs $50 billion per year

7. Change in Terminology: Acute Brain Attack (Not CVA)

  • Term aids public education efforts
  • Identifies the brain as the organ involved
  • Implies appropriate sense of urgency
  • Likens event to heart attack
  • CVA = cerebrovascular accident
    • Bad term because stroke is preventable and treatable

8. Stroke Definition and Types

  • General Definition
    • Sudden brain dysfunction due to blood vessel problem
  • Ischemic stroke(80%)
    • decreased blood supply to a focal area of brain
    • mostly thromboembolism (blood clot)
  • Hemorrhagic stroke(20%)
    • blood vessel rupture within skull not due to trauma
    • intracerebral (inside the brain tissue) or subarachnoid (under the coverings of the brain)

9. Ischemic Stroke

  • Most common cause: thromboembolism
  • Possible sources of clot:
  • Heart
  • Large artery (to brain)
  • Small artery (in brain)

Clot occluding artery CLOT INFARCT 10. Intracerebral Hemorrhage

  • Most common cause:
  • chronic hypertension
  • Other causes:
  • Vessel malformation
  • Tumor, bleeding abnormalities

Bleeding into brain 11. Subarachnoid Hemorrhage

  • Most common cause:
  • aneurysm rupture
  • Other causes:
  • Vessel malformation
  • Tumor, bleeding abnormalities

Bleeding around brain 12. Transient Ischemic Attack (TIA)

  • Reversible focal dysfunction present for minutes toless than 1 hour
  • Among TIA patients who go the ED:
    • 5% have stroke in next 2 days
    • 10% have stroke in next 3 months
    • 25% have a recurrent event (TIA or stroke) within 3 months
  • Stroke risk can be decreased with proper therapy
  • Do not enable patients to disregard the importance of a TIA , even if they have had them before and know what they are!

13. Ischemic Stroke:Nonmodifiable Risk Factors

  • Advanced age
  • Male gender
  • Family history of early stroke or MI

14. Ischemic Stroke:Modifiable Risk Factors

  • Hypertension (systolic and diastolic)
  • Cigarette smoking
  • Prior stroke/ TIA
  • Heart disease
  • Diabetes mellitus, hyperlipidemia
  • Hypercoagulable states
  • Carotid bruit
  • Cocaine, excess alcohol

Could this be you? 15. The Stroke Battle Cry Time is Brain: Save the Penumbra!! 16. Time Is Brain: Save The Penumbra Clot in Artery Thepenumbrais a zone ofreversible ischemiaaround a core of irreversible infarction. This area of brain is salvageable in the first few hours after onset of acute ischemic stroke symptoms. (DEAD) 17. Time is Brain: Save the Penumbra

  • Patient symptoms are due to both the infarcted core and the ischemic penumbra
  • One cannot determine by exam how much brain can still be saved
    • Therefore, the full extent of the damage is not immediately clear. Deficits could get worse or could get better
  • Treatment aims to salvage the circulation to the penumbra
    • If treated early enough, all of the brain tissue could be salvageable

18. Time is Brain:Save the Penumbra

  • Thrombolytic agent t-PA can limit brain damage safely if given within 3 hoursit reduces risk of disability due to ischemic stroke by 30%
  • t-PA is currently administered only if:
    • clinical diagnosis (no hemorrhage) confirmed by CT scan
    • within 3 hours of onset (the sooner, the better)
    • age 18 or older
    • no other absolute contraindications

19. Time is Brain:Save the Penumbra

  • Other interventions such as intraarterial thrombolytics and clot retrieval devices are being used in facilities with specialized capabilities for some stroke patients
    • Treatment windows are expanding to 6 to 8 hours or more as facilities gain more experience with new devices
  • The Penumbra is damaged by seizure, hypotension, hyperglycemia, fever, acidosis
    • This has implications for what we need to evaluate, monitor and treat in the field

20. Time is Brain:Determine Cause

  • In ED:define likelihood of ischemic stroke
  • Full evaluation may take days and requires admission to the hospital
  • Differential diagnosis is not extensive
    • Ischemia vs. hemorrhage
    • Mimics include:tumor, trauma, seizure, migraine, hypoglycemia, overdose

21. Stroke Mimics

  • These conditions can result in focal cerebral dysfunction and mimic a stroke:
    • hypoglycemia improves w/D50
    • seizure w/postictal state staring/limb shaking at onset
    • migraine previous similar events
    • tumor onset over weeks to months
    • abscess onset over weeks to months
    • subdural hematoma posttrauma

22. The Stroke Primary Survey: The FAST-G Exam 23. Cincinnati Prehospital Stroke Scale FAST

  • Perform as part of Primary Survey under D for Disability
  • Also incorporated in the FAST stroke primary evaluation tool and the MEND stroke secondary evaluation tool that youll hear about later
    • F acial droop
    • A rm drift
    • S peech
    • T ime patient was last seen or known to be normal
  • This is a BLS level evaluation tool!

24. F acial Droop (Cranial Nerves): Show Teeth or Smile

  • Abnormal:
    • One side of face does not move as well as the other side

Right-sided droop AHA 1997 25. F acial Droop

  • You may have to encourage the patient to try
  • Even in unresponsive patients, facial droop may be obvious
  • Its common also to see drooling from the affected side

Facial droop can be caused by other disorders as well (such as Bells Palsy), so a complete detailed stroke examination is VERY important. If ONLY cranial nerve function is disrupted, stroke is less likely. Left facial droop 26. A rm Drift (Motor): Hold arms out, palms down and close eyes

  • Abnormal:
    • One arm cannot be lifted or drifts down

Right-sided drift AHA 1997 27. A rm Drift

  • Normal finding is for both arms not to move once extended or to move together
  • If patient is unable to obey commands, look for spontaneous movement or movement in response to verbal/painful stimulus
    • If patient is unresponsive and not moving at all DO NOT mark this as abnormal. You just dont know the answer.

28. S peech:Repeat Phrase

  • You cant teach an old dog new tricks.
  • Abnormal:
    • Wrong or inappropriate words or unable to speak(aphasia)
      • Caused by left hemispheric deficit
    • Slurred words(dysarthria)