Stroke

Question 1

Hemorrhagic stroke

Answer 1

Blood flow to brain is interrupted by a ruptured blood vessel

Question 2

Ischemic Stroke

Answer 2

Blood flow to brain is interrupted by occlusion (87% of all strokes)

• Plaque due to atherosclerosis collects along the artery walls, narrowing arteries leading to or lying within the brain
• Disruption within the vessel wall can cause a clot to form, further narrowing or occluding artery
• Pieces of clot can break off and travel deeper into the arteries and eventually lodge in a smaller vessel-causing a stroke there

Question 3

Signs of stroke

Answer 3

• Facial droop
• Aphasic/can’t speak
• Limp/Weakness
• Vision changes

Question 4

Assessment in Field (EMS)

Answer 4

1. Rule out other causes (hypoglycemia and/or stroke)
2. Confirm not on blood thinners
3. Time of symptom onset or last seen normal
4. Cincinnati Prehospital stroke scale
   - Facial droop (ask to smile)
   - Arm Drift (close eyes, ask to hold hands out in front)
   - Abnormal speech (ask to repeat “you can’t teach an old dog new tricks”)

Question 5

Treatment (In ER)

Answer 5

1. Provide oxygen if sat is unknown or less than 94%
2. Ideally, go straight to CT scan
3. Confirm IV patency and draw blood samples (blood glucose, electrolytes, CBC, Coagulation studies)
4. Recheck blood sugar upon arrival
5. EKG: may show recent arrhythmia or MI that caused stroke
   - EKG should not delay CT scan, unless high suspicion of ACS

Question 6

CT scan time goal

Answer 6

25 minutes from arrival to ER

Question 7

Purpose of CT Scan

Answer 7

If hemorrhage is present: no rtPA

No hemorrhage present (Normal CT): suggests acute ischemic stroke and need to decide if patient eligible for rtPA

Question 8

Time Window allotted to receive rtPA

Answer 8

• Within 3 hours of symptom onset (for best outcomes)

- Window can be extended to 4.5 hours for some patients

Question 9

Fibrinolytic Checklist

Answer 9

1. Neuro Exam: move extremities, sensation, ask patient to speak
2. Review contraindications
3. Blood pressure within parameters (SBP 185 or less, DBP 110 or less)- may need IV therapy to manage
4. Review adverse effects with patient
   - Cerebral hemorrhage (5% risk) which may lead to death

Question 10

rtPA contraindications

Answer 10

1. Brain Hemorrhage
2. Prior stroke
3. Abnormal blood vessels in the brain
4. Recent bleeding anywhere
5. History of clotting problems
6. Recent surgery or accidents
7. Certain prescription medications

Question 11

If patients decline rtPA, what do you give?

Answer 11

Aspirin

Question 12

rtPA administration basics

Answer 12

• weight-based
• infuses over 1 hour
• monitor BP and neuro checks q 15 minutes
• monitor neurologic/mental status

Question 13

Secondary Interventions (if rtPA is not an option)

Answer 13

Endovascular Therapy

• intra-arterial rtPA and/or mechanical clot disruption/retrieval
• patients must still meet inclusion criteria
• may be given up to 6 hours from symptom onset, but better outcomes with shorter times