NEUROLOGICAL

EMERGENCIES:
STROKE
WHAT IS A STROKE?

“Neurological deficit of cerebrovascular cause that persists beyond 24 hours or is

interrupted by death within 24 hours.” - WHO

Death or injury of brain tissue from oxygen deprivation.

 STROKE FACTS

• A stroke is a medical emergency!

• Approximately 795,000 each year in the US, 5th leading cause of death (133,000)
• 2nd most frequent cause of death world-wide (>6M)
• 5th leading cause of death in the US
• A leading cause of adult disability
• On average, someone in the US has a stroke every 40 seconds
• Over 4 million stroke survivors in the US
• Crosses all ethnic, racial, and socioeconomic groups
• Direct and indirect cost of stroke annually in US: $38.6 Billion (2009)
 TYPES OF STROKE

• Ischemic (87%)
• Thrombosis
• Embolism
• Systemic hypoperfusion (shock)
• Cerebral Venous Sinus Thrombosis (CVST)

• Hemorrhagic (13%)
• Intracerebral
• Subarachnoid
 CVA VS TIA

• TIAs are strokes where symptoms last less than two hours. “mini-stroke”
• Caused by small clots
• Complete resolution typically occurs without further treatment within 24 hours
• About 15% of all strokes (CVAs) occur after a TIA
• TIA is a medical emergency – even if symptoms have resolved

• CVAs are strokes where symptoms are typically persistent until treated by medical
professionals.
• ASA recommends terminology changes - “Brain Attack”
 RISK FACTORS

Controllable Non-controllable
• Hypertension (35-50% of stroke risk) • Age
(decrease 10 mmHg Systolic or 5mmHg • Increases exponentially from 30
Diastolic reduces risk ~ 40%) • 95% > 45 YO
• Hyperlipidemia (high cholesterol) • 67% > 65 YO
• Diabetes (2 to 4x multiple) • Gender
• Tobacco Use (2 to 4x multiple) • Women are at higher risk

• Alcohol Use • 60% of stroke deaths are women

• Physical Inactivity (decrease risk 30m/5d/wk) • Race

• Obesity • South Asian (40%)

• African American
• Heart Disease
• Family History and Genetics
• Atrial Fibrillation
• Previous Stroke or TIA
• Pregnancy
 SIGNS / SYMPTOMS

• Hemiparesis – one-sided weakness (very common)

• Aphasia – difficulty speaking or inability to speak
• Headache – caused by hemorrhage (less common, but very important)
• Confusion or Altered Mental Status
• Dizziness
• Numbness, weakness, or paralysis – usually on one side of the body
• Loss of bladder and/or bowel control
 SIGNS / SYMPTOMS

• Impaired vision or loss of vision in one eye

• Hypertension
• Dyspnea – difficulty breathing or snoring respirations
• Nausea or vomiting
• Seizures
• Unequal pupils
• Unconsciousness (uncommon)
COMMON
STROKE
SYMPTOMS

LEFT HEMISPHERE STROKE RIGHT HEMISPHERE STROKE

• Speech problems – what is being said or • Dysarthria – slurred speech

inability to get words out • Left sided neglect
• Problems with comprehension • Right gaze preference
• Left gaze preference • Weakness or numbness of left face, arm, or
• Weakness or numbness of right face, arm, leg
or leg
 COMMON STROKE SYMPTOMS

BRAINSTEM STROKE SYMPTOMS SILENT STROKES

• Nausea, vomiting, or vertigo • Asymptomatic

• Speech problems • Statistically significant
• Dysphasia - swallowing problems • Only detected by MRI
• Abnormal eye movements
• Decreased consciousness
• Crossed findings
 COMMON STROKE SYMPTOMS

INTRACEREBRAL HEMORRHAGE SUBARACHNOID HEMORRHAGE

• Nausea and Vomiting • Worst headache of life

• Headache • Intolerance to light
• One sided weakness • Neck stiffness or pain
• Decreased consciousness
COMMON STROKE MIMICS

• Alcohol intoxication • Migraines

• Cerebral infections • Neuropathies (Bell’s Palsy)
• Drug overdose / toxicity • Seizure and post seizure, Todd’s
• Epidural hematoma Paralysis

• Hypoglycemia • Brain tumors

• Metabolic disorders • Hypertensive encephalopathy

 EARLY RECOGNITION OF STROKES

BE-FAST!
• Balance – Loss of balance, headache, or dizziness
• Eyes – Blurred vision or loss of visual fields
• Face – One side of the face drooping
• Arms – Arm or leg weakness
• Speech – Difficulty speaking or forming words
• Time – Time is brain – seek treatment immediately!
 PATIENT ASSESSMENT
(2019 MARYLAND MEDICAL PROTOCOLS)

Initiate General Patient Care

• Scene Size-Up
• Primary Assessment
• Secondary Assessment
• Perform glucometer check as part of vital sign assessment.
• Perform Stroke Assessments
- The Cincinnati Prehospital Stroke Scale
- Posterior Cerebellar Assessment
- If the Cincinnati Prehospital Stroke Scale OR the Posterior Cerebellar Assessment is POSITIVE perform
the Los Angeles Motor Scale (LAMS).
 PATIENT ASSESSMENT
(2019 MARYLAND MEDICAL PROTOCOLS)

Cincinnati Prehospital Stroke Scale

• Facial Droop (have patient show teeth or smile)
Normal – both sides of face move equally
Abnormal – one side of face does not move as well as the other side
• Arm Drift (patient closes eyes and holds both arms straight out for 10 seconds)
Normal – both arms move the same or do not move at all
Abnormal – one arm does not move or one arm drifts down compared to the other
• Abnormal Speech (have the patient say “you can’t teach an old dog new tricks”)
Normal – patient uses correct words with no slurring
Abnormal – patient slurs words, uses the wrong words, or is unable to speak
 PATIENT ASSESSMENT
(2019 MARYLAND MEDICAL PROTOCOLS)

Posterior Cerebellar Assessment (NEW 2019)

Balance and Eyes
- Sudden onset of loss of balance or dizziness
- Sudden vision loss (including intermittent loss or blurred vision)

Other symptoms may include:

- Contralateral sensory deficits (occasionally accompanied with motor deficits)
- Alexia without agraphia (able to write but not read)
 PATIENT ASSESSMENT
(2019 MARYLAND MEDICAL PROTOCOLS)

Los Angeles Motor Scale (LAMS)

• Facial droop
• Grip Strength
Absent – 0
Normal – 0
Present – 1
Weak grip – 1
• Arm drift
No grip – 2
Absent – 0
Drifts down – 1
Falls rapidly – 2
PATIENT ASSESSMENT
(2019 MARYLAND MEDICAL PROTOCOLS)
Strokes during pregnancy or shortly after giving birth are rare – but a significant increase
recently.

Fibrinolytic checklist is NO longer used for stroke patients (2017)

 PATIENT TREATMENT
(2019 MARYLAND MEDICAL PROTOCOLS)

• Do not administer aspirin

• Position patient with head elevated at 30 degrees
• If patient has a positive Posterior Cerebellar Assessment OR Cincinnati Prehospital Stroke
Scale AND can be delivered to the hospital within 20 hours of last known well time:
• Patient is Priority 1 – notify receiving facility with “Stroke Alert with a last known well time of
XX:XX” ASAP!
• Transport patient to closest Acute Stroke Ready, Primary, or Comprehensive Stroke Center
• If no stroke center with 30 minutes, go to the nearest hospital
• Consider aeromedical transport
• Obtain and document a contact telephone number for one or more individuals who have details
about the patient’s medical history – this must be provided to the receiving facility.
 PATIENT TREATMENT
(2019 MARYLAND MEDICAL PROTOCOLS)

• Administer oxygen at 2-6 lpm via NC unless hypoxic or in respiratory distress

• Use glucometer and treat accordingly if glucose is less than 70 mg/dl

• ALS Interventions include:

• Establish IV access with Lactated Ringers
• Consult if patient is hypotensive
• Consider obtaining blood sample using closed system
• Do not treat hypertension in the field
 PEDIATRIC PATIENTS (UNDER 18)
(2019 MARYLAND MEDICAL PROTOCOLS)

• Stroke is uncommon but does occur. Most often caused by:

• Congenital Heart Defects
• Infections (including Chicken Pox, Meningitis, or Encephalitis)
• Brain Injury
• Blood Disorders (such as Sickle Cell Disease)

• Most often seen in infants, but can occur at any age

• Consult with Pediatric Base Station, arrange transport to a Pediatric Trauma Center.
• Johns Hopkins Children’s Center, Baltimore
• Children’s National Medical Center, DC
 ACUTE ISCHEMIC STROKE
HOSPITAL TREATMENT OPTIONS
• IV-tPA – Tissue Plasminogen Activator “clot-buster” (alteplase)
• Patient must be within the time window of 3.5 hours (4.5 hours for some patients)

• Intra-arterial Thrombolysis
• Doctor uses a catheter to administer tPA directly into the clot
• Treatment can be administered up to 6 hours from symptom onset
• Patients must meet strict criteria

• Mechanical Thrombectomy
• Uses a device to retrieve the clot
• Treatment can be administered up to 8 hours from symptom onset
• If IV-tPA fails or patient is ineligible, they may be eligible for mechanical thrombectomy
STROKE CENTERS

Acute Stroke Ready

• Acute Stroke Team available 24/7, at bedside within 15 minutes
• No designated beds for acute care of stroke patients
• Neurosurgical Services available within 3 hours
• Telemedicine available within 20 minutes of it being necessary
• IV thrombolytics and transfer of patients who have received IV thrombolytics for medical
management of stroke to PSC OR CSC
STROKE CENTERS

Primary Stroke Center

• Acute Stroke Team available 24/7, at bedside within 15 minutes
• Stroke unit or designated beds for acute care of stroke patients
• Neurosurgical Services available within 2 hours or available 24/7 if provided on site
• Telemedicine available if necessary
• IV thrombolytics and medical management of stroke
STROKE CENTERS

Comprehensive Stroke Center

• Acute Stroke Team available 24/7, at bedside within 15 minutes
• Dedicated neuro intensive care beds for complex stroke patients with on-site neurointensivist
24/7
• 24/7 availability of Neurointerventionist, Neuroradiologist, Neurologist, Neurosurgeon
• Telemedicine available if necessary
• IV thrombolytics, full range of neurological procedures, and medical management of stroke
 RECOVERY

• Rehab can be inpatient, outpatient, or a combination

• Various rehab programs depending on need, including:
• Physical Therapy
• Occupational Therapy
• Speech-Language Therapy
• Patient / Family Education
• Support Groups
 REDUCING RISK OF ADDITIONAL STROKES

• Maintain a healthy blood pressure – ideally below 120/80

• Maintain healthy blood sugar and cholesterol levels
• Address other health issues, especially atrial fibrillation and sleep apnea
• Adopt healthy lifestyle habits, including diet and physical and mental exercise
• Limit or eliminate alcohol, tobacco, and vaping
• Maintenance medications may be required, such as aspirin, depending on stroke type
EVIDENCED BASED NURSING PRACTICE
STROKE PATIENT
• https://scholar.google.com/scholar?
oi=bibs&cluster=10117672331690949192&btnI=1&hl=id
CONCLUSION

• Peran Keluarga sangat penting dalam penanganan pasien post stroke/pencegahan pasien
stroke untuk itu perlu untuk memperhatikan pasien dan keluarga dari segi psikologis
khususnya dalam upaya peningkatan self efficacy
QUESTIONS ?
SOURCES

• American Stroke Association (www.strokeassociation.org)

• MIEMSS 2019 Maryland Medical Protocols (www.miemss.org)
• Western Maryland Health System Stroke Center (www.wmhs.com)
• The Joint Commission [formerly JCAHO] (www.jointcommission.org)
• Wikipedia (www.wikipedia.org)