1. 1 Acute Stroke Care At the end of this study the participant will: –List 4 risk factors for stroke –Verbalize application of the Cincinnati Stroke Scale –Describe BJH management of a stroke

2. 2 Incidence and Prevalence From the American Heart Association  750,000 new or current strokes per year  NOT disease of elderly: Almost 60% are less than 65 years of age  #3 leading cause of death  #1 - Heart disease  #2 – Cancer  In 2004, females accounted for 60.8 percent of stroke deaths.

3. 3 Stroke Etiology Ischemic Hemorrhagic Embolic Thrombotic Pathology: blockage of blood supply to specific area(s) brain clots account for 75% of all strokes partial to complete blockage Pathology: rupture of an artery or vessel Arterio Venous Malformation Aneurysm Hypertension

4. 4 Modifiable Stroke Risk Factors hypertension carotid artery disease smoking birth control pill use diabetes atrial fibrillation heart disease high cholesterol tobacco use physical inactivity and obesity history of TIAs (transient ischemic attacks) excessive alcohol/some illegal drugs

5. 5 Unmodifiable Stroke Risk Factors  Increase age  Sex (M > F)  More women die than men  Heredity (family history)  Prior stroke or heart attack  Ethnicity (African-American, Hispanic-American)

6. 6 Stroke Warning Signs  Sudden numbness or weakness of the face, arm or leg, especially on one side of the body  Sudden confusion, trouble speaking or understanding  Sudden trouble seeing in one or both eyes  Sudden trouble walking, dizziness, loss of balance or coordination  Sudden, severe headache with no known cause

7. 7 Cincinnati Stroke Scale  Developed as a Prehospital Stroke Scale  Easy to do  Takes 15 sec to complete exam –Facial Droop  have the patient show teeth or smile –Arm Drift  patient closes eyes and holds arms straight out, palms up for 10 seconds –Abnormal Speech  ask patient to say “you can’t teach an old dog new tricks” If any 1 of these 3 signs is abnormal, the probability of a stroke is 72%

8. 8 BJH Stroke Team  CODE STROKE PAGER  40-SMART or 407-6278  Activate if symptoms of acute stroke occur, known < 3 hours  This is a “Stroke Code” numeric pager number.  Treated with same significance as a cardiac or pulmonary arrest  Do not need an order to activate pager  This pager notifies Neuro Chief Resident/Neuro JR Resident/Stroke Attending Physician

9. 9 abcdefg BJH STROKE TEAM  When calling 40-SMART  Be Prepared to State  Be Prepared to State:  Patient’s name  Patient’s room number or location  Time of symptom onset  Symptoms  Division contact person  Treat it like any emergency call.  Stay calm  Repeat information if needed  Stay on line until caller has all information

10. 10 BJH STROKE CARE  DO NOT activate Stroke Code Pager IF:  Patient’s symptom onset is greater than 3 hours  Patient has had surgery in past 14 days  GI or urinary hemorrhage in past 21 days  History of previous intracranial hemorrhage  MI in past 3 months

11. 11 Emergent Stroke Care  Don’t forget the Basics  A irway  Muscular impairment can lead to respiratory distress  B reathing  Alterations due to type, location, and extent of stroke

12. 12 abcdefg Emergent Stroke Care  C irculation  BP management – (be careful since HTN is a physiologic response) Hypertension management - do NOT over treat or lower too fast –Goal should be not less than baseline –Drugs should be short acting, maintain cerebral blood flow –Hypotension management - isotonic fluid before pressors, look for other source

13. 13 ACUTE STROKE CARE  Management  Seizure  Evaluate possible causes  Treatment  May be etiology of stroke symptoms  Cerebral edema  Risk for dangerous ICP elevation  CO 2 levels - maintain low normal  Fluid management with isotonic fluids

14. 14 Thrombolytic Therapy (TPA)  Patients must present < 3 hrs of symptom onset  Baseline CT to exclude intracranial hemorrhage and other risk factors  Review patient history for potential contraindications  severe HTN (SBP >185, not responsive to Rx)  hyperglycemia/hypoglycemia  recent surgery/GI bleed Potential complications  Worsening of stroke  Stroke area becomes hemorrhagic  Bleeding

15. 15 Acute Stroke Treatment Modalities Thrombotic/Embolic Stroke  Carotid Endarterectomy  Angioplasty/Stents  TPA  New-Catheter Embolectomy Hemorrhagic Stroke  Aneurysm Clipping  Coiling  AVM Embolization/ Removal

16. 16 Acute Stroke Treatment Modalities Standard drug therapy for thrombotic/embolic strokes  Thrombolytics: only for those diagnosed within 3 hours of onset of symptoms  heparin  then coumadin

17. 17 Secondary Stroke Prevention  Anti-hypertensive management (goal <120/80)  Smoking cessation  Anticoagulation/ Antiplatelet (ASA 81mg vs 325mg)  Plavix  Ticlid  Dipyridamole  Coumadin

18. 18