Did you know based on statistical epidemiology that every 40 seconds someone in the United States has a stroke? What’s more intriguing is that one out of six people will suffer a stroke in his or her lifetime. Therefore, everyone should be ready at all times because even with risk factors or no risk factors anyone may potentially have a stroke.
This is the principal reason why Palm Desert Resuscitation Education (PDRE) is steadfast in informing healthcare providers as well as the public at large about the etiology, risk factors, symptoms, signs, diagnostic tests, and possible treatment of a stroke or also known as cerebrovascular accident (CVA) considering that it is, in fact, a leading cause of death – it is currently the #5 cause of death in the United States – and adversely affects many people every year. Did you also know that it is actually one of main causes of disability among adults in the United States? For someone who has suffered and survived a major ischemic or hemorrhagic stroke, it is very disheartening to observe and experience the victim’s physical, mental, and/or social incapacity, especially in regards to his or her diminished daily activities of living, which we all might take for granted until it is partially or completely taken away from us due to a disabling but preventable medical condition.
How do we identify the telltale signs of an acute ischemic or hemorrhagic stroke?
How do we respond promptly with appropriate care and treatment based on your experience as a healthcare provider or even a non-healthcare provider, taking into account your limitations and knowing your clear roles and responsibilities as a rescuer in either an in-hospital setting or (most often) in an out-of-hospital setting where the majority of strokes happen?
THE PATHOPHYSIOLOGY OF A STROKE
The pathophysiology of a stroke occurs when the blood flow to the brain is fully interrupted by a clot (ischemic stroke) or when a vein or artery ruptures (hemorrhagic stroke). About 87% of all strokes in the United States are ischemic in nature and are due to atherosclerosis plaque build-up that abnormally accumulates along the blood vessels of the brain, which may lead to narrowing of the blood vessel lumen to the point of no blood perfusion and eventual neurological sequelae. What can also happen, at times, is that pieces of a benign atherosclerotic plaque can dislodge off and travel down to a narrow blood vessel(s) and may subsequently cause a stroke or brain tissue injury due to the lack of life-sustaining oxygen and nutrients in the affected area(s) of the brain. A sudden onset of stroke symptoms and signs then manifests in the victim that, if actually recognized early and immediately, may afford some precious time to get help immediately and can actually save someone’s life and/or prevent neurological debilitation from a stroke. This leads us to the importance and concept of understanding the stroke algorithm and chain of survival.
STROKE ALGORITHM AND CHAIN OF SURVIVAL
Rapid recognition and reaction to the stroke warning signs is the first step in the stroke algorithm and chain of survival
Rapid EMS dispatch
Rapid EMS system transport and pre-arrival notification to the receiving hospital
Rapid diagnosis and treatment in the hospital
As you can see from the stroke algorithm and chain of survival, as with acute coronary syndromes, timing is key! However, one has to coordinate the latter initial protocols with the 8 D’s of Stroke Care. By following diligently these crucial steps starting with recognition, responding to a stroke emergency as soon as possible can lead to rapid stroke treatment and may even save the victim’s life. There is a narrow window of time in which a stroke can be effectively and safely treated, for example, with fibrinolysis if it is an ischemic stroke (after a negative non-contrast CT imaging study of the brain and no other significant risk factors for excessive hemorrhage), consulting immediately with the neurosurgeon if it is a massive hemorrhagic stroke, or transferring the patient to the stroke unit in a hospital institution capable of managing any forms of stroke even after it has occurred. If that small window of time of therapy for a stroke is missed, then it could mean a difference between complete recovery, permanent disability, or even death. This is why carefully understanding the 8 D’s of Stroke Care is very imperative.
8 D’S OF STROKE CARE
DETECTION OF A STROKE – SYMPTOMS AND SIGNS
Because many strokes occur at home, it is integral that family members and laypersons alike recognize the symptoms and signs of a stroke. It may happen that one second a person is doing fine, then all of a sudden he or she can turn for the worse. The rescuer must know that this is a case of a possible stroke by easily remembering the mnemonic F.A.S.T. as promoted by the American Heart Association (AHA) and Palm Desert Resuscitation Education (PDRE):
An important fact to understand, whether you are a healthcare provider or even a layperson (who does not have any form of medical background), is the Cincinnati Pre-hospital Stroke Scale that is a system utilized to identify and detect a potential stroke in a pre-hospital setting. Essentially, it assesses for the abnormal neurological symptoms and signs of motor weakness like unilateral facial drooping and arm drifting or numbness as well as aphasia’s such as speech difficulties (i.e., slurred speech) and/or comprehension problems (i.e. confusion and/or disorientation). As illustrated previously in the pictures above, at least one positive out of the three common symptoms and signs of the F.A.S.T. mnemonic may indicate that the patient is having an actual stroke and increases his or her risk by at least 72%.
Once some or all of the symptoms and signs of a stroke are recognized, then calling 911 and activating the emergency medical response system (EMS) through a dispatcher becomes a rescuer’s next priority. It is of high urgency for emergency medical technicians, paramedics, firefighters, or other first responders to quickly arrive at the scene and assist a patient who has a life-threatening medical condition, like a suspected stroke or a sudden cardiac arrest, for example. The purpose of swiftly dispatching the medical emergency team (EMT) or rapid response team (RRT) is to improve the patient outcomes by identifying and treating early clinical deterioration. Of course, once the vital signs are obtained and other reversal causes are ruled out as fast as possible, these EMTs or RRTs can then transfer the patient with a positive pre-hospital stroke assessment (via the Cincinnati Pre-hospital Stroke Scale) to a medical institution capable of performing a STAT Head CT scan imaging study to rule out brain hemorrhage and, if clinically appropriate, provide and administer fibrinolytic therapy to reverse the damage in the affected brain tissues and prevent decompensation of the stroke patient. Certainly, a competent physician and/or advanced healthcare provider need to respond to the suspected stroke quickly even if it might be reversed 24 hours later if it is, let’s say, a Transient Ischemic Attack (TIA).
The ensuing step is to rapidly deliver and divert the patient with a suspected stroke to a hospital or medical center with a CT san imaging study capabilities even if it is 10-15 minutes away. The EMS rescuers are hopeful that the periods of delivery to the medical institution capable of performing this STAT Head CT scan to look for a brain bleed is as minimally short as possible. Remember, time is essential and key for the brain and heart!
Another significant life-saving tool utilized by the EMTs and RRTs is a clear, concise radio communication of the patient’s current condition, clinical history, pertinent pre-hospital diagnostic study results and the estimated time of arrival to the destined emergency department (ED) team to quickly and efficiently triage the suspected stroke patient and swiftly prepare the stroke team, including the attending neurologist and stroke unit healthcare providers.
It cannot be over-emphasized enough that there is a very limited time of therapy to begin fibrinolytic therapy if indicated (e.g., immediate rtPA infusion administration). Getting the advanced notice of a suspected stroke patient from the EMS will make the ED staff and stroke team be poised and ready to deliver appropriate and urgent therapy.
FACE DROOPING Does one side of your face droop or is it numb? Try to smile.
ARM WEAKNESS Is one arm weak or numb? Try to raise both arms. Does one arm drift downward?
SPEECH DIFFICULTY Is your speech slurred or are you unable to speak? Try to repeat a simple sentence like, "The sky is blue." Can you say it correctly?
TIME TO CALL 9-1-1 If you or a loved one has any of these symptoms, even if the symptoms go away, call 9-1-1 and go to the hospital immediately
From the delivery to the ED door, the suspected stroke patient must be clinically assessed again within 10 minutes. Some medical institution may take the patient directly to the CT scan if there is a high probability of a stroke based on the history of present illness and current abnormal neurological symptoms and signs of the patient as evaluated by the healthcare provider(s).
Of course, in any acute illness as in a stroke case, the “ABCs” are critical in the initial assessment and at times provide prognosis of the patient’s acute life-threatening medical condition to prevent deterioration to a worse clinical state. Unstable vital signs should be considered, such as hypoxemia, and blood studies should be ordered which may include serum glucose levels, electrolytes, CBC, and coagulation findings just to name a few urgent laboratory studies. Just a note, even if the EMS may have performed a STAT finger stick analysis of the patient’s serum glucose levels, the blood sugar levels should be taken again in the ED to look for hypoglycemia or hyperglycemia, especially in both type 1 and type 2 diabetic patients. ED personnel must also rule out other medical causes by performing a portable CXR to look for pulmonary causes of the patient’s grave medical condition and a 12-lead ECG to identify thrombosis as in a recent heart attack or myocardial infarction (e.g., UA/NSTEMI or STEMI) or a catastrophic arrhythmia as another potential cause of the patient’s abnormal neurological symptoms and signs. Nevertheless, performing other diagnostic studies like a CXR and/or ECG should not delay directing the patient to have an immediate STAT Head CT scan imaging study unless there is a very high probability that the medical condition is, possibly, an acute coronary syndrome (ACS) or other life-threatening medical conditions, for example.
Preferably, during the first 25 minutes of a suspected stroke patient’s arrival at the ED door as per the most current and up-to-date guidelines by the American Heart Association (AHA) and the majority of medical associations, the emergency department physician must perform a thorough medical and clinical history, a targeted physical examination with an emphasis on the neurological examination (specifically, ideally in conjunction with the National Institutes of Health Stroke Scale or just NIHSS), and actually determine a time of symptom onset based on the data provided initially by the patient (if possible), patient’s family members or friends, innocent bystanders, EMS, and/or other healthcare providers involved with the care of the suspected stroke patient.
In terms of the NIHSS, it is a very methodical evaluation tool that offers a quantifiable measure of stroke-related neurological deficit. In accordance with the NIH Stroke Scale International as indicated in the organization’s educational website – http://www.nihstrokescale.org/ – the NIHSS is 15-item neurologic examination stroke scale that can be completed in less than 10 minutes or so to clinically assesses the suspected stroke patient’s level of consciousness, language, neglect, visual-field loss, extra-ocular muscle movement, motor strength, ataxia, dysarthria, and sensory loss among the most common typical or atypical signs of a stroke.
Clear indicators through the quantifiable measures of the NIHSS or as per the judgement of the ED physician that highly suggests a stroke are a signal to urgently perform a STAT Head CT scans imaging study preferably within 45 minutes of the patient’s arrival at the ED door. The clock is ticking.
If there is a positive intracranial hemorrhage(s) from the Head CT scan, then the stroke team will not be able to provide fibrinolytic therapy and must consult immediately with the neurovascular surgeon and stroke team in case the massive brain bleed may be dangerously life-threatening, such as one that shows a midline shift of the brain or hypovolemic shock, that may likely lead to sudden death. However, if there is a normal Head CT scan that is negative for brain hemorrhage, this suggests an acute ischemic stroke that directs the advanced healthcare provider to determine and decide whether rtPA therapy is appropriate or pursue other avenues of therapy if “clot busters” are not recommended.
A repeat neurological examination, stabilization of vital signs, and the fibrinolytic checklist are highly warranted moving forward for the patient’s safety and clinical condition because it basically tells you if the stroke patient is, on one hand, a candidate for rtPA or other direct clotting factor inhibitors or, on the other hand, may not receive anticoagulation due to their past medical history of severe bleeding and/or increased risk factor for uncontrollable hemorrhage. If and only if the stroke patient is cleared based on the comprehensive fibrinolytic checklist and the window of therapy for fibrinolysis is still within 3 hours of symptoms onset, then the advanced healthcare provider must then ask for consent directly from the patient, patient’s spouse/family members, or power-of-attorney/healthcare proxy (ethically speaking, if the patient is not competent or does not have capacity to make medical decisions and care for his or her own well-being).
Some contraindications to receiving fibrinolytic therapy are the following but are not exhaustive:
Brain hemorrhage based on the Head CT scan results
Prior CVA(s) or stroke(s)
Abnormal blood vessels in the brain, such as major intracranial aneurysms
Recent bleeding, as in the gastrointestinal system or other areas of the body prone to hemorrhage
History of clotting and coagulation problems
Recent surgery, especially neurosurgery
Recent major accidents
Current therapy with anticoagulation
DRUG/DEVICE & DISPOSITION
Before initiating fibrinolytic therapy and if it is clinically appropriate, it is customary to get a medical consent from the patient or possibly the patient’s family members or healthcare proxy who are there to support the stroke patient because there is a small chance of a major and fatal cerebral bleed after initiating anticoagulation. Even if the risk of an intracranial hemorrhage with clot busters is less than 5%, there should be consideration that a hemorrhagic stroke or excessive bleeding may happen. However, the upside to fibrinolytic therapy in an acute ischemic stroke is that it may break up the atherosclerotic plaque that is narrowing one or more of the arteries of the brain, potentially restoring or improving blood perfusion to the other areas of the brain. It actually improves neurological recovery by 30% if the fibrinolytic therapy is given within the recommended 3 hours of neurological symptom onset in an acute ischemic stroke, outweighing potential life-threatening risks involved with anticoagulation. Regardless, it is better to make the window of 3 hours for fibrinolytic therapy but some suggests 4.5 hours may also be appropriate in other instances. In any case, the earlier the administration of anticoagulation in an acute ischemic stroke, the more likely that the patient recovers without neurological deficits or disability.
PRIMARY PREVENTION & SECONDARY PREVENTION OF STROKE
It is important to emphasize that no treatment is perfect and, sometimes, even if everything is done right, the patient might not even survive the stroke or may still suffer neurological problems and disability, which far too often can lead to a very low-quality of life not only experienced by the stroke patient but as well as their caretakers, usually the family members and friends who will most likely have great difficulty even just trying to assist in their loved one’s daily activities of living. Therefore, it is better to prevent the stroke than actually treating it, as is the case in most acute or chronic medical conditions, whether they are debilitating or not. The risk factors for a stroke must be minimized through primary prevention by averting disease or injury before it ever occurs. First and foremost, primary prevention can happen through mass education of the public with healthy and safe habits that aids in stroke deterrence. In addition, secondary prevention is also vital in stroke prevention by aiming to reduce the impact of a disease or injury by following up with regular examinations by competent healthcare providers who screen potential stroke patients with diagnostic tests to detect disease in its earliest stages and/or provide pharmacological therapy to prevent further cerebrovascular accidents in combination with primary prevention to teach their patients ways to decrease, lessen, or completely get rid of their lifetime risk factor(s) for a stroke.
Naturally, as stated by the Stroke Association, particular risk factors for a stroke cannot be altered as in the patient’s advanced age, hereditary/family history, race, sex (gender), and prior stroke, TIA or heart attack. Nevertheless, the other side of the coin suggests that it is wise to avoid or prevent a stroke entirely by changing one’s lifestyle to avert uncontrolled high blood pressure; stopping or minimizing cigarette smoking; managing diabetes mellitus appropriately; improving diet through portion control, decreasing fatty foods and red meat, reducing salt intake, and eating more fruits and vegetables; increasing physical activity; and, lastly, losing weight by being within the recommended average body max index for one’s weight and height. Clearly, there may be other less familiar risk factors of stroke such as medical conditions that increase coagulation in the body (e.g., atrial fibrillation and Sickle Cell Disease just to mention a few) or other medical problems that mandate a patient to take daily blood thinners to prevent or treat thrombosis (i.e., atrial fibrillation, deep vein thrombosis, pulmonary embolisms, and other hypercoagulable states). There are other rare risk factors for a stroke such as illicit drug abuse and alcohol abuse that most people do not even think about. Going further than substance abuse risk factors for a stroke are other, less well-documented stroke risk factors like living in a specific geographic location and low socioeconomic area where stroke most often occurs. The latter risk factors for a stroke may be one of the influences in why some people are more prone to a stroke and why others are not. They are something to think about.
STROKE EDUCATION IS IMPORTANT FOR EVERYONE!
It is truly important that families and healthcare providers alike recognize the symptoms and signs of a stroke by easily remembering the mnemonic F.A.S.T. to be able to save precious time before the victim deteriorates immediately. Remember, a stroke can happen to anyone and it may even happen to be your family member or close friend who is directly or indirectly affected by it, so please help the Palm Desert Resuscitation Education (PDRE) and American Heart Association (AHA) inform everyone in your community to know and understand the importance of stroke education and how to prevent it in the first place!
Cardiovascular Disease and Acute Stroke are one of the leading causes of death in the United States. Knowing CPR can potentially save someone’s life after a heart attack or a stroke, which why it is also important to know how you can help someone in cardiopulmonary arrest with basic CPR, even if it is “hands-only CPR.” This is a great transition to being cognizant of a few vital facts about why CPR is critical to know, especially in an out-of-hospital setting.
Who Can You Save With CPR?
The life you save with CPR is most likely to be a loved one.
4 out of 5 cardiac arrests happen at home.
Statistically speaking, if called on to administer CPR in an emergency, the life you save is likely to be someone at home: a child, a spouse, a parent or a friend.
Why Take Action?
Failure to act in a cardiac emergency can lead to unnecessary deaths.
Effective bystander CPR provided immediately after sudden cardiac arrest can double or triple a victims chance of survival, but only 46% of those victims get CPR from a bystander.
Only about 10% of people who suffer a cardiac arrest outside the hospital survive.
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