1 st Quarter 2009 CE Packet

Transcription

1 252 McHenry Street T (262) PO Bx 400 F (262) Burlingtn, WI st Quarter 2009 CE Packet Strke Strke is a nnspecific term encmpassing a hetergeneus grup f pathphysilgic causes, including, thrmbsis, emblism and hemrrhage. There are tw types f strke. Hemrrhagic Strke is when bleeding ccurs directly int the brain parenchyma. The usual mechanism is thught t be leakage frm small intracerebral arteries damaged by chrnic hypertensin. Hemrrhagic strkes have a predilectin fr certain sites f the brain, including the thalamus, putamen, cerebellum, and brain stem. In additin t the area f the brain injured by the hemrrhage, the surrunding brain can be damage by pressure prduced by the mass effect f the hematma. A general increase in intracranial pressure may ccur. Ischemic Strke ccurs when there is sudden lss f bld circulatin t an area f the brain, resulting in a crrespnding lss f neurlgical functin, als called CVA (Cerebral Vascular Accident) r strke syndrme. Ischemic strke mst ften is caused by extracranial emblism r intracranial thrmbsis, but may als be caused by decreased cerebral bld flw. On the cellular level, any prcess that disrupts bld flw t a prtin f the brain unleashes an ischemic cascade, leading t the death f neurns and cerebral infarctin. Frequency Hemrrhagic strke accunts fr 10-15% f all strkes. Recent reprts indicate an incidence exceeding 500,000 new strkes f all types per year. Mrtality/Mrbidity Strke is the third leading cause f death and the leading cause f disability in the US. Mrbidity is mre severe and mrtality rates are higher fr hemrrhagic strke than fr ischemic strke. Only 20% f patients regain functinal independence. The 30-day

2 mrtality rate fr hemrrhagic strke is 40-80%. Apprximately 50% f all deaths ccur within the first 48 hurs. Race, Age, and Sex African Americans have a higher incidence f hemrrhagic and ischemic strkes than ther races in the United States. The incidence f hemrrhagic strke in the Japanese ppulatin is increased. Men are at higher risk fr strke than wmen. Additinally, wmen seem t respnd better than men t interventins such as TPA. Althugh strke ften is cnsidered a disease f elderly persns, 25% f strkes ccur in persns yunger than 65 years. Histry Strke shuld be cnsidered in any patient presenting with an acute neurlgic deficit (fcal r glbal) r altered level f cnsciusness. N histrical feature distinguishes ischemic frm hemrrhagic strke, althugh nausea, vmiting, headache, and change in level f cnsciusness are mre cmmn in hemrrhagic strkes. Cmmn symptms f strke include abrupt nset f hemiparesis, mnparesis, r quadriparesis; mncular r bincular visual lss; visual field deficits; diplpia; dysarthria; ataxia; vertig; aphasia; r sudden decrease in the level f cnsciusness. Althugh such symptms can ccur alne, they are mre likely t ccur in cmbinatin. Establishing the time f nset f these symptms is f paramunt imprtance when cnsidering patients fr pssible thrmblytic therapy. An essential questin is, "When was the patient last seen nrmal?" It is advisable fr emergency clinicians t rapidly enlist the assistance f family members r relatives t establish time f nset and t identify ther pertinent cmpnents f the patient's histry f presentatin. The median time frm symptm nset t ED presentatin ranges frm 4-24 hurs in the United States. Multiple factrs cntribute t delays in seeking care fr symptms f strke. Many strkes ccur while patients are sleeping (als knwn as "wake-up" strke) and are nt discvered until the patient wakes. Strke can leave sme patients t incapacitated t call fr help. Occasinally, a strke ges unrecgnized by the patient r their caregivers. Strke mimics cmmnly cnfund the clinical diagnsis f strke. One study reprted that 19% f patients diagnsed with acute ischemic strke by neurlgists befre cranial CT scanning actually had nncerebrvascular causes fr their symptms. The mst frequent strke mimics include seizure (17%); systemic infectin (17%); brain tumr (15%); txic-metablic cause, such as hypnatremia (13%); and psitinal vertig (6%). Miscellaneus disrders mimicking strke include syncpe, trauma, subdural hematma, herpes encephalitis, transient glbal amnesia, dementia, demyelinating disease, myasthenia gravis, Parkinsnism, hypertensive encephalpathy, and

3 cnversin disrders. A critical masquerading metablic derangement nt t be missed by prviders is hypglycemia. Physical Intracerebral hemrrhage (ICH) may be clinically indistinguishable frm ischemic strke. Hypertensin cmmnly is a prminent finding. An altered level f cnsciusness r cma is mre cmmn with hemrrhagic strkes than with ischemic strkes. Often, this is due t an increase in intracranial pressure. Fcal neurlgical deficits The type f deficit depends upn the area f brain invlved. If the dminant hemisphere (usually left) is invlved, a syndrme cnsisting f right hemiparesis, right hemisensry lss, left gaze preference, right visual field cut, and aphasia may result. If the nndminant (usually right) hemisphere is invlved, a syndrme f left hemiparesis, left hemisensry lss, right gaze preference, and left visual field cut may result. Nndminant hemisphere syndrme als may result in neglect when the patient has a left-sided hemi-inattentin and ignres the left side. If the cerebellum is invlved, the patient is at high risk f herniatin and brainstem cmpressin. Herniatin may cause a rapid decrease in the level f cnsciusness, apnea, and death. Other signs f cerebellar r brainstem invlvement include the fllwing:! Gait r limb ataxia! Vertig r tinnitus! Nausea and vmiting! Hemiparesis r quadriparesis! Hemisensry lss r sensry lss f all 4 limbs! Eye mvement abnrmalities resulting in diplpia r nystagmus! Orpharyngeal weakness r dysphagia! Crssed signs (ipsilateral face and cntralateral bdy)! Many ther strke syndrmes are assciated with ICH, ranging frm mild headache t neurlgical devastatin. At times, a cerebral hemrrhage may present as a new-nset seizure. Causes Hypertensin (up t 60% f cases) Advanced age (risk factr) Cerebral amylidsis (affects peple wh are elderly and may cause up t 10% f ICHs) Cagulpathies (e.g., due t underlying systemic disrders such as bleeding diathesis r liver disease) Anticagulant therapy Thrmblytic therapy fr acute mycardial infarctin (MI) and acute ischemic strke (can cause iatrgenic hemrrhagic strke) Abuse f ccaine and ther sympathmimetic drugs

4 Arterivenus malfrmatin Intracranial aneurysm Vasculitis Histry f prir strke (risk factr) Diseases assciated with increased bld viscsity and the use f ral cntraceptives place patients at a higher risk fr ischemic strke. Previus TIA Transient Ischemic Attack (TIA) (Transient Ischemic Attack) a neurlgical deficit that reslves within 24 hurs. Rughly 80% reslve within 60 minutes. TIA s precede nearly 30% if ischemic stkes. Treatment RAPID TRANSPORT!!! Stkes are t be treated as a life threatening emergency and shuld be transprted emergently t the clset apprpriate facility. Treat prblems with ABC s as they present themselves. Get nset time f symptms frm family members if pssible. ECG shuld be btained fr all patients with acute strke because as many as 60% f all cardigenic embli are assciated with atrial fibrillatin r acute MI. Sme reprts have als recmmended cntinuus cardiac mnitring fr all patients, since 4% f patients have a life-threatening arrhythmia during the curse f their illness and 3% have cncurrent MI. Acute ischemic strke has been assciated with acute cardiac dysfunctin and arrhythmia, which then crrelate with wrse functinal utcme and mrbidity at 3 mnths.

5 Suspected CVA LEVEL Suspected CVA FR B V I P 1. Initial Medical Care Special Cnsideratins: If BP is greater than 90 mmhg: elevate head f bed degrees. Prtect paralyzed limbs frm injury. Cmplete Neur Alert checklist enrute t hspital. Cnsider ET/RSI if GCS < 8 Obtain and recrd bld glucse levels. Glasgw Cma Scale Cincinnati Prehspital Strke Scale Eye Opening: Facial Drp: have patient shw teeth r smile: Spntaneus 4 Nrmal bth sides f face mve equally well. In respnse t speech 3 Abnrmal ne side f face des nt mve as well In respnse t pain 2 as the ther side. Nne 1 Best Verbal Respnse: Oriented cnversatin 5 Arm Drift: have patient clse eyes and hld bth arms ut: Cnfused cnversatin 4 Nrmal bth arms mve the same r bth arms Inapprpriate wrds 3 d nt mve at all (ther findings, such as prnatr Incmprehensible sunds 2 grip, may be helpful). Nne 1 Abnrmal ne arm des nt mve r ne arm drifts dwn cmpared with the ther. Best Mtr Respnse: Obeys 6 Lcalizes 5 Withdraws 4 Abnrmal flexin 3 Abnrmal extensin 2 Nne 1 Speech: have patient say yu can t teach an ld dg new tricks : Nrmal patient uses crrect wrds with n slurring. Abnrmal patient slurs wrds, uses inapprpriate wrds r is unable t speak. AHC-SR EMS Apprved 7/01/08 Revised Aurra Health Care Suth Regin Pre-Hspital ALS/BLS Patient Care Prtcls M - 5

6 EMS Neurlgic Checklist Aurra Health Care Suth Regin EMS Prgram Date: Patient: Age: Sex: BASIC DATA EXAMINATION Witness Name: Witness Phne: BP Left Arm: / BP Right Arm: / Dispatch Time: EMS Arrival Time: Departure t ED Time: ED Arrival Time: Last Patient Witnessed Withut Symptms Additinal Histry Time: Date: Allergies: Criteria Medicatins: Yes N Past Histry: Head Trauma at Onset Last Meal: Seizure at Onset Events Prir: Taking Warfarin (Cumadin) Cincinnati Prehspital Strke Scale Check if Abnrmal Histry f Bleeding Prblems Mental Status On-Scene Enrute Management Level f Cnsciusness D nt treat hypertensin. Speech D nt allw aspiratin. Questins (age, mnth, etc) NPO, Head Up, O2 Cmmands D nt give glucse (unless glucse is less than 60). Facial Drp On-Scene Enrute IV NS, Bld Sugar Facial Drp ECG Rhythm (Abnrmal ne side des nt mve as well as ther.) If AMI, 12-Lead and transmit t ED. Arm Drift On-Scene Enrute Strke Specific EMS t ED Reprt (Reprt Items) Mtr-Arm Drift Symptm Onset Neurlgic Exam (Clse eyes and hld ut bth arms. Abnrmal arm can t mve r drifts dwn.) Time (Last time w/ S&S) Trauma Seizure Level f Cnsciusness Speech Language Mtr Strength Witness (Name and Cntact Inf) Cincinnati scale is cnsidered Abnrmal fr a psitive-negative fund during scale assessment.

7 252 McHenry Street T (262) PO Bx 400 F (262) Burlingtn, WI st Quarter 2009 CE Packet Quiz 1. What are tw types f Strke? A. Spinal and Abdminal B. Prximal and Distal C. Traumatic and Nn Traumatic D. Hemrrhagic and Ischemic 2. There is a distinguishable difference in Sign and Symptms between Hemrrhagic and Ischemic Stkes. True False 3. What is ne key questin that needs t be asked t family members regarding a patients signs and symptms?? 4. What are three factrs that cntribute t delays in seeking emergency care? What cmmn prminent finding d mst patients experience when having a Strke? A. Hypertensin B. Unrespnsive C. Hallucinatins D. Full Paralysis

8 6. What are three findings when the Cerebellum r Brain Stem are invlved in a Intracerebral Hemrrhage? What are three causes f a Strke? What is the definitin f a TIA (Transient Ischemic Attack) 9. What are TIA s precursrs fr? A. Obesity B. Strke C. MVA D. Nn f the abve 10. When treating a patient having a Strke in the field, what des this patient need the mst? 11. Per AHC SREMS Prtcl, what are three cnsideratins when it cmes t Initial Medical Care in a patient having Strke symptms? What ther medical cnditin mimics Strke like symptms? 13. What are the three tests f the Cincinnati Strke Scale?

9 What is the name f the numeric scale is used t assess a patient s level f cnsciusness and what are they? 15. What shuld accmpany the patient having Strke like symptm t the ED?