Monique-Lorelyn A.

Roa, RN

Stroke definition:

STROKE is a BRAIN ATTACK

Stroke is:
Sudden onset of focal

neurological deficit lasting for more than 24 hours due to an underlying vascular pathology

EARLY HOURS OF STROKE: THE ROLE OF THE PHYSICIANS IN ACUTE STROKE CARE
Ask??? Is the hospital & its medical staff prepared and

equipped to provide stroke care? The admitting medical personnel (ER PHYSICIAN) has the major responsibility to provide acute efficient stroke management is & early medical treatment which can reduce the risk of death or disability from stroke. When available: Refer to physician trained in stroke care and admit to a stroke unit/ ICU

THE ROLE OF THE PHYSICIANS IN ACUTE STROKE CARE:

Confirm not that the diagnosis is STROKE & not

mimickers; that the stroke is ISCHEMIC & not HEMORRHAGIC. Determine if acute treatment with thrombolytic agent (r-tPa) is advisable Do diagnostics to screen for acute medical or neurological complications of stroke Determine vascular distributions of the stroke & provide clues on likely pathophysiology & etiology.

Emergency Room Management Priorities

Ascertain clinical diagnosis of stroke (history,

physical and neurologic exam) Exclude common stroke mimickers Provide basic emergent supportive care (CABs = formerly ABC) Initial neurovital signs, BP, MAP, RR, T, pupils Monitor and manage BP. Treat if MAP> 130 Identify co-morbidities and Risk Factors Perform stroke scales (NIHSS, GCS, ROSIER) Provide O2 support to maintain O2 sat > 95% Ensure adequate hydration. Recommended IVF: 0.9% Nacl

EMERGENT DIAGNOSTICS:
CBC w/ platelet count

CBG or RBS
PT/PTT Serum K and Na

ECG
Non contrast CT Scan of brain or MRI asap

COMPUTE FOR MAP

MAP = 2 (Diastolic) + Systolic 3

Ex: BP= 220/110 mmHg MAP= 2 (110)+ 220 / 3 MAP= 146
Treatment should be done asap!!!

TIME GOALS
ED Arrival
10 mins
Immediate general assessment & stabilization 25 mins

Immediate neurologic assessment by stroke team

45 mins

3 hours

Stroke Admission

Review risk/benefits of the need for fibrinolytic therapy w/ patient & family

60 mins

Completion & interpretation of CT Scan

Recognition of Stroke
Various stroke recognitions scales to aid in the fast diagnosis of

stroke for timely referral of appropriate patients to acute stroke units necessary for effective provision of skilled care FAST ROSIER Scale Glasgow Coma Scale (GCS) Cincinnati Prehospital Stroke Scale (CPSS) Hunt and Hess National Institutes of Health Stroke Scale (NIHSS)

These were applied to first line services such as

Paramedics, Ambulance staff, Emergency department Nurses and Physicians General practitioners in primary care hospitals

ACT

Face Does the face look uneven? Ask the person to smile.
Arm Does one arm drift down? Ask the person to raise both arms. Speech Does their speech sound strange? Ask the person to repeat a simple phrase. Time If you observe any of these symptoms, call for help immediately

CINCINNATI STROKE SCALE

Evaluates three major physical findings: Facial droop Motor arm weakness Speech abnormalities
Patients with 1 of these 3 findings as a new event 72% probability of an ischemic stroke If all 3 findings are present > 85% probability of an acute stroke

Facial Droop

Arm Drift
Have the patient close his/her eyes and hold both arms

out for 10 seconds

Normal both arms move the same way, or both arms

do not move at all.

Abnormal one arm does not move or one arm drifts

down compared to the other arm.

ROSIER
Recognition of Stroke in the Emergency Room (ROSIER)

scale
seven-item (total score from -2 to +5) stroke recognition

instrument
constructed on the basis of clinical history

loss of consciousness, convulsive fits/seizures

and neurological signs face, arm, or leg weakness, speech disturbance, visual field defect

GLASGOW COMA SCALE

SPERM MONITORING
SENSORIUM- awake, drowsy, stuporous, comatose PUPILS- measure both pupil size in mm; BR, SR, NR EYE MOVEMENT- spontaneous full, spontaneous

limited, (+)/(-) dolls eye RESPIRATION- regular normal (12-20 cpm), regular fast (>20 cpm), regular slow (<12 cpm), Irregular, apneic, cyanotic MOTOR RESPONSE- spontaneous (moves limbs purposely when commanded), apply painful stimulus (localizes, flexion, extension, decorticate, decerebrate, no response at all

The National Institutes of Health Stroke Scale (NIHSS)

is a systematic assessment tool that provides a quantitative

measure of stroke-related neurologic deficit. is a 15-item neurologic examination stroke scale used to evaluate the effect of acute cerebral infarction on the levels of consciousness, language, neglect, visual-field loss, extraocular movement, motor strength, ataxia, dysarthria, and sensory loss. Ratings for each item are scored with 3 to 5 grades with 0 as normal, and there is an allowance for untestable items. The single patient assessment requires less than 10 minutes to complete.

Language

Summary:
ACT FAST
COMPUTE MAP ACCURATELY! USE THE STROKE RECOGNITION SCALES

TIME IS BRAIN!!!!!

Source: Guidelines for the Prevention, Treatment and Rehabilitation of Stroke by the SSP

THANK YOU!