Stroke – What Happens Next



Stroke – What Happens Next?

Purpose

To provide healthcare professionals with the fundamental knowledge needed to recognize and manage stroke patients using evidence-base practice and standards by the American Stroke Association as we move forward in being recognized as a Stroke Center of excellence.

Objectives

Upon completion of this case study the student/OakBend employee will be able to:

• Identify the two major categories of stroke

• List 5 risk factors that contribute to Acute Ischemic Stroke

• Describe 5 common presenting symptoms of an Acute Stroke

• Describe the characteristics of the National Institute of Health Stroke Survey (NIHSS)

• Discuss measures to prevent PE/DVT for the Acute Ischemic Stroke patient

• List the critical elements in the Standard of care of the stroke patient

What Will It Take

To Be A Level I Primary Stroke Hospital?

• Coordination with the EMS Services on the activation of stroke (6 min before the arrival of the patient)

• Stroke Team available 24 hours, 7 days a week

• Written Protocols/Orders

• Trained ED staff

• Specialized Unit for Care

• Patients that require Neurosurgeon prepare quickly to transfer patient within 30 minutes

• CT or Brain scan within 25minutes of physician’s order and interprets results within 20 minutes (turn around time total 45 minutes)

• Standard Lab available 24/7

• Public Education Program

• Database or registry for process improvement

• Meets the Brain Attack Coalition 11 elements (Evidence Base Practice)

• Meets the American Stroke Association’s Get With The Guidelines (GWTG) stroke

• Hospital staff of stroke center receives at continuing education

• JCAHO accreditation for Prmary Stroke Center

• Able to transport to a Comprehensive Stroke Center within 2 hours

WHY DID OAKBEND DEVELOP A STROKE PROGRAM?

• To meet the needs of high risk population that live in Fort Bend County

• We are the Joint Commission accredited Stroke Center

A STROKE IS A BRAIN ATTACK

When a person experiences severe chest pain and a heart attack is suspected, most people know to call 911. However, far fewer people know that a stroke demands equal urgency. A stroke is equivalent to a heart attack of the brain and should be thought of as a BRAIN ATTACK.

Stroke: What is it?

• Injury or death of brain tissues due to oxygen derivation; usually due to an interpretation of blood flow

• Also referred to as “Brain Attack” or “Cerebrovascular Accident” (CVA)

• A true emergency!

Background

• Fourth leading cause of death, and the leading cause of adult disability in the U.S.

• Approx. 795,000 people suffer from strokes each year

• Incidence increases with age

• Every four minutes someone dies of a stroke in the U.S.

• Frequent cause of disability

• About 4 million Americans are stroke survivors

Mortality/Morbidity

• A significant number of patients (15-30%) die from acute stroke within the first 30 days after the event

• Survival after hemorrhagic stroke is less common, with only a 20% survival rate

• Death in the first week after a stroke is directly due to the stroke in 90% of cases

• Pulmonary embolism is the most common death within 2-4 weeks of stroke

• Pneumonia is the most common cause of mortality within 2-3 months after the event. Thereafter, cardiac disease is the most common cause of death

TIME IS BRAIN!

Brain tissue ceases to function if deprived of oxygen for more than 60-90 seconds and after a few minutes will suffer irreversible injury possibly leading to death of the tissue

RIGHT VS LEFT BRAIN INJURY

Because the motor fibers from one side of the brain cross to the opposite side before passing down the cord, hemorrhage on the brain’s right side causes left sided paralysis, hemiplegia, and vise versa.

WHAT PART OF THE BRAIN DOES WHAT?

PERSONAL PREFERENCE; DOMINANCE

• One hemisphere has a slightly more developed, or dominant area in which written and spoken language is organized

• Over 95% of right handed people and even the majority of left handed people have dominance for speech in the left hemisphere

• Thus, a left hemisphere stroke will be more likely to produce aphasia and other language deficits

Left Handed Patients

• The studies have shown that left-handed ambidextrous individuals may have lower risk of sudden cardiac death than right-handers

• Left-handed or ambidextrous patients had a 76 percent lower risk of sudden death than right-handers

Right vs. Left

• Right (Non dominant) Hemisphere: Neglect of the left visual space, left visual field defect, left hemi paresis, left-sided sensory loss, poor left conjugate gaze, extinction of left-sided stimuli, dysarthia, difficulty in reading, writing, or calculating

• Left (Dominant) Hemisphere: Aphasia, right hemi paresis, right sided sensory loss, right visual field defect, poor right conjugate gaze, dysarthia, difficulty in reading, writing, or calculating

WHAT IS TIA ANYWAY? A MINI STROKE!

• Traditional definition: stroke like symptoms lasting 185 > o DBP > 110. Labetolol or Nicardipine infusions for persistently elevated bp, especially within the 1st 24 hrs

-Fenoldopam may be helpful in renal insufficiency

• SBP>230 or DBP>125

-use labetolol as directed above

-if response is unsatisfactory infuse sodium nitroprusside 0.5-10 microgram/kg per min

-aim for BP ................
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