The final lesson in chapter 7 covers Acute Stroke, its symptoms, and how care is provided. Stroke is defined as a condition in which normal blood flow to the brain is interrupted. The two variations of strokes are explained and the different ways in which care must be provided are discussed.
“Stroke is a condition in which normal blood flow to the brain is interrupted.
Strokes can occur in two variations: ischemic and hemorrhagic. In ischemic stroke, a clot lodges in one of the brain’s blood vessels, blocking blood flow through the blood vessel. In hemorrhagic stroke, a blood vessel in the brain ruptures, spilling blood into the brain tissue. In general, the symptoms of ischemic and hemorrhagic strokes are similar. However, the treatments are very different.
Clinical signs of stroke depend on the region of the brain affected by decreased or blocked blood flow. Signs and symptoms can include: weakness or numbness of the face, arm, or leg, difficulty walking, difficulty with balance, vision loss, slurred or absent speech, facial droop, headache, vomiting, and change in level of consciousness. Not all of these symptoms are present, and the exam findings depend on the cerebral artery affected.
The Cincinnati Prehospital Stroke Scale (CPSS) is used to diagnose the presence of stroke in an individual if physical findings are seen. Individuals with one of these three findings as a new event have a 72 percent probability of an ischemic stroke. If all three findings are present, the probability of an acute stroke is more than 85 percent. Becoming familiar and proficient with the tool utilized by the rescuers’ EMS system is recommended. Mock scenarios and practice will facilitate the use of these valuable screening tools.
To care for an individual with a stroke, proceed with this pathway. Start with activating EMS. Administer oxygen. Use four liters per minute of nasal cannula and titrate as needed to keep oxygen saturation to 94-99 percent. Perform fingerstick procedure. Check glucose. Hypoglycemia can mimic acute stroke. Check history. Determine precise time of symptom onset from the individual and witnesses. Examine the individual. Determine deficits, such as gross motor, gross sensory, and cranial nerves. Institute seizure precautions. Use at least two large gauge IVs in each antecubital fossa. Notify the hospital. Take the individual to a stroke center if possible.
Individuals with ischemic stroke who are not candidates for fibrinolytic therapy should receive aspirin unless contraindicated by true allergy to aspirin. All individuals with confirmed stroke should be admitted to Neurologic Intensive Care Unit if available.
Before giving anything by mouth, you must perform a bedside swallow screening. All acute stroke individuals are considered NPO on admission.
Stroke treatment includes blood pressure monitoring and regulation per protocol, seizure precautions, frequent neurological checks, airway support as needed, physical/occupational/speech therapy evaluation, body temperature, and blood glucose monitoring. Individuals who received fibrinolytic therapy should be followed for signs of bleeding or hemorrhage.
Certain individuals may be able to receive tPA up to 4.5 hours after symptom onset. Under certain circumstances, intra-arterial tPA is possible up to six hours after symptom onset. When the time of symptom onset is unknown, it is considered an automatic exclusion for tPA. If time of symptom onset is known, the National Institute of Neurological Disorders and Stroke (NINDS) has established the time goals.
The NINDS established time goals advise the individual to have general assessment by expert and urgent CT scan without contrast within 10 minutes of arrival. Within 25 minutes of arrival, you should perform a CT scan without contrast, perform a neurological assessment, and read CT scan within 45 minutes. Within 60 minutes of arrival, you should evaluate criteria for using and administering fibrinolytic therapy, or “clot-buster.” Fibrinolytic therapy may be used within three hours of symptom onset, or 4.5 hours in some cases. Within 180 minutes of arrival, the individual should be admitted to the stroke unit. For details on Emergency Department Staff, refer to Figure 45 in your corresponding ACLS manual. For Acute Stroke Algorithm, refer to Figure 46 in your corresponding ACLS manual.”
