Hi. I’m Mark for ACLS Certification Institute. Welcome to another Rapid Algorithm Review. Today we’re going to review stroke. There is nothing more time-sensitive than medical care during a stroke. Just like other algorithms, it all starts with the patient presentation. When assessing for stroke, a great pre-hospital or even hospital assessment is the Cincinnati Stroke Scale.
There are three components made up of:
- Facial droop
- Arm drift
- Slurred speech
Facial droop. Ask the patient to smile. We’re looking for asymmetry in the face. Is the face drooping? If it is on one side, well that’s facial droop.
Arm drift. Have the patient extend their arms palm up and close their eyes. We’re going to watch them for 10 seconds. We’re looking to see if one of those arms starts to drift away. It’d be positive for arm drift.
Slurred speech. Ask the patient to repeat a sentence like ‘you can’t teach an old dog new tricks.’ Are they able to say that without slurring their speech?
If they present with any one of these deficits, chances of having a stroke are 72%. If they present with all three of these deficits, about 87%. It’s fast. It’s reliable. It can be done in about 60 seconds.
First, get your assessment done. Second, support your ABCs. Provide oxygen if they’re hypoxic. Check a blood glucose. Alert the hospital that you’re going to that you have a possible stroke coming in, so they can prepare to receive this patient. Another critical factor is to assess their last known normal. When was the last time anybody saw this patient without neuro deficits, they were acting normally, everything was fine? When was the last time that they were presenting normal? We need that time. Sometimes you don’t need the assessment. The patient presents as if they’re having a stroke. I was teaching at the hospital yesterday, and I bopped upstairs to the ER because a former student of mine had brought a patient in and I wanted to go say hi. I’m talking to him, and he had brought in a stroke patient. He was telling me what happened at the scene. He showed up and saw the patient. He could see the facial droop. He could see that she was paralyzed on one side. She had slurred speech. He skipped the exam. He knows what’s going on. His scene time was minutes. In EMS, it’s really important to know what we can do. It’s more important to know what we can’t do, and we can’t fix this. Definitive care for this patient is in the hospital. His scene time was minutes. Load her up and let’s get going. Then he did all the supportive care on the way. He got the blood sugar, got the IV, notified the hospital. He did everything he was supposed to do, but he did it on the way to the hospital and reduced that time to get that CT so we could treat this patient.
If you’re in the ER and you’re preparing to receive a patient, the suggested timeline, if you look at the algorithm, is about 10 minutes. When the patient hits the door, in that 10 minutes we want to reassess the patient, make sure they’re oxygenated, review their history, order a CT scan immediately (get that cooking), obtain vascular access. All this should be done within the first 10 minutes, and activate the stroke team if you have a stroke team in your hospital—get them coming, get the experts moving on this. When your patient comes to the ER, we need to do a more detailed neuro exam, maybe an NIH Stroke Scale, which was developed by the National Institute for Neurologic Disorders and Stroke, or the Canadian Stroke Scale. This is more detailed so we can see if there are subtle differences in this patient’s neuro status as they progress through their care at the hospital.
Looking at strokes, we can break them into two categories: ischemic and hemorrhagic. In an ischemic stroke, a clot has formed. Just like in a heart attack, a vessel in the brain has developed some plaque, the plaque ruptured, formed a clot, and occluded blood flow and oxygenation of that part of the brain. Or a clot formed somewhere downstream, floated to the brain, got wedged in a vessel, occluded blood flow and that caused a stroke. Those are ischemic strokes. They account for about 87% of all strokes. We can treat them with fibrinolytic therapy and bust up that clot and restore blood flow to the brain. The other category is hemorrhagic stroke. In this case, a blood vessel has ruptured in the brain and it’s bleeding. That’s why it’s so important to get that CT scan as quickly as we can to rule out a hemorrhagic event. If we administer fibrinolytic therapy in a hemorrhagic event, it would be fatal to the patient. If we’re going to administer fibrinolytic therapy in an ischemic stroke, we need to try to do this within three hours of the patient’s last known normal. That’s why it’s so important to get that information in the field and relay it to the people in the hospital. We’d like to give that medication within three hours. With some patients, we could extend it out and you see it getting longer all the time (four or four-and-a-half hours), but it’s from the time of their last known normal. If the patient meets the criteria to receive fibrinolytic therapy, we want to administer that as quickly as we can. Review the concerns, the risks, the possible hazards, with the patient, and then suggest that the patient shouldn’t receive any anticoagulant therapy for 24 hours after we’ve administered the fibrinolytic therapy. If the patient is having an ischemic event but does not meet the criteria to receive fibrinolytic therapy, the algorithm suggests we can still administer aspirin and admit them to the proper unit for evaluation by a neuro team. If your CT scan reveals a hemorrhagic event, obviously they’re not going to get fibrinolytic therapy. We need to get Neurology involved with this patient very quickly. We may be transporting them (driving them or flying them) to a facility that can manage this hemorrhagic event.
I’m Mark for ACLS Certification Institute. Thank you for watching this Rapid Algorithm Review. Remember to like us on Facebook and, please, become a subscriber to our YouTube channel. Thanks, and I’ll see you in the next algorithm.