NurseReview.Org - Everything About Stroke Victims

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Information about NurseReview.Org - Everything About Stroke Victims

Published on March 16, 2008

Author: nclexvideos

Source: slideshare.net

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Neurology Migraine ALS Parkinson’s Headache Seizures Neuropathy Cardiology Stroke Heart attack Arrhythmias Heart failure Valvular disease

Neurology

Migraine ALS

Parkinson’s Headache

Seizures Neuropathy

Cardiology

Everything you ever wanted to know about stroke (but were afraid to ask) Timothy Lukovits, M.D.

stroke

Objectives Highlight some important differences and similarities between heart attack and stroke Motivate you to prevent a stroke

Highlight some important differences and similarities between heart attack and stroke

Motivate you to prevent a stroke

How is a stroke different from a heart attack? A stroke is a sudden neurological deficit caused by a blood vessel problem 2 types Ischemic strokes Hemorrhagic strokes The effects of a stroke are extremely varied

A stroke is a sudden neurological deficit caused by a blood vessel problem

2 types

Ischemic strokes

Hemorrhagic strokes

The effects of a stroke are extremely varied

 

Why is heart attack easier to recognize than stroke ? Painful Public and health care providers commonly recognize symptoms and need for action Often painless the stroke itself often affects awareness of symptoms Poor recognition of symptoms and need for action

Painful

Public and health care providers commonly recognize symptoms and need for action

Often painless

the stroke itself often affects awareness of symptoms

Poor recognition of symptoms and need for action

Copyright restrictions may apply. Pancioli, A. M. et al. JAMA 1998;279:1288-1292. Respondents unable to name 1 warning sign or risk factor for stroke

Which of the following are warning signs of stroke? Sudden weakness or numbness of the face, arm or leg, especially on one side of the body Sudden confusion, trouble speaking or understanding Sudden chest pain Sudden trouble seeing in one or both eyes Sudden trouble walking, dizziness, loss of balance or coordination Sudden, severe headache with no known cause

Sudden weakness or numbness of the face, arm or leg, especially on one side of the body

Sudden confusion, trouble speaking or understanding

Sudden chest pain

Sudden trouble seeing in one or both eyes

Sudden trouble walking, dizziness, loss of balance or coordination

Sudden, severe headache with no known cause

Sudden weakness or numbness of the face, arm or leg, especially on one side of the body Sudden confusion, trouble speaking or understanding Sudden chest pain Sudden trouble seeing in one or both eyes Sudden trouble walking, dizziness, loss of balance or coordination Sudden, severe headache with no known cause

Sudden weakness or numbness of the face, arm or leg, especially on one side of the body

Sudden confusion, trouble speaking or understanding

Sudden chest pain

Sudden trouble seeing in one or both eyes

Sudden trouble walking, dizziness, loss of balance or coordination

Sudden, severe headache with no known cause

Diagnosis is relatively easy. EKG and cardiac enzymes readily available. Diagnosis is difficult. Many things can mimic stroke. There is no blood test for stroke. MRI not readily available. Is heart attack easier to diagnose than stroke?

Diagnosis is relatively easy. EKG and cardiac enzymes readily available.

Diagnosis is difficult. Many things can mimic stroke. There is no blood test for stroke. MRI not readily available.

 

MRI with diffusion weighted imaging Isolated weakness right index finger JS Kim, Neurology, 2002

Where is the stroke?

 

CT scan of arteries of neck and head

Cause is usually rupture of a plaque within a coronary artery So the diagnostic and treatment strategy is fairly straightforward (find the blockage and open it up!) Atherosclerosis is important, but there are many other causes Determining the cause in an individual is often a deductive process Are the causes of heart attack and stroke different?

Cause is usually rupture of a plaque within a coronary artery

So the diagnostic and treatment strategy is fairly straightforward (find the blockage and open it up!)

Atherosclerosis is important, but there are many other causes

Determining the cause in an individual is often a deductive process

There are many potential causes of stroke

Stroke is not just a brain disease and often the brain is just an innocent bystander Usually caused by diseases that are affect the entire vascular system (atherosclerosis) Material blocking brain arteries usually comes from outside the brain (atrial fibrillation, carotid artery disease)

Usually caused by diseases that are affect the entire vascular system (atherosclerosis)

Material blocking brain arteries usually comes from outside the brain (atrial fibrillation, carotid artery disease)

How is a Cardiologist different than a Neurologist Basically a plumber or electrician Diagnostician Detective Daredevil

Basically a plumber or electrician

Diagnostician

Detective

Daredevil

Case Healthy 61 year-old man developed confused speech 1 day after falling out of a tree. August 11 th , topping a tree, fell and sustained a left collar bone fracture and small puncture of the lung. Next night suddenly developed confused speech.

Healthy 61 year-old man developed confused speech 1 day after falling out of a tree.

August 11 th , topping a tree, fell and sustained a left collar bone fracture and small puncture of the lung.

Next night suddenly developed confused speech.

 

 

 

 

Trauma (fall out of a tree) Vascular problem (leg vein injury) Blood disorder (hypercoagulability) Congenital heart anomaly (patent foramen ovale)

Trauma (fall out of a tree)

Vascular problem (leg vein injury)

Blood disorder (hypercoagulability)

Congenital heart anomaly (patent foramen ovale)

How are heart attack and stroke SIMILAR? Time is critical The first priority is to save tissue at risk

Time is critical

The first priority is to save tissue at risk

Kidwell 2004

You need to call 911 ASAP for both heart attack and stroke! There is a 3 hour time limit for the medication t-PA, and the sooner it’s given the better! Future strokes may be prevented if we identify the cause of stroke ASAP People brought by ambulance are treated faster Neurological deterioration and other complications may be prevented if a patient is hospitalized earlier

There is a 3 hour time limit for the medication t-PA, and the sooner it’s given the better!

Future strokes may be prevented if we identify the cause of stroke ASAP

People brought by ambulance are treated faster

Neurological deterioration and other complications may be prevented if a patient is hospitalized earlier

 

June 2006 7AM: A 75 year-old woman collapsed at home, brought to her local emergency room. She cannot move her right side or speak. The doctors there are not comfortable using t-PA so transfer to DHMC is requested. 1:02 PM: Arrival DHMC ED.

June 2006 7AM: A 75 year-old woman collapsed at home, brought to her local emergency room. She cannot move her right side or speak. The doctors there are not comfortable using t-PA so transfer to DHMC is requested.

1:02 PM: Arrival DHMC ED.

 

 

4:49 PM artery is opened

 

 

The system needs to be very coordinated

The system needs to be very coordinated

 

Improving Stroke Care at DHMC PREPARED INDIVIDUALIZED CARE PROTOCOLS TO DECREASE ERRORS A TEAM APPROACH RAPID EVALUATION

Ways everyone here can prevent a stroke Identify and control risk factors If a warning sign of stroke occurs, get attention

Identify and control risk factors

If a warning sign of stroke occurs, get attention

 

 

10y risk 88% !

10y risk 13% !

Preventing a heart attack or stroke is MUCH more effective (and safer) than a procedure!

Preventing a heart attack or stroke is MUCH more effective (and safer) than a procedure!

 

 

 

HJM Barnett 1999

Copyright restrictions may apply. Barnett, H. J. M. et al. Arch Neurol 2000;57:40-45. The medical and surgical 5-year Kaplan-Meier curves of freedom from ipsilateral stroke and perioperative stroke and death indicate a 5.9% difference favoring endarterectomy at 5 years in the Asymptomatic Carotid Atherosclerosis Study (ACAS)

Copyright ©2005 American Heart Association Alamowitch, S. et al. Stroke 2005;36:27-31 Kaplan-Meier 5-year risks of ipsilateral ischemic stroke for NASCET patients according to gender and degree of internal carotid artery stenosis in the medical and surgical groups

 

 

18/111 (16%) received t-PA Average cost for transportation $4,623

2004: 144 pts Rx t-PA 50% had t-PA started at 1 of 47 referring hospitals >50% of these have <60 beds

 

Meyer 2005

MGH TeleStroke

Effectiveness of Stroke Prevention Absolute risk reduction in a year: Strategy ARR (%) Warfarin for atrial fibrillation 8 Carotid endarterctomy for symptomatic dz 4 Smoking cessation 2 Antihypertensive therapy if BP elevated 2 Cholesterol lowering medications 2 Aspirin 1-2

Strategy ARR (%)

Warfarin for atrial fibrillation 8

Carotid endarterctomy for symptomatic dz 4

Smoking cessation 2

Antihypertensive therapy if BP elevated 2

Cholesterol lowering medications 2

Aspirin 1-2

Schaebitz W-R, 2000

 

anticoag RG Hart 2003

Stroke Diagnosis 40 years ago

Stroke Warning Signs Sudden weakness or numbness of the face, arm or leg, especially on one side of the body Sudden confusion, trouble speaking or understanding Sudden trouble seeing in one or both eyes Sudden trouble walking, dizziness, loss of balance or coordination Sudden, severe headache with no known cause

Sudden weakness or numbness of the face, arm or leg, especially on one side of the body

Sudden confusion, trouble speaking or understanding

Sudden trouble seeing in one or both eyes

Sudden trouble walking, dizziness, loss of balance or coordination

Sudden, severe headache with no known cause

What is a TIA ? Transient Ischemic Attack=Stroke symptoms that resolve with a short time. Can be a warning sign of impending stroke. The highest risk period of stroke following a TIA is the first 2 weeks. The risk of stroke soon after a TIA can now be estimated.

Transient Ischemic Attack=Stroke symptoms that resolve with a short time.

Can be a warning sign of impending stroke.

The highest risk period of stroke following a TIA is the first 2 weeks.

The risk of stroke soon after a TIA can now be estimated.

ABCD 2 Tool risk of stroke following TIA A Age> or = 60 1 B Blood pressure >140/90 1 C Clinical features unilateral weakness 2 speech impairment 1 D 2 Duration > 60 min 2 10-59 min 1 Diabetes 1

 

 

A B C D E F Systolic BP* 95-105 130-148 130-148 130-148 130-148 130-148 Diabetes No No Yes Yes Yes Yes Cigarettes No No No Yes Yes Yes Prior Atrial Fib. No No No No Yes Yes Prior CVD No No No No No Yes Estimated 10-year stroke risk in 55-year-old adults according to levels of various risk factors (FHS). Source: Wolf et al., Stroke.1991;22:312-318. *BP in millimeters of mercury (mmHg)

Which action would you take if you thought someone was having a heart or stroke? take the person a hospital advise the person to call a doctor call 911 call a spouse or family member do something else

take the person a hospital

advise the person to call a doctor

call 911

call a spouse or family member

do something else

Which action would you take if you thought someone was having a heart or stroke? take the person a hospital advise the person to call a doctor call 911 call a spouse or family member do something else

take the person a hospital

advise the person to call a doctor

call 911

call a spouse or family member

do something else

Bleeding into the heart doesn’t occur Brain hemorrhage is common

Bleeding into the heart doesn’t occur

Brain hemorrhage is common

CT scan: ischemic stroke

Intracerebral hemorrhage at 1 hour and 6 hours

Intra-arterial thrombolysis Time window=6 hours

Intra-arterial thrombolysis

Time window=6 hours

High resolution MRI to identify the unstable plaque Chu B, Circulation 2005

You need to open the artery

You need to open the artery

 

Like with heart disease, the treatment and prevention of stroke needs to be individualized! A 65 yo man attends a vascular disease prevention fair and an ultrasound shows a blockage of his left carotid artery. He is told to speak to his doctor ASAP and he becomes worried that there is a “time bomb” ticking in his neck.

A 65 yo man attends a vascular disease prevention fair and an ultrasound shows a blockage of his left carotid artery. He is told to speak to his doctor ASAP and he becomes worried that there is a “time bomb” ticking in his neck.

 

11/30/06

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