STROKESTROKESTROKESTROKE

Why Change? Improve Mortality Improve Mortality Devastating and Life Altering Devastating and Life Altering Cost expense of Long Term Care Cost expense of Long Term Care

S t r o k e F a c t s 3 rd Leading cause of death behind heart disease and cancer

S t r o k e F a c t s 1 st Leading cause of long term disability

S t r o k e F a c t s 28 Percentage of people who suffer stroke under the age of 65

S t r o k e F a c t s 700,000 People suffer a stroke each year

S t r o k e F a c t s 500,000 Are fatal

S t r o k e F a c t s 200,000 Are recurrent

Ischemic Stroke vs Intracranial Bleed Hemorrhagic Stroke

Blocked pipe vs. Ruptured pipe

So what is a TIA? Transient Ischemic Attack: Minor warning stroke indicative that the conditions of an ischemic stroke are present, the obstruction occurs for a short time and tends to resolve it self through normal mechanisms Minor warning stroke indicative that the conditions of an ischemic stroke are present, the obstruction occurs for a short time and tends to resolve it self through normal mechanisms Blocked pipe that clears itself Blocked pipe that clears itself

Thrombotic Embolic I s c h e m i c S t r o k e: S t r o k e:

Thrombotic Stroke Occurs when diseased or damaged arteries become blocked by the formation of a blood clot with in the brain Occurs when diseased or damaged arteries become blocked by the formation of a blood clot with in the brain Blocked up by itself Blocked up by itself

Embolic Stroke Blood clot forms somewhere else (usually the heart) and travels thru the blood stream to the arteries in the brain—the clot lodges there blocking the vessel and causing the stroke. Blood clot forms somewhere else (usually the heart) and travels thru the blood stream to the arteries in the brain—the clot lodges there blocking the vessel and causing the stroke. Patient’s symptoms will develop based on the path traveled by the clot Patient’s symptoms will develop based on the path traveled by the clot Someone else blocking your pipe Someone else blocking your pipe

Signs and Symptoms Sudden numbness or weakness of the face arm, or leg, especially one side of the body Sudden numbness or weakness of the face arm, or leg, especially one side of the body Sudden confusion, trouble speaking or understanding. 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 NEW?? E V E R Y T H I N G

Change of Perception

Stroke Pathway Detection: Early Recognition Detection: Early Recognition Dispatch: Early EMS Dispatch: Early EMS Delivery: Transport and Management Delivery: Transport and Management Door: ED triage Door: ED triage Data: ED evaluation and Management Data: ED evaluation and Management Decision: Specific Therapies Decision: Specific Therapies Drug: Thrombolytic and Future Agents Drug: Thrombolytic and Future Agents

T I M I N G Door to MD 10 minutes

T I M I N G Door to Neurologic Expertise : With in 15 minutes

T I M I N G Door to CT Scan With in 25 minutes

T I M I N G Door to CT Interpretation With in 45 minutes

T I M I N G DOOR to DRUG With in 60 minutes

Nursing Roles Check Glucose Check Glucose Two Large IV lines Two Large IV lines Oxygen as needed Oxygen as needed Cardiac monitor Cardiac monitor Continuous pulse-ox Continuous pulse-ox Stat NON-Contrast CT Stat NON-Contrast CT Scan Scan EKG EKG CXR CXR Get t-PA Prepare to mix Alert pharmacy Discuss options with patient and family Contact primary care provider

Treatment Fibrinolytics Fibrinolytics Antiplatelet meds Antiplatelet meds Anticoagulant meds Anticoagulant meds Cerebral angioplasty Cerebral angioplasty Carotid Endarterectomy Carotid Endarterectomy Rehab Rehab Treat underlying CAD/Afib Treat modifiable risk factors

Contra Indications for tPA Intra cranial hemorrhage Intra cranial hemorrhage Sub arachnoid hemorrhage Sub arachnoid hemorrhage Recent with in the last 3 months Recent with in the last 3 months Intra cranial surgery Intra cranial surgery Intra spinal surgery Intra spinal surgery Serious head trauma Serious head trauma Previous stroke Previous stroke

Contra Indications for tPA History of intracranial bleed History of intracranial bleed Uncontrolled HTN at time of treatment Uncontrolled HTN at time of treatment SBP >185 SBP >185 DBP>110 DBP>110

Contra Indications for tPA Seizure at the onset of STROKE Seizure at the onset of STROKE Active internal bleeding Active internal bleeding Intra cranial Neoplasm, AVM, Aneurysm Intra cranial Neoplasm, AVM, Aneurysm

Contra Indications for tPA Known Bleeding Issues Known Bleeding Issues Platelet count <100,000 Platelet count <100,000 Heparin within the last 48 hours Heparin within the last 48 hours Current use of Oral Anti Coagulants Current use of Oral Anti Coagulants INR > 1.7 INR > 1.7 PT >15 PT >15

So When Should We Think About REHAB? On the Day the STROKE occurred.