From the delivery to the ED door, the suspected stroke patient must be clinically assessed again within 10 minutes. Some medical institution may take the patient directly to the CT scan if there is a high probability of a stroke based on the history of present illness and current abnormal neurological symptoms and signs of the patient as evaluated by the healthcare provider(s).
Of course, in any acute illness as in a stroke case, the “ABCs” are critical in the initial assessment and at times provide prognosis of the patient’s acute life-threatening medical condition to prevent deterioration to a worse clinical state. Unstable vital signs should be considered, such as hypoxemia, and blood studies should be ordered which may include serum glucose levels, electrolytes, CBC, and coagulation findings just to name a few urgent laboratory studies. Just a note, even if the EMS may have performed a STAT finger stick analysis of the patient’s serum glucose levels, the blood sugar levels should be taken again in the ED to look for hypoglycemia or hyperglycemia, especially in both type 1 and type 2 diabetic patients. ED personnel must also rule out other medical causes by performing a portable CXR to look for pulmonary causes of the patient’s grave medical condition and a 12-lead ECG to identify thrombosis as in a recent heart attack or myocardial infarction (e.g., UA/NSTEMI or STEMI) or a catastrophic arrhythmia as another potential cause of the patient’s abnormal neurological symptoms and signs. Nevertheless, performing other diagnostic studies like a CXR and/or ECG should not delay directing the patient to have an immediate STAT Head CT scan imaging study unless there is a very high probability that the medical condition is, possibly, an acute coronary syndrome (ACS) or other life-threatening medical conditions, for example.
Preferably, during the first 25 minutes of a suspected stroke patient’s arrival at the ED door as per the most current and up-to-date guidelines by the American Heart Association (AHA) and the majority of medical associations, the emergency department physician must perform a thorough medical and clinical history, a targeted physical examination with an emphasis on the neurological examination (specifically, ideally in conjunction with the National Institutes of Health Stroke Scale or just NIHSS), and actually determine a time of symptom onset based on the data provided initially by the patient (if possible), patient’s family members or friends, innocent bystanders, EMS, and/or other healthcare providers involved with the care of the suspected stroke patient.
In terms of the NIHSS, it is a very methodical evaluation tool that offers a quantifiable measure of stroke-related neurological deficit. In accordance with the NIH Stroke Scale International as indicated in the organization’s educational website – http://www.nihstrokescale.org/ – the NIHSS is 15-item neurologic examination stroke scale that can be completed in less than 10 minutes or so to clinically assesses the suspected stroke patient’s level of consciousness, language, neglect, visual-field loss, extra-ocular muscle movement, motor strength, ataxia, dysarthria, and sensory loss among the most common typical or atypical signs of a stroke.
Clear indicators through the quantifiable measures of the NIHSS or as per the judgement of the ED physician that highly suggests a stroke are a signal to urgently perform a STAT Head CT scans imaging study preferably within 45 minutes of the patient’s arrival at the ED door. The clock is ticking.
If there is a positive intracranial hemorrhage(s) from the Head CT scan, then the stroke team will not be able to provide fibrinolytic therapy and must consult immediately with the neurovascular surgeon and stroke team in case the massive brain bleed may be dangerously life-threatening, such as one that shows a midline shift of the brain or hypovolemic shock, that may likely lead to sudden death. However, if there is a normal Head CT scan that is negative for brain hemorrhage, this suggests an acute ischemic stroke that directs the advanced healthcare provider to determine and decide whether rtPA therapy is appropriate or pursue other avenues of therapy if “clot busters” are not recommended.
A repeat neurological examination, stabilization of vital signs, and the fibrinolytic checklist are highly warranted moving forward for the patient’s safety and clinical condition because it basically tells you if the stroke patient is, on one hand, a candidate for rtPA or other direct clotting factor inhibitors or, on the other hand, may not receive anticoagulation due to their past medical history of severe bleeding and/or increased risk factor for uncontrollable hemorrhage. If and only if the stroke patient is cleared based on the comprehensive fibrinolytic checklist and the window of therapy for fibrinolysis is still within 3 hours of symptoms onset, then the advanced healthcare provider must then ask for consent directly from the patient, patient’s spouse/family members, or power-of-attorney/healthcare proxy (ethically speaking, if the patient is not competent or does not have capacity to make medical decisions and care for his or her own well-being).
Some contraindications to receiving fibrinolytic therapy are the following but are not exhaustive:
- Brain hemorrhage based on the Head CT scan results
- Prior CVA(s) or stroke(s)
- Abnormal blood vessels in the brain, such as major intracranial aneurysms
- Recent bleeding, as in the gastrointestinal system or other areas of the body prone to hemorrhage
- History of clotting and coagulation problems
- Recent surgery, especially neurosurgery
- Recent major accidents
- Current therapy with anticoagulation
DRUG/DEVICE & DISPOSITION
Before initiating fibrinolytic therapy and if it is clinically appropriate, it is customary to get a medical consent from the patient or possibly the patient’s family members or healthcare proxy who are there to support the stroke patient because there is a small chance of a major and fatal cerebral bleed after initiating anticoagulation. Even if the risk of an intracranial hemorrhage with clot busters is less than 5%, there should be consideration that a hemorrhagic stroke or excessive bleeding may happen. However, the upside to fibrinolytic therapy in an acute ischemic stroke is that it may break up the atherosclerotic plaque that is narrowing one or more of the arteries of the brain, potentially restoring or improving blood perfusion to the other areas of the brain. It actually improves neurological recovery by 30% if the fibrinolytic therapy is given within the recommended 3 hours of neurological symptom onset in an acute ischemic stroke, outweighing potential life-threatening risks involved with anticoagulation. Regardless, it is better to make the window of 3 hours for fibrinolytic therapy but some suggests 4.5 hours may also be appropriate in other instances. In any case, the earlier the administration of anticoagulation in an acute ischemic stroke, the more likely that the patient recovers without neurological deficits or disability.
PRIMARY PREVENTION & SECONDARY PREVENTION OF STROKE
It is important to emphasize that no treatment is perfect and, sometimes, even if everything is done right, the patient might not even survive the stroke or may still suffer neurological problems and disability, which far too often can lead to a very low-quality of life not only experienced by the stroke patient but as well as their caretakers, usually the family members and friends who will most likely have great difficulty even just trying to assist in their loved one’s daily activities of living. Therefore, it is better to prevent the stroke than actually treating it, as is the case in most acute or chronic medical conditions, whether they are debilitating or not. The risk factors for a stroke must be minimized through primary prevention by averting disease or injury before it ever occurs. First and foremost, primary prevention can happen through mass education of the public with healthy and safe habits that aids in stroke deterrence. In addition, secondary prevention is also vital in stroke prevention by aiming to reduce the impact of a disease or injury by following up with regular examinations by competent healthcare providers who screen potential stroke patients with diagnostic tests to detect disease in its earliest stages and/or provide pharmacological therapy to prevent further cerebrovascular accidents in combination with primary prevention to teach their patients ways to decrease, lessen, or completely get rid of their lifetime risk factor(s) for a stroke.
Naturally, as stated by the Stroke Association, particular risk factors for a stroke cannot be altered as in the patient’s advanced age, hereditary/family history, race, sex (gender), and prior stroke, TIA or heart attack. Nevertheless, the other side of the coin suggests that it is wise to avoid or prevent a stroke entirely by changing one’s lifestyle to avert uncontrolled high blood pressure; stopping or minimizing cigarette smoking; managing diabetes mellitus appropriately; improving diet through portion control, decreasing fatty foods and red meat, reducing salt intake, and eating more fruits and vegetables; increasing physical activity; and, lastly, losing weight by being within the recommended average body max index for one’s weight and height. Clearly, there may be other less familiar risk factors of stroke such as medical conditions that increase coagulation in the body (e.g., atrial fibrillation and Sickle Cell Disease just to mention a few) or other medical problems that mandate a patient to take daily blood thinners to prevent or treat thrombosis (i.e., atrial fibrillation, deep vein thrombosis, pulmonary embolisms, and other hypercoagulable states). There are other rare risk factors for a stroke such as illicit drug abuse and alcohol abuse that most people do not even think about. Going further than substance abuse risk factors for a stroke are other, less well-documented stroke risk factors like living in a specific geographic location and low socioeconomic area where stroke most often occurs. The latter risk factors for a stroke may be one of the influences in why some people are more prone to a stroke and why others are not. They are something to think about.
STROKE EDUCATION IS IMPORTANT FOR EVERYONE!
It is truly important that families and healthcare providers alike recognize the symptoms and signs of a stroke by easily remembering the mnemonic F.A.S.T. to be able to save precious time before the victim deteriorates immediately. Remember, a stroke can happen to anyone and it may even happen to be your family member or close friend who is directly or indirectly affected by it, so please help the Palm Desert Resuscitation Education (PDRE) and American Heart Association (AHA) inform everyone in your community to know and understand the importance of stroke education and how to prevent it in the first place!
We now offer Acute Stroke (Online) Classes for your education
Cardiovascular Disease and Acute Stroke are one of the leading causes of death in the United States. Knowing CPR can potentially save someone’s life after a heart attack or a stroke, which why it is also important to know how you can help someone in cardiopulmonary arrest with basic CPR, even if it is “hands-only CPR.” This is a great transition to being cognizant of a few vital facts about why CPR is critical to know, especially in an out-of-hospital setting.
Who Can You Save With CPR?
The life you save with CPR is most likely to be a loved one.
- 4 out of 5 cardiac arrests happen at home.
- Statistically speaking, if called on to administer CPR in an emergency, the life you save is likely to be someone at home: a child, a spouse, a parent or a friend.
Why Take Action?
- Failure to act in a cardiac emergency can lead to unnecessary deaths.
- Effective bystander CPR provided immediately after sudden cardiac arrest can double or triple a victims chance of survival, but only 46% of those victims get CPR from a bystander.
- Only about 10% of people who suffer a cardiac arrest outside the hospital survive.