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Rapid Algorithm Review Stroke

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 prehospital or even hospital assessment is the Cincinnati Stroke Scale and there's three components; made up of Facial Droop, Arm Drift and 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 then it's Facial Droop.

Next is Arm Drift. Have the patient extend their arms, palm up, close their eyes. We're going to watch them for  10 seconds and we're looking to see if one arm starts to drift away; they are positive for Arm Drift.

Next, Slurred Speech. Ask the patient to repeat a sentence like "You can't teach an old dog new tricks", if they're unable to say that without slurring their speech.

If they present with any one of these deficits, chances of having a stroke is seventy-two percent. If they present with all 3 of these deficits, about eighty-seven percent. It's fast, it's reliable,  it can be done in about 60 seconds.

First, get your assessment done. Second, support your ABC's. Provide oxygen if they're hypoxic. Check the 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. Other critical factors, assess their last known normal. When was the last time anybody saw this patient without neural 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 upstairs to the ER because a former student of mine brought a patient in.  I wanted to go say Hi. I'm talking to him and he brought in a stroke patient. He has told me what happened at the scene. He showed up, and he saw the patient, he could see the facial droop. He could see that she was paralyzed at one side. She had slurred speech. 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. We can't fix this. Definitive care for this patient is in the hospital. His scene time was minutes. Load her up, let's get it going. Then he did all the supportive care on the way. Got the blood sugar, got the IV, notify the hospital, 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 can treat this patient.

Now 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 CAT scan immediately, get that cooking. Obtain vascular access. All of these should be done in 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 Scale which was developed by the National Institute for Neurological Disorders and Stroke or the Canadian Stroke Scale. And this is more detailed so we can see if there's several differences in this patient's neural status as they progress with their care at the hospital.

Looking at strokes, we can break them into two categories: Ischemic and Hemorrhagic. And in the Ischemic stroke, a clot is formed. And just like in heart attack, a vessel in the brain develops some plaque, the plaque ruptured, formed a clot and occluded blood flow and oxygenation into that part of the brain. Or clot formed somewhere downstream, floated to the brain, got wedged in the vessel, occluded blood flow, and that cause a stroke. So those are ischemic strokes, and they account for about 87% of all strokes. We can treat them with Fibrinolytic Therapy and bust that clot, restore blood flow to the brain.

The other category is Hemorrhagic Stroke. in this case a blood vessel has ruptured in the brain, it's bleeding. That's why it's so important to get that CAT scan as quickly as we can to rule out a hemorrhagic event. If we administer a Fibrinolytic Therapy on a Hemorrhagic event, that will be fatal to the patient. Now if we administer Fibrinolytic Therapy in the Ischemic Stroke, we need to try to do this within the 3 hours of the patient's last known normal. That's why it's 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 3 hours. In some patients, we can extend that out, it just get, getting longer all the time for four and a half hours. But it's from the time of the last known normal.

Now if the patient meets the criteria, received Fibrinolytic Therapy. We want to administer that as quickly as we can. Review the concerns, the risks, the possible hazards with the patient, and suggest that the patient receive any anticoagulant therapy for 24 hours after we've administered a Fibrinolytic Therapy. If the patient is having an Ischemic event, obviously we're not going to give Fibrinolytic Therapy, the algorithm suggests we can still administer aspirin and then admit them to the proper unit for evaluation by a neurocan. Now if the CAT 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 him , driving him  or flying him into a facility that can manage this hemorrhagic event.

I'm Mark from ACLS Certification Institute.. Thank you for watching this algorithm. 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.