ACLS- Respiratory Arrest Case Questions with Complete Solutions Graded to Pass

out-of-hospital acute stroke care focuses on: - - rapid ID and assessment of pts with stroke - rapid transport w/ prearrival notification to facility capable of providing acute stroke care in-hospital acute stroke care - - ability to rapidly determine pt eligibility for fibrinolytic therapy - admin of fibrinolytic therapy to appropriate candidates, with availability of neurologic medical supervision within target times - consideration of new treatment options like endovascular therapy - initiation of stroke pathway and pt admission to stroke unit if available potential arrhythmias with stroke - - ECG does not take priority over obtaining CT scan - no arrhythmias specific for stroke - but may identify evidence of recent AMI or arrhythmias such as a-fib as cause of embolic stroke - most will not require treatment if hemodynamically stable drugs for stroke - - approved fibrinolytic agent (rtPA) - glucose (D50) - labetalol - nicardipine - Enalaprilat - Aspirin - nitroprusside major types of stroke - - *ischemic stroke:* accounts for 87% of all strokes and usually caused by occlusion of artery to a region of brain - *hemorrhagic stroke:* accounts for 13% of all strokes and occurs when blood vessel in brain suddenly ruptures into surrounding tissue; *fibrinolytics contraindicated in this type of stroke, also avoid anticoagulants* when should fibrinolytic therapy be provided for stroke? - ASAP, within 3 hours of onset of symptoms, or within 4.5 in selected pts when should endovascular therapy be given for stroke? - within 6 hrs of onset of symptoms, but better outcomes associated with shorter times to treatment (aka ASAP) Stroke Chain of Survival - 1) rapid recognition and reaction to stroke warning signs 2) rapid EMS dispatch 3) rapid EMS system transport and prearrival notification to receiving hospital 4) rapid diagnosis and treatment in hospital *8 D's of Stroke Care* - *Detection*: rapid recognition of stroke symptoms *Dispatch*: early activation and dispatch of EMS by 911 *Delivery*: rapid EMS ID, management, and transport *Door*: appropriate triage to stroke center *Data*: rapid triage, evaluation, and management in ED (data of patient) *Decision*: stroke expertise and therapy selection *Drug/Device*: fibrinolytic or endovascular therapy *Disposition*: rapid admission to stroke unit or critical care unit (position the patient somewhere) Suspected Stroke Algorithm - time goal for immediate general assessment of pt - within 10 min of hospital arrival time goal for neurologic assessment and CT scan - within 25 min of hospital arrival time goal for interpretation of CT scan - within 45 min of ED arrival time goal for initiation of fibrinolytic therapy in appropriate pts (without contraindications) - within 1 hour of hospital arrival and 3 hrs from symptom onset time goal for endovascular therapy timed from onset of symptoms - 6 hours in selected pts time goal for door-to-admission time - 3 hours signs and symptoms of stroke - - sudden weakness or numbness of face, arm, or leg, especially on one side of body - sudden confusion - trouble speaking or understanding - sudden trouble seeing in one or both eyes - sudden trouble walking - dizziness or loss of balance or coordination - sudden severe headache with no known cause Cincinnati Prehospital Stroke Scale (CPSS) - 3 physical findings: 1) facial droop (have pt smile or try to show teeth) 2) arm drift (have pt close eyes and hold both arms out, with palms up) 3) abnormal speech (have patient say, "you can't teach an old dog new tricks") sensitivity of 59% and specificity of 89% *if any 1 of these 3 signs is abnormal, probability of stroke is 72%; presence of all 3 findings is 85% stroke* facial droop - normal: both sides of face move equally abnormal: one side of face does not move as well as other side arm drift - normal: both arms move the same OR both arms do not move at all abnormal: one arm does not move OR one arm drifts down compared with other abnormal speech - normal: pt uses correct words with no slurring abnormal: pts slurs words, uses wrong words, unable to speak critical EMS assessments and actions (Step 1, define and recognize signs of stroke) - - Support ABCs - perform stroke assessment (CPSS) - establish time (determine when pt was last known to be normal) - triage to stroke center - alert hospital - check glucose (during transport)