Brain Attack! What to Look For and How to Deal With Stroke

How many times have you seen references to the dangers of cardiovascular disease or warnings about the importance of early recognition and treatment for the signs and symptoms of heart attack? Organizations such as the American Heart Association have done so well at publicizing heart disease and layperson care that many high schools now require successful completion of a CPR course as a prerequisite for graduation. Another positive impact of this publicity is the now-common placement of semiautomatic external defibrillators in public places such as shopping malls and commercial aircraft. Acute myocardial infarction, more commonly known as heart attack, is undeniably universally recognized as life-threatening.

Now ask yourself what you've heard about stroke. Did you know that strokes are significantly more devastating than heart attacks? The No. 3 killer of middle-aged and older patients worldwide, stroke still receives little public recognition despite its annual cost of approximately $43 billion in the United States alone. Did you also know this devastation can be avoided? If the symptoms are recognized early and immediate treatment is sought, stroke can be treated, and its victims maintained as productive members of society.

Case Study
As part of an ALS ambulance crew, you are dispatched to a private residence for a 42-year-old patient who is reported to be lethargic. You arrive at a clean and well-kept home without any obvious threats, but you take body substance isolation precautions as you approach the door. Mrs. Smith meets you there, anxious and frightened, and says her husband is sitting on the couch, semiconscious and breathing strangely. When you inquire about his history, she tells you he's been treated for hypertension and non-insulin-dependent diabetes mellitus, that he often forgets to take his HCTZ and metoprolol, and that his physician just prescribed fenofibrate at yesterday's office visit. She also mentions that he was holding his head and complained of a severe headache when he sat down on the couch more than six hours ago; she found him still there when she was ready for bed.

You find Mr. Smith leaning to the left and somewhat pale, with irregular breathing. He does not respond when you call his name but does respond to a painful tactile stimulus. You immediately administer oxygen at 10-15 lpm via non-rebreathing mask and observe that he is warm but afebrile, mildly diaphoretic and without any evidence of trauma. Mr. Smith is loaded on your stretcher for transport, and en route to the hospital you continue your assessment. His blood pressure is 190/118, he has an irregular ventilatory rate of 14, and he shows sinus bradycardia on the monitor at a rate of 51 without ectopy. He has a full, bounding radial pulse and a blood glucose reading of 140mg/dL. His GCS is 7, so you contact online medical direction and receive orders for rapid sequence intubation. After you place an 18-gauge IV line of 0.9% normal saline at a keep-open rate, you administer 0.1 mg/kg midazolam for sedation, 0.1 mg/kg pancuronium as a paralytic, and 1 mg/kg lidocaine to reduce the increased intracranial pressure that can be seen with intubation, especially in light of the patient's bradycardia, which can also indicate increased ICP. A 7.5mm endotracheal tube is passed through the vocal cords, and placement is verified with auscultation over the epigastrium and bilateral lung fields, an esophageal detection device and capnography. Mr. Smith is placed on a ventilator at a rate of 12 breaths per minute and a tidal volume of 800 mL, with oxygen saturation readings of 98% and an end-tidal CO2 reading of 40 mm/Hg. His condition does not change during your 25-minute transport to the hospital.

On arrival at the emergency department, he is taken immediately to CT, diagnosed with a massive cerebrovascular accident and transferred to the stroke unit, where he dies hours later. Had Mr. Smith or his wife recognized the symptoms early and sought care in a timely manner, the outcome may have been different!