All right, so let's get started on the two different types of
strokes, ischemic versus hemorrhagic.
So there's two different types of strokes for the most part
these most of them will fall into this.
You may see the term CVA or cerebrovascular accident.
So essentially you can classify Cvas as ischemic or hemorrhagic
strokes, the two more common ones that we're going to talk
about here today. So again, cerebral, brain,
vascular, we talked about our vasculature, right, veins,
arteries, limps. In this situation, we're talking
about different types of vasculature and an accident that
has happened. So again, what we have here is
the most common type. So the most common type is going
to be ischemic. This is going to account for
about 85% of the strokes that happen.
And in this situation, we're actually talking about blood
clots. The flow to a certain portion of
the brain has decreased or completely stopped and now we've
developed an ischemic stroke. Ischemic meaning what lack of
blood flow to a certain area ischemia.
So again, we talk about the four eyes of structural compromise.
So it's one of the quick tips that I've come up with, four
eyes of structural compromise. And what that means is that
ischemia, infarct, infection or inflammation are going to stop
and hurt the structural compromise of that portion of
the brain, that portion of the brain.
So what are we dealing with with hemorrhagic stroke?
Hemorrhagic is a bleed and it falls into ask Graf.
If we're having a hemorrhagic stroke, we're talking about a
blood vessel that has burst causing bleeding around the
brain tissue. So hence hemorrhagic stroke,
ischemic, we take away blood supply.
Hemorrhagic, we're having a burst.
But what's the difference aside from the fact that we're taking
away blood supply and one that's hemorrhaging?
How about risk factors, signs and symptoms, education and
treatment? So what type of questions are
all of these? They're great freebie questions.
They're great. Select all that applied
questions case study as we'll get into today, matrix or grid.
And then we have further teaching, further intervention
as well too. So let's get into the risk
factors for each one. Now.
Some of the risk factors may overlap, and when they overlap,
these are great ways to ask matrix or grid, anything that
has similar overlap. I talk about this all the time.
And different cardio issues and different GI issues and
different endocrine issues. If there are things that
overlap, the board's love to test them.
There's room for confusion and I'm going to try to confuse you
by asking a question between the two because I want to see if you
truly understand it. So what are some risk factors?
Well, both of them have hypertension, but let's just go
down ischemic as well too. Diabetes, smoking, high
cholesterol, sedentary lifestyle, family history.
Does this all sound familiar? History of atrial fibrillation
because again, we're looking at that clot.
But look at all these risk factors, sedentary lifestyle,
family history, diabetes, hypertension, smoking, high
cholesterol. Where do all these come into
play as well too? Just in clot formation, don't
they cause us to be a little bit more hypercoagulable?
Yeah, they do. So how are we going to end up
taking care of these? What is the mnemonic that I say
will always, always hold true needs educate them on nutrition,
exercise, Etoh. Now we avoid alcohol, not just
decrease, avoid DS, don't smoke and sleep.
In all these situations we can try to control what we can aside
from family history, but even if we have a family history, we can
still try to decrease the chance of it happening with hemorrhagic
stroke, Hypertension is up there.
Any type of aneurysm is there as well too.
If it's a bleed, how about anticoagulants?
Any type of trauma to the head, increased or heavy alcohol use,
drugs like cocaine, methamphetamines, any type of
underlying issue that would lead us to bleed as well too.
So things like hemophilia where we're at risk for bleeding as
well too. So again, we're talking about
signs and or sorry, risk factors for ischemic versus hemorrhagic
stroke. Again, the difference is one
we're having ischemia, we're having decreased blood supply.
The other one we're actually bleeding into the brain tissue.
One is more common than the other by a significant amount,
85%. But what is one of the most
silent? What is the most silent killer
or what is the silent killer? Hypertension, Hypertension.
So think about, and we hear about this all the time,
hypertension, people pass away, stroke in the middle of their
sleep. They just don't wake up.
Blood pressures 210 / 110, two 20 / 130 that hypertension is
going to lead to stroke. And when they're sleeping,
nobody knows. There's no way to help them at
that point. They don't know what's happening
while they're awake. Maybe they see some signs and
symptoms, maybe somebody else notices it, but when they go to
sleep that hypertension is going to is going to creep up.
And if they have a stroke in their sleep, chances are they're
going to pass away. Think about heavy alcohol use.
How many times you see heavy alcohol use come in and you're
like, wow, this person was a heavy drinker and then they
passed away in their seat big time, big time.
So we need to educate people, especially as we see other risk
factors that we must control. Hypertension.
If we see somebody now here, let's go into some farm, let's
go a little bit different right now, but let's tie some things
in. If we have somebody with
hypertension 210 / 110, what is the drug that can react real
quick that they could take orally?
If we see them in the clinic, if we see them in the hospital,
maybe in the hospital we'll do IV.
But in the clinic, in the clinic, we can use Clonidine .1
point, 2.3 milligrams. Yeah, absolutely.
We can do Clonidine and then we can keep using it to decrease
the blood pressure. But what's the problem with
Clonidine that the boards would love to ask about?
They like to ask about a side effect called rebound
hypertension. Rebound hypertension, meaning if
I stop it abruptly, which just as a concept, how often do we
want to abruptly stop a medication?
More times than not we don't. So now we abruptly stop
Clonidine boom, our blood pressure not just went back up
to where it was, it's actually gone further up.
That is rebound hypertension. But if we're in a hospital
setting and we've got elevated blood pressure, what are two
class of drugs and more specifically D drugs that are
going to help with that excessive blood pressure, that
hypertension, beta blocker and a calcium channel blocker and more
specifically beta blocker. We love labetalol and calcium
channel blocker. We love nicartopine,
nicartopine. So again, knowing the difference
in this situation with ischemic stroke, because we have some
sort of a blockage, because there's some sort of a clot, we
can use TPA and we'll get into TPA here in a little bit with
the hemorrhagic bleed. We've got to think about
surgery, things like clipping, coiling, craniotomy, a
craniotomy, craniacomy to give that brain room to bleed because
our skull cannot expand. So what's going to happen is
that intracranial pressure in a bleed, in a hemorrhagic stroke
is a is a complication because as it continues to bleed, what
can happen? We can get herniation because of
that intracranial pressure. But now we're going to get into
the signs and symptoms for ischemic stroke.
We're going to get that sudden numbness, especially on one side
of the body, that hemiplegia, so one side of the body, face, arm,
leg. We're getting weakness and
numbness. Of course you're going to have
altered mental status. It is one of the key indications
that we're going to say, hey, what is going on?
They're confused, they have trouble speaking, understanding
speech. Maybe they've got vision issues.
One pupil is larger than the other then walking, dizziness,
balance, coordination. Knowing that we've got an
ischemic stroke and now we're having different types of signs
and symptoms from this ischemic stroke in hemorrhagic stroke,
we're going to have a sudden severe headache, sudden severe
headache. And one of the one of the
telltale signs is when somebody complaints of Womble, which is
the worst headache of my life, worst headache of my life.
In that situation, we're thinking that it's possibly a
subarachnoid hemorrhage. In other situations they can
develop lots of consciousness and again, we can develop that
weakness, numbness, often one sided as well too.
We're concerned about seizures in this situation and this one
as well with visual disturbances.
So a lot of overlapping signs and symptoms.
A lot of overlapping signs and symptoms.
So what are we going to educate them on?
Well, in each one of these situations, needs is always
going to hold true. Nutrition, exercise, ETOH, don't
smoke and sleep, don't smoke and sleep.
So what are we going to educate them beyond the needs is
controlling blood pressure. If hypertension is a risk factor
for both of them, then of course controlling blood pressure is
going to be priority. So needs is predominantly going
to take care of all the signs and symptoms.
With hemorrhagic stroke, we're worried about anticoagulation
because we don't want them to bleed out.
We're worried about controlling blood pressure in both of them.
And then we do want to anticoagulate in ischemic
stroke, in ischemic stroke. So now let's get down to
treatment. So what is TPA and what why is
it so important? TPA is tissue plasminogen
activator. So yeah, it's going to break
down the clot. It's going to break down the
clot. So out to place is the more
common TPA that we're going to see on the boards.
But the guidelines for use of TPA are what's important because
we can't just say, oh, this person's got ischemic stroke or
hemorrhagic stroke. How do we determine between the
two? Well, the signs and symptoms
potentially, but how are we going to decide between the two?
How do we know which one is which?
We're going to do ACT scan, right?
Do ACT scan. And now we can determine which
type of a stroke it is, what type of a stroke it is.
Then we have to determine if it's ischemic stroke, which
again is a majority, what are the guidelines?
So the guidelines are as such for TPA, we must give it within
3 to 4 1/2 hours, which means if a person had an ischemic stroke
two days ago, are we giving them TPA?
No. But ultimately, the sooner we
give it to them, the sooner we give it to them, the better.
But there are some contraindications.
The contraindications are if it's obviously a hemorrhagic
stroke, because if it's going to break down clots, all we're
doing is causing that stroke to get worse.
So that's why it's so important that we do ACT scan.
So if they've had any recent surgery or trauma within 14
days, we do not administer TPA. If they have an active internal
bleed, AGI bleed, genital urinary bleed, any type of
active bleed, it is contraindicated.
Again, it's going to cause us to worsen the situation.
If their blood pressure currently, if it's above 185 to
110, we must get the blood pressure down, which is why I
talked about labetalol and nycardipine before we can
administer TPA. So we're on a real time crunch
to get that blood pressure down and then make sure we're still
between that three or below that 3 to 4 1/2 hours.
So blood pressure greater than 185 / 110, this one is the one
that's going to stick out the most, especially on the boards
and in real life. Why is that?
Because the number one cause, the number one sign risk factor
is hypertension. So we're worried about that in
this situation. The next one, history of an
intracranial bleed. So if they have a history of an
intracranial bleed or hemorrhage, again, all this is
going to do is make situations worse.
So bleeding, bleeding, bleeding TPA causing that clot to blast
or to not develop. Hence why any type of a bleed is
going to be contraindicated. Same thing with recent
anticoagulant use. Recent anticoagulant use
contraindicated and typically we're going to be looking at an
INR that's greater than 1.7 and blood sugar is the last one.
Blood sugar less than 50 or greater than 400 must be
controlled before we're able to administer TPA.
So again, the guidelines, if we're to administer it in
ischemic stroke, first we got to do ACT scan, make sure that it
is in fact an ischemic stroke. Now we're going to do TPA if
it's with within the time frame of three to 4 1/2 hours or
below, 3 to 4 1/2 hours below. They cannot have had a
hemorrhagic stroke. They cannot have internal
bleeding. They cannot have a history of
intracranial hemorrhage. They cannot have anticoagulant
use. All are bleeding, bleeding,
bleeding, bleeding. So if you just think about the
concept of bleeding, it's contraindicated.
And again, active is going to be what we're looking for, blood
glucose we just talked about. And then again, recent surgery
or trauma within the past 14 days, again, the concept comes
down to bleeding, bleeding, bleeding.
We're not trying to make things worse.
So these are the things that we're going to be doing now
we're going to apply and see where we're going to be able to
ask these questions. So again, brand new questions
that we're asking and that we've never done before.
And then we've got a case study as well, too.