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All right, so let's get started 
on the two different types of 

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strokes, ischemic versus 
hemorrhagic. 

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So there's two different types 
of strokes for the most part 

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these most of them will fall 
into this. 

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You may see the term CVA or 
cerebrovascular accident. 

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So essentially you can classify 
Cvas as ischemic or hemorrhagic 

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strokes, the two more common 
ones that we're going to talk 

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about here today. 
So again, cerebral, brain, 

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vascular, we talked about our 
vasculature, right, veins, 

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arteries, limps. 
In this situation, we're talking

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about different types of 
vasculature and an accident that

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has happened. 
So again, what we have here is 

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the most common type. 
So the most common type is going

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to be ischemic. 
This is going to account for 

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about 85% of the strokes that 
happen. 

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And in this situation, we're 
actually talking about blood 

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clots. 
The flow to a certain portion of

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the brain has decreased or 
completely stopped and now we've

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developed an ischemic stroke. 
Ischemic meaning what lack of 

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blood flow to a certain area 
ischemia. 

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So again, we talk about the four
eyes of structural compromise. 

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So it's one of the quick tips 
that I've come up with, four 

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eyes of structural compromise. 
And what that means is that 

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ischemia, infarct, infection or 
inflammation are going to stop 

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and hurt the structural 
compromise of that portion of 

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the brain, that portion of the 
brain. 

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So what are we dealing with with
hemorrhagic stroke? 

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Hemorrhagic is a bleed and it 
falls into ask Graf. 

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If we're having a hemorrhagic 
stroke, we're talking about a 

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blood vessel that has burst 
causing bleeding around the 

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brain tissue. 
So hence hemorrhagic stroke, 

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ischemic, we take away blood 
supply. 

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Hemorrhagic, we're having a 
burst. 

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But what's the difference aside 
from the fact that we're taking 

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away blood supply and one that's
hemorrhaging? 

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How about risk factors, signs 
and symptoms, education and 

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treatment? 
So what type of questions are 

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all of these? 
They're great freebie questions.

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They're great. 
Select all that applied 

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questions case study as we'll 
get into today, matrix or grid. 

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And then we have further 
teaching, further intervention 

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as well too. 
So let's get into the risk 

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factors for each one. 
Now. 

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Some of the risk factors may 
overlap, and when they overlap, 

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these are great ways to ask 
matrix or grid, anything that 

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has similar overlap. 
I talk about this all the time. 

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And different cardio issues and 
different GI issues and 

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different endocrine issues. 
If there are things that 

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overlap, the board's love to 
test them. 

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There's room for confusion and 
I'm going to try to confuse you 

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by asking a question between the
two because I want to see if you

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truly understand it. 
So what are some risk factors? 

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Well, both of them have 
hypertension, but let's just go 

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down ischemic as well too. 
Diabetes, smoking, high 

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cholesterol, sedentary 
lifestyle, family history. 

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Does this all sound familiar? 
History of atrial fibrillation 

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because again, we're looking at 
that clot. 

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But look at all these risk 
factors, sedentary lifestyle, 

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family history, diabetes, 
hypertension, smoking, high 

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cholesterol. 
Where do all these come into 

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play as well too? 
Just in clot formation, don't 

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they cause us to be a little bit
more hypercoagulable? 

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Yeah, they do. 
So how are we going to end up 

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taking care of these? 
What is the mnemonic that I say 

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will always, always hold true 
needs educate them on nutrition,

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exercise, Etoh. 
Now we avoid alcohol, not just 

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decrease, avoid DS, don't smoke 
and sleep. 

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In all these situations we can 
try to control what we can aside

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from family history, but even if
we have a family history, we can

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still try to decrease the chance
of it happening with hemorrhagic

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stroke, Hypertension is up 
there. 

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Any type of aneurysm is there as
well too. 

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If it's a bleed, how about 
anticoagulants? 

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Any type of trauma to the head, 
increased or heavy alcohol use, 

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drugs like cocaine, 
methamphetamines, any type of 

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underlying issue that would lead
us to bleed as well too. 

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So things like hemophilia where 
we're at risk for bleeding as 

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well too. 
So again, we're talking about 

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signs and or sorry, risk factors
for ischemic versus hemorrhagic 

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stroke. 
Again, the difference is one 

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we're having ischemia, we're 
having decreased blood supply. 

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The other one we're actually 
bleeding into the brain tissue. 

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One is more common than the 
other by a significant amount, 

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85%. 
But what is one of the most 

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silent? 
What is the most silent killer 

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or what is the silent killer? 
Hypertension, Hypertension. 

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So think about, and we hear 
about this all the time, 

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hypertension, people pass away, 
stroke in the middle of their 

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sleep. 
They just don't wake up. 

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Blood pressures 210 / 110, two 
20 / 130 that hypertension is 

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going to lead to stroke. 
And when they're sleeping, 

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nobody knows. 
There's no way to help them at 

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that point. 
They don't know what's happening

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while they're awake. 
Maybe they see some signs and 

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symptoms, maybe somebody else 
notices it, but when they go to 

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sleep that hypertension is going
to is going to creep up. 

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And if they have a stroke in 
their sleep, chances are they're

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going to pass away. 
Think about heavy alcohol use. 

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How many times you see heavy 
alcohol use come in and you're 

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like, wow, this person was a 
heavy drinker and then they 

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passed away in their seat big 
time, big time. 

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So we need to educate people, 
especially as we see other risk 

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factors that we must control. 
Hypertension. 

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If we see somebody now here, 
let's go into some farm, let's 

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go a little bit different right 
now, but let's tie some things 

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in. 
If we have somebody with 

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hypertension 210 / 110, what is 
the drug that can react real 

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quick that they could take 
orally? 

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If we see them in the clinic, if
we see them in the hospital, 

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maybe in the hospital we'll do 
IV. 

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But in the clinic, in the 
clinic, we can use Clonidine .1 

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point, 2.3 milligrams. 
Yeah, absolutely. 

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We can do Clonidine and then we 
can keep using it to decrease 

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the blood pressure. 
But what's the problem with 

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Clonidine that the boards would 
love to ask about? 

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They like to ask about a side 
effect called rebound 

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hypertension. 
Rebound hypertension, meaning if

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I stop it abruptly, which just 
as a concept, how often do we 

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want to abruptly stop a 
medication? 

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More times than not we don't. 
So now we abruptly stop 

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Clonidine boom, our blood 
pressure not just went back up 

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to where it was, it's actually 
gone further up. 

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That is rebound hypertension. 
But if we're in a hospital 

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setting and we've got elevated 
blood pressure, what are two 

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class of drugs and more 
specifically D drugs that are 

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going to help with that 
excessive blood pressure, that 

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hypertension, beta blocker and a
calcium channel blocker and more

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specifically beta blocker. 
We love labetalol and calcium 

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channel blocker. 
We love nicartopine, 

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nicartopine. 
So again, knowing the difference

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in this situation with ischemic 
stroke, because we have some 

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sort of a blockage, because 
there's some sort of a clot, we 

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can use TPA and we'll get into 
TPA here in a little bit with 

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the hemorrhagic bleed. 
We've got to think about 

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surgery, things like clipping, 
coiling, craniotomy, a 

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craniotomy, craniacomy to give 
that brain room to bleed because

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our skull cannot expand. 
So what's going to happen is 

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that intracranial pressure in a 
bleed, in a hemorrhagic stroke 

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is a is a complication because 
as it continues to bleed, what 

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can happen? 
We can get herniation because of

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that intracranial pressure. 
But now we're going to get into 

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the signs and symptoms for 
ischemic stroke. 

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We're going to get that sudden 
numbness, especially on one side

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of the body, that hemiplegia, so
one side of the body, face, arm,

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leg. 
We're getting weakness and 

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numbness. 
Of course you're going to have 

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altered mental status. 
It is one of the key indications

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that we're going to say, hey, 
what is going on? 

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They're confused, they have 
trouble speaking, understanding 

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speech. 
Maybe they've got vision issues.

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One pupil is larger than the 
other then walking, dizziness, 

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balance, coordination. 
Knowing that we've got an 

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ischemic stroke and now we're 
having different types of signs 

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and symptoms from this ischemic 
stroke in hemorrhagic stroke, 

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we're going to have a sudden 
severe headache, sudden severe 

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headache. 
And one of the one of the 

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telltale signs is when somebody 
complaints of Womble, which is 

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the worst headache of my life, 
worst headache of my life. 

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In that situation, we're 
thinking that it's possibly a 

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subarachnoid hemorrhage. 
In other situations they can 

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develop lots of consciousness 
and again, we can develop that 

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weakness, numbness, often one 
sided as well too. 

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We're concerned about seizures 
in this situation and this one 

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as well with visual 
disturbances. 

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So a lot of overlapping signs 
and symptoms. 

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A lot of overlapping signs and 
symptoms. 

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So what are we going to educate 
them on? 

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Well, in each one of these 
situations, needs is always 

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going to hold true. 
Nutrition, exercise, ETOH, don't

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smoke and sleep, don't smoke and
sleep. 

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So what are we going to educate 
them beyond the needs is 

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controlling blood pressure. 
If hypertension is a risk factor

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for both of them, then of course
controlling blood pressure is 

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going to be priority. 
So needs is predominantly going 

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to take care of all the signs 
and symptoms. 

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With hemorrhagic stroke, we're 
worried about anticoagulation 

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because we don't want them to 
bleed out. 

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We're worried about controlling 
blood pressure in both of them. 

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And then we do want to 
anticoagulate in ischemic 

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stroke, in ischemic stroke. 
So now let's get down to 

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treatment. 
So what is TPA and what why is 

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it so important? 
TPA is tissue plasminogen 

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00:12:03,160 --> 00:12:06,600
activator. 
So yeah, it's going to break 

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down the clot. 
It's going to break down the 

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00:12:09,120 --> 00:12:12,520
clot. 
So out to place is the more 

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00:12:12,520 --> 00:12:14,760
common TPA that we're going to 
see on the boards. 

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But the guidelines for use of 
TPA are what's important because

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we can't just say, oh, this 
person's got ischemic stroke or 

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hemorrhagic stroke. 
How do we determine between the 

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two? 
Well, the signs and symptoms 

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potentially, but how are we 
going to decide between the two?

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00:12:35,640 --> 00:12:37,000
How do we know which one is 
which? 

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00:12:37,960 --> 00:12:40,240
We're going to do ACT scan, 
right? 

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00:12:40,360 --> 00:12:43,200
Do ACT scan. 
And now we can determine which 

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00:12:43,200 --> 00:12:47,520
type of a stroke it is, what 
type of a stroke it is. 

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Then we have to determine if 
it's ischemic stroke, which 

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again is a majority, what are 
the guidelines? 

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00:12:57,480 --> 00:13:04,040
So the guidelines are as such 
for TPA, we must give it within 

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00:13:04,840 --> 00:13:11,320
3 to 4 1/2 hours, which means if
a person had an ischemic stroke 

200
00:13:11,320 --> 00:13:13,160
two days ago, are we giving them
TPA? 

201
00:13:13,520 --> 00:13:16,040
No. 
But ultimately, the sooner we 

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00:13:16,040 --> 00:13:19,000
give it to them, the sooner we 
give it to them, the better. 

203
00:13:19,400 --> 00:13:22,440
But there are some 
contraindications. 

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00:13:22,720 --> 00:13:27,920
The contraindications are if 
it's obviously a hemorrhagic 

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00:13:27,920 --> 00:13:31,280
stroke, because if it's going to
break down clots, all we're 

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00:13:31,280 --> 00:13:33,600
doing is causing that stroke to 
get worse. 

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00:13:33,840 --> 00:13:35,960
So that's why it's so important 
that we do ACT scan. 

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00:13:36,320 --> 00:13:40,960
So if they've had any recent 
surgery or trauma within 14 

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00:13:40,960 --> 00:13:46,320
days, we do not administer TPA. 
If they have an active internal 

210
00:13:46,320 --> 00:13:50,760
bleed, AGI bleed, genital 
urinary bleed, any type of 

211
00:13:50,800 --> 00:13:53,720
active bleed, it is 
contraindicated. 

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00:13:53,720 --> 00:13:58,000
Again, it's going to cause us to
worsen the situation. 

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00:13:59,760 --> 00:14:05,080
If their blood pressure 
currently, if it's above 185 to 

214
00:14:05,080 --> 00:14:10,440
110, we must get the blood 
pressure down, which is why I 

215
00:14:10,440 --> 00:14:13,480
talked about labetalol and 
nycardipine before we can 

216
00:14:13,480 --> 00:14:16,560
administer TPA. 
So we're on a real time crunch 

217
00:14:16,800 --> 00:14:19,480
to get that blood pressure down 
and then make sure we're still 

218
00:14:19,480 --> 00:14:22,840
between that three or below that
3 to 4 1/2 hours. 

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00:14:23,440 --> 00:14:27,800
So blood pressure greater than 
185 / 110, this one is the one 

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00:14:27,800 --> 00:14:29,920
that's going to stick out the 
most, especially on the boards 

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00:14:29,920 --> 00:14:31,920
and in real life. 
Why is that? 

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00:14:32,120 --> 00:14:35,240
Because the number one cause, 
the number one sign risk factor 

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00:14:35,240 --> 00:14:39,160
is hypertension. 
So we're worried about that in 

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00:14:39,160 --> 00:14:44,400
this situation. 
The next one, history of an 

225
00:14:45,520 --> 00:14:48,760
intracranial bleed. 
So if they have a history of an 

226
00:14:48,760 --> 00:14:52,760
intracranial bleed or 
hemorrhage, again, all this is 

227
00:14:52,760 --> 00:14:54,280
going to do is make situations 
worse. 

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00:14:54,280 --> 00:14:58,400
So bleeding, bleeding, bleeding 
TPA causing that clot to blast 

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or to not develop. 
Hence why any type of a bleed is

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going to be contraindicated. 
Same thing with recent 

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anticoagulant use. 
Recent anticoagulant use 

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contraindicated and typically 
we're going to be looking at an 

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INR that's greater than 1.7 and 
blood sugar is the last one. 

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Blood sugar less than 50 or 
greater than 400 must be 

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controlled before we're able to 
administer TPA. 

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00:15:33,640 --> 00:15:38,040
So again, the guidelines, if 
we're to administer it in 

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ischemic stroke, first we got to
do ACT scan, make sure that it 

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is in fact an ischemic stroke. 
Now we're going to do TPA if 

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00:15:46,600 --> 00:15:51,200
it's with within the time frame 
of three to 4 1/2 hours or 

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00:15:51,200 --> 00:15:55,840
below, 3 to 4 1/2 hours below. 
They cannot have had a 

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00:15:55,880 --> 00:15:58,120
hemorrhagic stroke. 
They cannot have internal 

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00:15:58,120 --> 00:15:59,840
bleeding. 
They cannot have a history of 

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00:15:59,840 --> 00:16:02,360
intracranial hemorrhage. 
They cannot have anticoagulant 

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00:16:02,360 --> 00:16:04,000
use. 
All are bleeding, bleeding, 

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00:16:04,000 --> 00:16:06,920
bleeding, bleeding. 
So if you just think about the 

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concept of bleeding, it's 
contraindicated. 

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00:16:10,320 --> 00:16:15,320
And again, active is going to be
what we're looking for, blood 

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glucose we just talked about. 
And then again, recent surgery 

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00:16:18,640 --> 00:16:22,280
or trauma within the past 14 
days, again, the concept comes 

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00:16:22,280 --> 00:16:23,400
down to bleeding, bleeding, 
bleeding. 

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00:16:23,400 --> 00:16:24,760
We're not trying to make things 
worse. 

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00:16:24,760 --> 00:16:25,920
We're not trying to make things 
worse. 

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00:16:26,400 --> 00:16:29,200
So these are the things that 
we're going to be doing now 

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00:16:29,880 --> 00:16:34,480
we're going to apply and see 
where we're going to be able to 

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ask these questions. 
So again, brand new questions 

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00:16:38,240 --> 00:16:41,120
that we're asking and that we've
never done before. 

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And then we've got a case study 
as well, too.