time is brain

Tuesday, April 9, 2013

To every life, an end must come and for the Iron Lady, Margaret Thatcher that end came because of stroke. She is not alone. Stroke is the number three cause of death, trailing only heart attack and cancer. The death can come quickly. If enough brain is damage, whether it is because of a blocked artery or because of bleeding, swelling can put pressure on the automatic centers of the brain that control the heart and breathing and death is inevitable. But death can occur later and much more slowly. The ability to swallow can be lost and the risk of aspirating saliva and food can cause pneumonia or an infection of the lung. The inability to easily move can cause blood clots that travel to the lung or skin can break down and cause major infection.

Stroke is bad but there is potential salvation if the patient gets to medical care fast enough. The window to make the diagnosis and inject clot busting drugs is measured in minutes and many of those are lost because the patient or the family do not recognize the signs of a stroke, or choose to ignore them, hoping that they will resolve on their own .Sometimes they of. It’s called a TIA or a transient ischemic attack, better named a stroke that the body fixed itself. Unfortunately, there is no guarantee that the slurred speech, loss of vision or weakness will get better.

There is a simple tool, known as the Cincinnati Prehospital Stroke Scale. If the patient has a problem with:

  • Smiling, the face should move symmetrically
  • Raising both arms: looking for weakness on one side of the body
  • Speaking, a simple sentence

Call 911

Stroke is stressful for emergency personnel as well. There are many hoops to jump through in hope that the patient is a candidate for tPA, the clot buster. The history and physical exam needed to qualify the patient takes time. Blood tests and a CT scan of the brain need to be completely. IVs, EKGs, catheters need to be in place and a long discussion need to be held with the patient and family. The risk reward equation is challenging. One third of 33% of patients may see benefit but up to 6% of patients may bleed in the brain because of the drug. Still, the benefit outweighs the risk, especially if tPA is injected as early as possible. The widow of opportunity runs our quickly. The magic number is 3 hours from time that the symptoms began, not the time that the patient showed up at the hospital door. That 3 hours can be extended to 4 ½ in some circumstances and perhaps up to 6 hours if there is an interventional radiologist or neurosurgeon waiting.

The sadness for many stroke victims is that they do not make it to the hospital in time. Instead of focusing on reversing the problem, the treatment team looks at salvage, minimizing further brain damage and hoping that weeks and months of rehabilitation will allow the patient to return to a functional life. For that reason, the American Heart Association has worked hard at including stroke recognition as part of basic life support. The public knows to call 911 for a victim with chest pain and the potential for heart attack. The public has to learn that the same urgency is needed for the patient with stroke symptoms.

Call 911. Time is brain

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