Rural Emergency Medicine

This is part of the Med in Small Doses series, which aims to give you a snapshot of a disease or disorder. For information about the series, or common abbreviations click here. Can't remember what to look for on suspicion of a Stroke? Run through how to perform a neurological exam to refresh your memory.

3rd most common cause of mortality, 1st morbidity. Haemorrhagic stroke ↑ morbidity & mortality. 20% of pts die in hospital. M>F.    2/3 ppl >65yrs.

RFs: ↑ Age, M, FHx, Prev. stroke/TIA, ethinicity (African), HTN,
AF, DM, ATH, ↑ lipids, HRT, ↑ EtOH, Obesity.

PATHO: Ischaemic Stroke (85%) – occlusion. Pale infarct a/w thrombosis. No change at 1-6hrs → pale, soft & swollen tissue (48hrs) → gelatinous & friable (2-10 days).
Haemorrhagic (~15%). Red infarct. Ruptured vessel in brain tissue or SAS. Multiple ± confluent petechial haemorrhages. Venous infarcts common in haemorrhagic.

CFs: Sudden onset motor/sensory loss, visual loss, sudden severe headache (e.g. “thunderclap”), Δ in consciousness. F.A.S.T

F acial weakness
A rm weakness
S peech difficulty/slurred speech.
T ime to act (e.g. 000, get to ED)

New York State Department of Health

Ix:  CT, MRI, U/S of Carotids, CXR, ECG. FBC, U&E, Glucose, O2 Sats.

The 4 Ps 
P lasma: FBC, U&E, ESR, glucose, lipids 
P ump, i.e heart (ECG, echocardiogram) 
P ipes: carotid Doppler ultrasound 
P icture of brain: CT/MRI; detects ischaemia or haemorrhages 

Goals – Px tissue damage, functional loss & reoccurrence. ↑ Rehab.  Admission to a Stroke Unit, if available, is highly desirable → better outcomes.
Ischaemic: IV Thrombolysis (TPa within 3hrs – rarely done in QLD), Aspirin, thrombectomy, supportive care, OT, PT, Speech, Education.
Haemorrhagic: supportive care, mild sedatives, help blood to clot, Ca2+C-Blockers.

Management: ABCDEFGHI 
A  Advice – lifestyle changes e.g. stop smoking, reduce alcohol intake, lose weight
B  BP control
C  Cholesterol control
D  Diabetes control
E  Elastic stockings (prophylaxis for DVT, PE)
F  Fibrillation (anticoagulate, rate control and cardiovert as required)
G  Guardian drugs (aspirin, ACE inhibitors, etc)
H  Help from OT, speech & language therapy (SALT) & specialist stroke nurse
I   Incontinence care & limit Immobility (pressure sores and contractures may develop otherwise)

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