WK4 - Lecture 18 - CVA.pdf

DH 410 EMERGENCIES IN DENTAL PRACTICE LECTURE: CEREBROVASCULAR ACCIDENT Objectives  Understand and differentiate between the types of cerebrovascular accidents  Understand and discuss the pathophysiology of both types of CVA  Understand and describe the symptoms of CVA  Dis...

DH 410 EMERGENCIES IN DENTAL PRACTICE LECTURE: CEREBROVASCULAR ACCIDENT Objectives  Understand and differentiate between the types of cerebrovascular accidents  Understand and discuss the pathophysiology of both types of CVA  Understand and describe the symptoms of CVA  Discuss precautions to take when presented with a patient who has a history of CVA CVA “stroke” “brain attack”  Characterized by occlusion or hemorrhage of a blood vessel resulting in lack of oxygen  Parts of the brain are damaged or die CVA  Etiologies:  Thrombus  Embolus  Ruptured blood vessel  Types:  TIA  Ischemic  Hemorrhagic CVA  2nd leading cause of death world wide  4.6 million annually  5th leading cause of death and disability in the U.S. 1 every 40 seconds 3rd leading cause of death for women 1 in 5 women have a stroke in their lifetime Anyone Age (65+) at higher risk Risk Factors for CVA  Atrial fibrillation (A fib)  Affects 2 million Americans  Two atria quiver The two atria of the heart quiver, instead of regularly beating which causes them to move around 300-600 times a minute (instead of 60- 80 times a minute).  Heart pumps blood inefficiently resulting in pooling of blood – leads to thrombi (blockage at point of origin)  Increases risk of CVA 5 fold Risk Factors for CVA  Oral contraceptives  Menopause due to estrogen changes  Estrogen is a neural protective hormone  Diabetics  Familial history of CVA (3x more likely)  Ischemic is hereditary  Smoking / Tobacco Use  Physical Inactivity  Atherosclerosis  thrombi, emboli  Hypertension  Every 10mmHg above systolic 160 = 30% greater risk of CVA  Transient Ischemic Attacks (TIA)  “Mini stoke” Similar as angina is to MI (heart attack)  Blood supply to the brain is briefly interrupted  No permanent damage  Lasts 15 – 60 minutes Warning sign to a possible CVA  10% of all strokes preceded by TIA  CVA often occur within 4 days of TIA  Types of CVA  Ischemic  Hemorrhagic Ischemic CVA  Text: ‘Cerebral Infarction”  Blockage in cerebral blood vessel  Thrombus or embolus Thrombus = formed in vessel, blocks that vessel Embolus = detached thrombus  85% CVAs Hemorrhagic CVA  Rupture of a cerebral blood vessel  Surrounding tissue fills with blood and increases pressure in the brain  Abrupt onset  50-60% death rate (area dependent)  15% of all CVAs  Factors:  Hypertension  Aneurysm (abnormal swelling of vessel , weakened vessel walls– with added pressure ruptures)  Signs and Symptoms: CVA  May stop and start again as stroke progresses  Severity and location influences symptoms that are exhibited  Signs and Symptoms: CVA  Confusion  Difficulty finding or forming words  Slurred speech  Loss of balance, dizziness  Weakness or numbness on one side of the body  facial droop  Vision changes – loss of half the visual field IMPORTANT: START TIME since the onset of symptoms is VITAL Significant impact for treatment eligibility (time-limited therapies) Emergency Management: CVA “Time is brain” Onset of symptoms < 3 hours to treatment (Ischemic) Stroke Scales  Early identification of a stroke  Cincinnati Prehospital Stroke Scale (CPSS)  Looking for facial palsy, arm motor weakness, dysarthria  Ask patient to smile Observe for weakness on one side of face  Ask patient to stick out tongue Observe for tongue to go to one side  Ask patient to hold out both arms palm up and eyes closed for 10 seconds Observe for weakness in one arm Stroke Scales  Ask patient to repeat simple sentence Observe for difficulty in speech “The sky is blue in Cincinnati” “You can’t teach an old dog new tricks”  Ifany of the components found to be abnormal then assume CVA  Stroke Scales  Los Angeles Pre-hospital Stroke Scale  https://www.ahajournals.org/doi/pdf/10.1161/01.STR.31.1.71  Age greater than 45 years  History of seizure disorder  Time of onset of neurological symptoms less than 24 hours  Patient ambulatory prior to event  Blood glucose level between 60 and 400  Facial symmetry  Grip strength  Arm weakness determined by drift  Positive responses in all areas indicate CVA *More accurate; takes much longer Emergency Management: CVA  Perform stroke scale  Note TIME  Position: semi-supine (semi-Fowler)  Contact EMS immediately  C-A-B, as needed  Definitive Care:  Monitor vital signs  Administer oxygen (dyspnea) Emergency Management  In hospital  CT scan to determine etiology  Hemorrhagic Surgery will be performed  Ischemic < 3 hours onset of symptoms IV thrombolytic therapy with Alteplase (r-tPa) – dissolves thrombus or embolus to restore blood flow Ineffective after 3 hours Contraindicated for hemorrhagic CVA References Malamed, S. F. (2022). Medical emergencies in the dental office. Elsevier. Little, J. W., Miller, C., & Rhodus, N. L. (2017). Little and Falace’s dental management of the medically compromised patient. Mosby. Grimes, E. B. (2014). Medical emergencies: Essentials for the Dental Professional. Prentice Hall https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3217673/table/d33 e200/?report=objectonly https://onlinelibrary.wiley.com/doi/pdf/10.1002/9781118783467.ap p5 https://www.ahajournals.org/doi/pdf/10.1161/01.STR.31.1.71