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Atrial Fibrillation Anatomy, ECG and Stroke, Animation.




Atrial fibrillation is the most common type
of cardiac arrhythmia. In a healthy heart,
the sinoatrial node or SA node initiates all
electrical impulses in the atria. In atrial
fibrillation, electrical impulses are initiated
randomly from many other sites called ectopic
sites in and around the atria, commonly near
the roots of pulmonary veins. These un-synchronized,
chaotic electrical signals cause the atria
to quiver or fibrillate rather than contract.
Although the atrial rate during atrial fibrillation
can be extremely high, most of the electrical
impulses do not pass through the atrioventricular
â€" the AV - node to the ventricles. This
is due to refractory properties of the cells
of the AV node. Those that do come through are
irregular. Ventricular rate or heart rate
is therefore irregular and can range from
slow - less than 60 - to rapid -more than
100 - beats per minute.
On an ECG, atrial fibrillation is characterized
by absence of P-waves and irregular narrow
QRS complexes. Reminder: P-wave represents
electrical activity of the SA node that is
now obscured by activities of multiple ectopic
sites. The baseline may appear undulating
or totally flat depending on the number of
ectopic sites in the atria. In general, larger
number of ectopic sites results in flatter
baseline.
As the atria do not function properly, the
heart puts out less blood, and heart failure
may occur. The most common complication of
atrial fibrillation, however, is the formation
of blood clots in the atria. As the atria
do not empty completely into the ventricles,
the blood may stagnate inside the atria and
blood clots may form. These clots may then
pass into the bloodstream, get stuck in small
arteries and block them. When a blood clot
blocks an artery in the brain, a stroke may
result.

https://www.youtube.com/watch?v=tPqs4xKPG3A


Code Stroke Educational Training




This video is produced by the South Australian
Stroke Clinical Network as a training tool
for nurses and doctors. It explains the Code
Stroke scenario which we use in this state
to ensure rapid assessment of patients to
enable administration of thrombolysis wherever
possible.
OK, so the bolus is at 11.40, we'll keep a
close eye on you. The community need to recognize
a stroke and know what to do. Spread the word
of FAST. F for face asymmetry of smile, A
for arm weakness, S for speech disturbance
and T for telephone zero, zero, zero in Australia
and note the time.
Once the ambulance service have been called
the code stroke process begins.
And the time of onset was. OK see you in ED.
Thanks for the call.
Roger. We'll see you on arrival.
Following the pre-notification the stroke
nurse then activates the hospital code stroke
team. The stroke team meets the patient on
arrival in the emergency department.
ISBAR is a tool used to provide effective
and accurate communication. I for introduction;
in this case a 49 year old Mr Bob Major. S
for situation; he was at work with a sudden
onset of left face, arm, leg weakness and
slurred speech. Time of onset was 11 o'clock.
B for background; He lives independently at
home with a past medical history of atrial
fibrillation. A is for assessment; the ROSIER
score, Recognition Of Stroke In the Emergency
Room, he scored four with a face arm leg weakness
and slurred speech. R is for recommendations;
an acute assessment by the stroke team for
suitability for thrombolysis.
In a code stroke scenario all members of the
emergency department and stroke team have
pre-defined roles so it's a very rapid assessment
of the patient. We do things like heart tracing,
taking bloods, putting in a jelco, telling
the patient what's going to happen, doing
a neurological assessment and then transferring
them to radiology within about 15minutes.
The National Institute for Health Stroke Severity
Scale is known as the NIHSS. It enables doctors
and nurses all over the world to make a standardised
assessment of the severity of stroke.
Bob, we need to do a neurological examination
on you. Tell me how old you are?
49
What month is it now?
It's March
Do this for me, close your eyes, now open
them. With your hand make a fist and open
it out. See my pen here? Don't take your eyes
off my pen. Follow my pen all the way. Point
to the finger that wiggles. Point to the finger
that wiggles. Ok so he's got some left visual
neglect. Give me a great big smile, show me
all your teeth. Screw up your eyes tight and
raise up your eyebrows. So it's weak on that
left side. Now I need to know whether you
can feel this. This is sharp?
Yes
Can you feel this?
Yes
It's not as sharp. What about here?
Yep
And here?
Um just
Ok sharper on the right or the left
Much sharper on the
What about here?
OK, no.
So you can feel it but it's not as sharp.
Yeah
So we have some left sensory loss. Lift up
your right arm, keep it up, keep it up strong
for 10. One, two, three, four, five, six,
seven, eight, nine, ten. Lovely. Lift this
one up for me. Come on, lift if up. What can
you do? Anything at all? It's pretty weak,
isn't it? OK, ah so I'm going to give him
a three for his arm. Lift up your right leg.
Keep it up for five. One, two, three, four,
five. Rest down. Lift up your left one. Come
on lift it up. What have we got here anything?
OK still very weak. With this finger touch
my finger touch your nose. Back to my finger,
back to your nose, back to my finger, back
to your nose. Can you try with your left hand?
No
No, there's no ataxia there. Now please rattle
these words off for me please.
Pip, stone, fifteen, catastrophe, impossibility.
Yep.
Um, so we'll need to rush down to the CT scanner.
I've rung them to say we are on our way.
Hi Andrew, this is Bob Major for his code
stroke imaging.
Hello Bob. Have you ever had a CT before?
I don't think so.
I'm going to be taking you in and seeing what
we can do for you, yep.
As part of the code stroke imaging protocol
all or some of the imaging is performed. Everyone
gets a plain CT scan to determine the type
of stroke and to rule out a bleed.
CT angiogram is performed to look at the intra
and extra cranial vessels. A perfusion scan
may also be performed which highlights already
infarcted brain or whether there's brain at
threat of infarction. This is the penumbra
and that's the brain you're trying to save.
In preparation for thrombolysis the patient
must be informed of the risks. One, the drug
will do nothing. Two it may make you better
or totally better. Three, and this is important,
it could make you worse. It could make you
bleed from anywhere in your body, especially
your brain, which could be serious and even
life threatening. Other problems include;
allergic reactions and local bruising. Reassure
the patient they will be monitored very carefully
for signs of deterioration over the next twenty
four hours.
There are absolute contraindications to thrombolysis,
which include; if there's no clear time of
onset, an uncontrolled blood pressure of 185/110,
serious bleeding or clotting disorders, an
INR of greater than one point five or seizure
at onset without vessel occlusion.
Relative contraindications include; recent
heart attacks, strokes, head injuries, a very
severe stroke with a NIHSS of greater than
22, operations or biopsies.
The stroke doctor will discuss the patient
with the Consultant. He will give him a clear
time of onset, the clinical findings, the
medical history, the blood test results and
the results of the CT scan. The consultant
will review the images and the patient and
decide whether thrombolysis is indicated and
the drug will only be offered if the Stroke
Consultant thinks it's the best treatment
for the patient.
Bob I want you to sign this consent form for
thrombolysis.
Bob how much do you weigh?
89 kilos
89 kilos. The total dose is 80.1. Ten percent
bolus is eight. 60mil infusion is 72.1 and
we're using two 50 milligram vials.
Ok, so our infusion will be 72.1. Let's go.
Actilyse is given 0.9 milligrams per kilogram.
The maximum dose is 90 milligrams. It will
come in a 50 milligram vial and a ten milligram
vial. The patient will have cardiac monitoring
in-situ and be constantly checked to observe
for bleeding, headache, changes in clinical
signs, signs of allergic reaction, angioedema
and anaphylaxis, is rare, but possible. All
right Bob, we are going to keep a close eye
on you. By completing standardised neurological
and frequent vital signs observations early
detection of deterioration will be made. The
modified NIHSS includes questions on level
of consciousness, visual fields, gaze, arm
and leg movement, sensation, language and
whether there's neglect. With a possible score
out of 32. If the score increases by four
or more, the patient is deteriorating and
will need urgent medical review and possible
re-scan of the brain to rule out a bleed.
You'll be pleased to know that our patient,
Bob Major, made a good recovery with his thrombolysis
and was discharged to rehabilitation on day
three.

https://www.youtube.com/watch?v=Va_N7g5Qrh4