Emergency Care Of Stroke
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Emergency Care Of Stroke Presentation Transcript

  • 1. PREHOSPITAL & ED MANAGEMENT OF STROKE
  • 2.       Principal Causes of Deaths In Government Hospitals Malaysia in 2002 1 Heart Diseases & Diseases of Pulmonary Circulation 15.99% 2 Septicemia 14.51% 3 Malignant Neoplasm 9.16% 4 Accident 6.76% 5 Perinatal Conditions 5.56% 6 Pneumonia 4.98% 7 Cerebrovascular Diseases 4.48% 8 Diseases of Digestive Systems 4.38% 9 Kidney Diseases 3.72% 10 Ill-Defined Conditions 2.74%
  • 3. The Era of Reperfusion: Guideline 2000
    • Intravenous tPA for patients with ischemic stroke
    • - Within 3 hours of onset of symptoms (Class I)
    • - Between 3 and 6 hours of onset of symptoms (Class Indeterminate)
    • II. Intra-arterial fibrinolysis may be beneficial (Class IIb)
    “ Time is brain”
  • 4. Basic life support (BLS) role in stroke management
    • “ Phone first” for unresponsive adults
    • (Class Indeterminate)
    • Prehospital identification of stroke victims (Class 1)
    • Rapid transport & notification (Class1)
    • Rapid /early dispatch of stroke victims like MI (Class1)
    • Transport to center capable of starting rapid fibrinolytic (Class IIb)
  • 5. Stroke Chain of Survival and Recovery (7D's) 1. Detection - note the onset of signs and symptoms 2. Dispatch - call 9 99/991 and have EMS dispatched immediately 3. Delivery - transport patient to hospital with assessment and care 4. Door - immediate emergency department triage 5. Data - prompt laboratory and CT diagnostic studies 6. Decision - diagnosis and decision about appropriate therapy 7. Drug - administration of appropriate drugs or other intervention
  • 6. DETECTION DISPATCH DELIVERY DOOR DATA DECISION DRUG Recognizing signs & symptoms Calling for help (999/991) Initial assessment & stabilization Appropriate hospital delivery Initial investigation Treatment modality Choosing appropriate drugs
  • 7. DETECTION – PH Cincinnati Stroke Scale
  • 8. Pre-hospital Management of Stroke Initial assessment & management:
    • Airway,Breathing,Circulation
    • Vital signs check – BP, PR, Respiratory Rate
    • Capillary blood sugar
    • Determine time of onset
    • En route – an IV, O2, Cardiac Monitoring
    • Notify receiving appropriate hospital
    • Transport ASAP – TIME IS BRAIN !!!
  • 9. ED Management of Acute Stroke
  • 10. ED Management of Acute Stroke The completion of 4 D’s……… Door - immediate emergency department triage Data - prompt laboratory and CT diagnostic studies Decision - diagnosis and decision about appropriate therapy Drug - administration of appropriate drugs or other intervention
  • 11.
    • What concern us in the ED………
    • Triage, primary survey & initial stabilization (Door)
    • History, general & neuro assessment (Door)
    • Determine whether ischemic or hemorrhagic stroke
    • (Data)
    • IV. Initial treatment & supportive care (Decision)
    • V. Early referral for definitive treatment (Drug)
  • 12.
    • Immediate general assessment (<10 min from arrival)
    • Assess ABCs, vital signs
    • Oxygen provision
    • Obtain IV access, blood investigations (FBC, BUSE,
    • coagulation profiles
    • Blood sugar
    • Obtain 12-lead ECG
    • Alert neurology team
  • 13.
    • Immediate neurological assessment…
    • Review history
    • Establish time of onset (< 3 hours ?)
    • Physical examination
    • Determine GCS/NIH stroke scale/Hunt & Hess
    • Urgent non-contrast CT scan (door to CT < 25 minutes
    • from arrival)
    • Read CT scan (door to CT read < 45 minutes from arrival
    • Rule out trauma/other causes
  • 14.
    • Is it ischemic or hemorrhagic stroke???
    • CT scan is the most important diagnostic test
    • Do without contrast
    • Increased density suggest bleed
    • Be aware that SAH may present with normal CT
    • If suspicious, do LP
    • MRI is NOT ROUTINE (not superior to CT)
    • Though MRI detect early bleed & more sensitive
  • 15.  
  • 16.  
  • 17. ED Management of Acute Stroke
  • 18. ED Management of Acute Stroke
    • Initial treatment & supportive care
    • General Emergency Therapy
    • - Maintain adequate tissue oxygenation
    • - Prevent hypoxia
    • - Risk of airway compromise in stroke patient
    • - Airway obstruction, hypoventilation, aspiration
    • atelectasis
    • - Consider elective intubation
    • - Routine O2 supplement is not recommended
    • unless hypoxic
  • 19.
    • Initial treatment & supportive care
    • Management of Elevated Blood Pressure
    • - Hypertension may occur after the insult
    • - BP elevated from the stress of stroke, full
    • bladder, hypoxia, raised ICP
    • - Optimal management is controversy
    • - DO NOT treat aggressively
    • - Little scientific basis & no clinically proven
    • benefit for lowering BP
    • - Treat urgently in hypertensive encephalopathy,
    • acute pulmonary edema, renal failure/AMI
    ED Management of Acute Stroke (Circulation,2000;102(suppl I):I-204-I-216)
  • 20. ED Management of Acute Stroke
    • Management of Elevated Blood Pressure
    • No data to define for level of treatment
    • From CONCENCUS (NOT EVIDENCE BASE) treat only if
    • - DBP > 120 mmHg
    • - SBP > 220 mmHg
    • Lower BP cautiuosly
    • - Use IV antihypertensive (i.e labetolol)
    • - Avoid oral short acting agent (i.e nifedipine)
    • (Stroke, 2003;34:1056-1083)
    • (Circulation,2000;102(suppl I):I-204-I-216
  • 21. ED Management of Acute Stroke III. Management of seizures - Life-threatening complication if recurs - Anticonvulsant recommended - Prophylaxis is not indicated - A,B,C, O2, Normothermia - Benzodiazepine, phenytoin, phenobarbitone Adams HJ et al. Stroke. 1994;25:1901-1914
  • 22. ED Management of Acute Stroke
    • Management of Raised ICP
    • - Cerebral edema & raised ICP are common
    • cause of death after stroke (10-20%)
    • - Goals of therapy:
    • reduction of elevated ICP
    • maintenance of cerebral perfusion
    • (CPP=MAP-ICP)
  • 23. ED Management of Acute Stroke
    • Management of Raised ICP (Cont.)
    • - If suspect:
    • fluid restriction
    • head elevation (20-30%)
    • support of ventilation
    • control of agitation
    • - Optimal PaCO2 30 to 35 mmHg (immediate effect)
    • - Normoventilation vs Hyperventilation
    • - Avoid aggressive tracheal suctioning
    • - Pharmacological therapy:
    • hyperosmolar therapy (0.5g/kg per dose over 20 min)
    • diuretics
    • hypertonic saline
    • acetazolamide
    • barbiturates (1 to 5 mg/kg)
    • - ICP monitoring (guide therapy, worsening condition)
    Broderick JP et al. Stroke. 1999;30:905-915 Adams HJ et al. Stroke. 1994;25:1901-1914
  • 24. ED Management of Acute Stroke
    • Fever
    • - Poor neurological outcome with fever
    • - A recent meta-analysis suggested marked
    • increase in mortality & morbidity
    • - Find source of fever
    • - Issue of modestly induced hypothermia in
    • treating stroke (neuroprotective)
    Azzimondi G et al. Stroke. 1995;26:2040-2043 Jorgensen HS et al. The Copenhagen Stroke Study. Stroke 1999;30:2008-2012
  • 25. ED Management of Acute Stroke
    • Cardiac Rhythm
    • - MI & cardiac arrhythmias are potential
    • complications
    • - Disturbances in autonomic nervous systems
    • - ECG changes:
    • ST depression
    • QT interval prolongation
    • inverted T wave
    • Acute MI (release of cathecolamine)
    • - Most common arrhythmia is atrial fibrillation
    • - Sudden death can occur
    Myers MG et al. Sroke.1982;13:838-842 Kolin A. Stroke. 1984;15:990-993
  • 26. ED Management of Acute Stroke
    • Blood sugar
    • - Always check blood sugar!
    • - Diabetes is a well known risk factor
    • - Detrimental effects of both hypo &
    • hyperglycemia
    • anaerobic glycolysis
    • increase blood brain barrier
    • - No relation between HbA1C & stroke outcome
    • - No database evidence showing euglycemia
    • change the impact of stroke
    Bruno A et al. Neurology.1999;52:280-284 Scot JF et al. Stroke. 1999;30;793-799 Weir CJ et al. BMJ.1997;314:1303-1306
  • 27.
    • Pharmacological & Interventional Therapies
    • Ischemic Stroke
    • Fibrinolytic Therapy
    • - Intraarterial & intravenous fibrinolytics in
    • ischemic stroke
    • - The Cochrane Stroke Review group
    • 17 trials with > 5000 patients, > 50% received
    • rtPA
    • patients treated < 3 hours had reduced death &
    • dependency
    • problems with heterogeneity in the study
  • 28. Pharmacological & Interventional Therapies The National Institute of Neurological Disorders & Stroke rtPA Stroke Trial prospective,blinded RCT < 3 hours of stroke onset use of IV rtPA (0.9mg/kg 10% bolus over 1 min & the rest over 1 hour infusion) 30% more likely no/minimal disability BUT 10X more likely to get intracranial bleed overall mortality NOT increased
  • 29. Pharmacological & Interventional Therapies The National Institute of Neurological Disorders & Stroke rtPA Stroke Trial Based on part I & II: IV administration of rtPA is recommended for carefully selected patients with acute ischemic stroke with no contraindications to fibrinolytic therapy & given within 3 hours of stroke onset (Class I)
  • 30. Pharmacological & Interventional Therapies
  • 31. Pharmacological & Interventional Therapies Characteristics of patients with ischemic stroke who Could be treated with rtPA: Diagnosis of ischemic stroke Measurable neurological deficit Hemorrhagic stroke excluded Onset of symptoms < 3 hours SBP<185mmHg & DBP<110mmHg CT does not show a multilobular infarction The patient & family understand the risk & benefits
  • 32. Pharmacological & Interventional Therapies WHY LESS THAN 3 HOURS ???????? The ATLANTIS Trial: Recombinant Alteplase for ischemic stroke 3 to 5 hours after symptom onset (A RCT) No significant end points differences The benefit was not maintained at 30 days Increased rate of intracranial bleed Routine use of IN rtPA > 3 hours is not recommended (Class indeterminate) Clark W et al. Recombinant Alteplase for ischemic stroke 3 to 5 hours After symptom onset: the ATLANTIS study: a RCT. JAMA. 1999;282:2019-2026
  • 33. Pharmacological & Interventional Therapies
    • ANTICOAGULANT THERAPY ????
    • No efficacy has been established
    • Stroke Treatment – Aspirin
        • Two important trials:
        • International Stroke Trial (IST)
        • Chinese Acute Stroke Trial (CAST)
        • Combined analysis (n=40,090)
        • Death / nonfatal strokes reduced 11%
        • Reduces the subsequent stroke in TIA
        • 160 – 300mg within 48 hours reduces recurrent
        •  
  • 34. Pharmacological & Interventional Therapies
    • ANTICOAGULANT THERAPY ????
    • Stroke Treatment – Heparinoids
        • Two important trials:
        • International Stroke Trial (IST)
        • TOAST (Trial of ORG 10172)
        • Decreased recurrent ischemic strokes
        • Increased hemorrhagic events
        • No net stroke benefit
    •  
  • 35. Pharmacological & Interventional Therapies LOW MOLECULAR WEIGHT HEPARIN ???? Norwegian Trial Compare deltaparin & aspirin No significant differences in outcomes & recurrent Higher rate of bleeding in deltaparin group Aspirin group has fewer second stroke German Trial Use 4 different doses of certoparin No favourable outcome among the four groups High incidence of spontaneous bleed Berge E et al. Lancet;2000;355:1205-1210 Diener HC et al. Stroke;32:22-29
  • 36. Pharmacological & Interventional Therapies OTHER TREATMENTS ???? Ca2+ channel blockers Volume expander Hemodilution Low molecular weight dextran NO FAVOURABLE OUTCOME Clark WM et al. Stroke.1999;31:2592-2597
  • 37.
    • CONCLUSIONS
    • Public & pre-hospital providers must be taught to
    • identify features of stroke
    • Early hospital consultations is required
    • Stroke can be ischemic or hemorrhagic
    • Ischemic stroke can be treated with fibrinolytics if presented within 3 hours of onset
    • Stroke is “Brain Attack” & should be considered as acute myocardial infarcton
    • Pre-hospital care involves early detection and stabilization
    • ED care involves early confirmation & further stabilization and complications recognition
  • 38. THANK YOU