PREHOSPITAL & ED MANAGEMENT OF STROKE
      Principal Causes of Deaths In Government Hospitals Malaysia in 2002 1 Heart Diseases & Diseases of Pulmonary Circula...
The Era of Reperfusion:  Guideline 2000 <ul><li>Intravenous tPA for patients with ischemic stroke </li></ul><ul><li>- With...
Basic life support (BLS) role in  stroke management <ul><li>“ Phone first” for unresponsive adults  </li></ul><ul><li>(Cla...
Stroke Chain of Survival  and Recovery (7D's) 1.  Detection  -  note the onset of signs and symptoms 2.  Dispatch  -  call...
DETECTION DISPATCH DELIVERY DOOR DATA DECISION DRUG Recognizing signs & symptoms Calling for help (999/991) Initial assess...
DETECTION – PH Cincinnati Stroke Scale
Pre-hospital Management of Stroke Initial assessment & management: <ul><li>Airway,Breathing,Circulation </li></ul><ul><li>...
ED Management of Acute Stroke
ED Management of Acute Stroke The completion of 4 D’s……… Door -  immediate emergency department triage Data -  prompt labo...
<ul><li>What concern us in the ED……… </li></ul><ul><li>Triage, primary survey & initial stabilization (Door) </li></ul><ul...
<ul><li>Immediate general assessment (<10 min from arrival) </li></ul><ul><li>Assess ABCs, vital signs </li></ul><ul><li>O...
<ul><li>Immediate neurological assessment… </li></ul><ul><li>Review history </li></ul><ul><li>Establish time of onset (< 3...
<ul><li>Is it ischemic or hemorrhagic stroke??? </li></ul><ul><li>CT scan is the most important diagnostic test </li></ul>...
 
 
ED Management of Acute Stroke
ED Management of Acute Stroke <ul><li>Initial treatment  & supportive care </li></ul><ul><li>General Emergency Therapy </l...
<ul><li>Initial treatment  & supportive care </li></ul><ul><li>Management of Elevated Blood Pressure </li></ul><ul><li>- H...
ED Management of Acute Stroke <ul><li>Management of Elevated Blood Pressure </li></ul><ul><li>No data to define for level ...
ED Management of Acute Stroke III. Management of seizures - Life-threatening complication if recurs - Anticonvulsant recom...
ED Management of Acute Stroke <ul><li>Management of Raised ICP </li></ul><ul><li>- Cerebral edema & raised ICP are common ...
ED Management of Acute Stroke <ul><li>Management of Raised ICP (Cont.)  </li></ul><ul><li>- If suspect: </li></ul><ul><li>...
ED Management of Acute Stroke <ul><li>Fever </li></ul><ul><li>- Poor neurological outcome with fever </li></ul><ul><li>- A...
ED Management of Acute Stroke <ul><li>Cardiac Rhythm </li></ul><ul><li>- MI & cardiac arrhythmias are potential </li></ul>...
ED Management of Acute Stroke <ul><li>Blood sugar </li></ul><ul><li>- Always check blood sugar! </li></ul><ul><li>- Diabet...
<ul><li>Pharmacological & Interventional Therapies </li></ul><ul><li>Ischemic Stroke </li></ul><ul><li>Fibrinolytic Therap...
Pharmacological & Interventional Therapies The National Institute of Neurological Disorders & Stroke rtPA Stroke Trial pro...
Pharmacological & Interventional Therapies The National Institute of Neurological Disorders & Stroke rtPA Stroke Trial Bas...
Pharmacological & Interventional Therapies
Pharmacological & Interventional Therapies Characteristics of patients with ischemic stroke who Could be treated with rtPA...
Pharmacological & Interventional Therapies WHY LESS THAN 3 HOURS ???????? The ATLANTIS Trial:  Recombinant Alteplase for i...
Pharmacological & Interventional Therapies <ul><li>ANTICOAGULANT THERAPY ???? </li></ul><ul><li>No efficacy has been estab...
Pharmacological & Interventional Therapies <ul><li>ANTICOAGULANT THERAPY ???? </li></ul><ul><li>Stroke Treatment – Heparin...
Pharmacological & Interventional Therapies LOW MOLECULAR WEIGHT HEPARIN ???? Norwegian Trial Compare deltaparin & aspirin ...
Pharmacological & Interventional Therapies OTHER TREATMENTS ???? Ca2+ channel blockers Volume expander Hemodilution Low mo...
<ul><li>CONCLUSIONS </li></ul><ul><li>Public & pre-hospital providers must be taught to </li></ul><ul><li>identify feature...
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Emergency Care Of Stroke

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Emergency Care Of Stroke

  1. 1. PREHOSPITAL & ED MANAGEMENT OF STROKE
  2. 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. 3. The Era of Reperfusion: Guideline 2000 <ul><li>Intravenous tPA for patients with ischemic stroke </li></ul><ul><li>- Within 3 hours of onset of symptoms (Class I) </li></ul><ul><li>- Between 3 and 6 hours of onset of symptoms (Class Indeterminate) </li></ul><ul><li>II. Intra-arterial fibrinolysis may be beneficial (Class IIb) </li></ul>“ Time is brain”
  4. 4. Basic life support (BLS) role in stroke management <ul><li>“ Phone first” for unresponsive adults </li></ul><ul><li>(Class Indeterminate) </li></ul><ul><li>Prehospital identification of stroke victims (Class 1) </li></ul><ul><li>Rapid transport & notification (Class1) </li></ul><ul><li>Rapid /early dispatch of stroke victims like MI (Class1) </li></ul><ul><li>Transport to center capable of starting rapid fibrinolytic (Class IIb) </li></ul>
  5. 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. 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. 7. DETECTION – PH Cincinnati Stroke Scale
  8. 8. Pre-hospital Management of Stroke Initial assessment & management: <ul><li>Airway,Breathing,Circulation </li></ul><ul><li>Vital signs check – BP, PR, Respiratory Rate </li></ul><ul><li>Capillary blood sugar </li></ul><ul><li>Determine time of onset </li></ul><ul><li>En route – an IV, O2, Cardiac Monitoring </li></ul><ul><li>Notify receiving appropriate hospital </li></ul><ul><li>Transport ASAP – TIME IS BRAIN !!! </li></ul>
  9. 9. ED Management of Acute Stroke
  10. 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. 11. <ul><li>What concern us in the ED……… </li></ul><ul><li>Triage, primary survey & initial stabilization (Door) </li></ul><ul><li>History, general & neuro assessment (Door) </li></ul><ul><li>Determine whether ischemic or hemorrhagic stroke </li></ul><ul><li>(Data) </li></ul><ul><li>IV. Initial treatment & supportive care (Decision) </li></ul><ul><li>V. Early referral for definitive treatment (Drug) </li></ul>
  12. 12. <ul><li>Immediate general assessment (<10 min from arrival) </li></ul><ul><li>Assess ABCs, vital signs </li></ul><ul><li>Oxygen provision </li></ul><ul><li>Obtain IV access, blood investigations (FBC, BUSE, </li></ul><ul><li>coagulation profiles </li></ul><ul><li>Blood sugar </li></ul><ul><li>Obtain 12-lead ECG </li></ul><ul><li>Alert neurology team </li></ul>
  13. 13. <ul><li>Immediate neurological assessment… </li></ul><ul><li>Review history </li></ul><ul><li>Establish time of onset (< 3 hours ?) </li></ul><ul><li>Physical examination </li></ul><ul><li>Determine GCS/NIH stroke scale/Hunt & Hess </li></ul><ul><li>Urgent non-contrast CT scan (door to CT < 25 minutes </li></ul><ul><li>from arrival) </li></ul><ul><li>Read CT scan (door to CT read < 45 minutes from arrival </li></ul><ul><li>Rule out trauma/other causes </li></ul>
  14. 14. <ul><li>Is it ischemic or hemorrhagic stroke??? </li></ul><ul><li>CT scan is the most important diagnostic test </li></ul><ul><li>Do without contrast </li></ul><ul><li>Increased density suggest bleed </li></ul><ul><li>Be aware that SAH may present with normal CT </li></ul><ul><li>If suspicious, do LP </li></ul><ul><li>MRI is NOT ROUTINE (not superior to CT) </li></ul><ul><li>Though MRI detect early bleed & more sensitive </li></ul>
  15. 17. ED Management of Acute Stroke
  16. 18. ED Management of Acute Stroke <ul><li>Initial treatment & supportive care </li></ul><ul><li>General Emergency Therapy </li></ul><ul><li>- Maintain adequate tissue oxygenation </li></ul><ul><li>- Prevent hypoxia </li></ul><ul><li>- Risk of airway compromise in stroke patient </li></ul><ul><li>- Airway obstruction, hypoventilation, aspiration </li></ul><ul><li> atelectasis </li></ul><ul><li>- Consider elective intubation </li></ul><ul><li>- Routine O2 supplement is not recommended </li></ul><ul><li> unless hypoxic </li></ul>
  17. 19. <ul><li>Initial treatment & supportive care </li></ul><ul><li>Management of Elevated Blood Pressure </li></ul><ul><li>- Hypertension may occur after the insult </li></ul><ul><li>- BP elevated from the stress of stroke, full </li></ul><ul><li> bladder, hypoxia, raised ICP </li></ul><ul><li>- Optimal management is controversy </li></ul><ul><li>- DO NOT treat aggressively </li></ul><ul><li>- Little scientific basis & no clinically proven </li></ul><ul><li> benefit for lowering BP </li></ul><ul><li>- Treat urgently in hypertensive encephalopathy, </li></ul><ul><li> acute pulmonary edema, renal failure/AMI </li></ul>ED Management of Acute Stroke (Circulation,2000;102(suppl I):I-204-I-216)
  18. 20. ED Management of Acute Stroke <ul><li>Management of Elevated Blood Pressure </li></ul><ul><li>No data to define for level of treatment </li></ul><ul><li>From CONCENCUS (NOT EVIDENCE BASE) treat only if </li></ul><ul><li>- DBP > 120 mmHg </li></ul><ul><li>- SBP > 220 mmHg </li></ul><ul><li>Lower BP cautiuosly </li></ul><ul><li>- Use IV antihypertensive (i.e labetolol) </li></ul><ul><li>- Avoid oral short acting agent (i.e nifedipine) </li></ul><ul><li>(Stroke, 2003;34:1056-1083) </li></ul><ul><li>(Circulation,2000;102(suppl I):I-204-I-216 </li></ul>
  19. 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
  20. 22. ED Management of Acute Stroke <ul><li>Management of Raised ICP </li></ul><ul><li>- Cerebral edema & raised ICP are common </li></ul><ul><li> cause of death after stroke (10-20%) </li></ul><ul><li>- Goals of therapy: </li></ul><ul><li>reduction of elevated ICP </li></ul><ul><li>maintenance of cerebral perfusion </li></ul><ul><li>(CPP=MAP-ICP) </li></ul>
  21. 23. ED Management of Acute Stroke <ul><li>Management of Raised ICP (Cont.) </li></ul><ul><li>- If suspect: </li></ul><ul><li>fluid restriction </li></ul><ul><li>head elevation (20-30%) </li></ul><ul><li>support of ventilation </li></ul><ul><li>control of agitation </li></ul><ul><li>- Optimal PaCO2 30 to 35 mmHg (immediate effect) </li></ul><ul><li>- Normoventilation vs Hyperventilation </li></ul><ul><li>- Avoid aggressive tracheal suctioning </li></ul><ul><li>- Pharmacological therapy: </li></ul><ul><li>hyperosmolar therapy (0.5g/kg per dose over 20 min) </li></ul><ul><li>diuretics </li></ul><ul><li>hypertonic saline </li></ul><ul><li>acetazolamide </li></ul><ul><li>barbiturates (1 to 5 mg/kg) </li></ul><ul><li>- ICP monitoring (guide therapy, worsening condition) </li></ul>Broderick JP et al. Stroke. 1999;30:905-915 Adams HJ et al. Stroke. 1994;25:1901-1914
  22. 24. ED Management of Acute Stroke <ul><li>Fever </li></ul><ul><li>- Poor neurological outcome with fever </li></ul><ul><li>- A recent meta-analysis suggested marked </li></ul><ul><li> increase in mortality & morbidity </li></ul><ul><li>- Find source of fever </li></ul><ul><li>- Issue of modestly induced hypothermia in </li></ul><ul><li> treating stroke (neuroprotective) </li></ul>Azzimondi G et al. Stroke. 1995;26:2040-2043 Jorgensen HS et al. The Copenhagen Stroke Study. Stroke 1999;30:2008-2012
  23. 25. ED Management of Acute Stroke <ul><li>Cardiac Rhythm </li></ul><ul><li>- MI & cardiac arrhythmias are potential </li></ul><ul><li> complications </li></ul><ul><li>- Disturbances in autonomic nervous systems </li></ul><ul><li>- ECG changes: </li></ul><ul><li>ST depression </li></ul><ul><li>QT interval prolongation </li></ul><ul><li>inverted T wave </li></ul><ul><li>Acute MI (release of cathecolamine) </li></ul><ul><li>- Most common arrhythmia is atrial fibrillation </li></ul><ul><li>- Sudden death can occur </li></ul>Myers MG et al. Sroke.1982;13:838-842 Kolin A. Stroke. 1984;15:990-993
  24. 26. ED Management of Acute Stroke <ul><li>Blood sugar </li></ul><ul><li>- Always check blood sugar! </li></ul><ul><li>- Diabetes is a well known risk factor </li></ul><ul><li>- Detrimental effects of both hypo & </li></ul><ul><li> hyperglycemia </li></ul><ul><li>anaerobic glycolysis </li></ul><ul><li>increase blood brain barrier </li></ul><ul><li>- No relation between HbA1C & stroke outcome </li></ul><ul><li>- No database evidence showing euglycemia </li></ul><ul><li> change the impact of stroke </li></ul>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
  25. 27. <ul><li>Pharmacological & Interventional Therapies </li></ul><ul><li>Ischemic Stroke </li></ul><ul><li>Fibrinolytic Therapy </li></ul><ul><li>- Intraarterial & intravenous fibrinolytics in </li></ul><ul><li> ischemic stroke </li></ul><ul><li>- The Cochrane Stroke Review group </li></ul><ul><li>17 trials with > 5000 patients, > 50% received </li></ul><ul><li>rtPA </li></ul><ul><li>patients treated < 3 hours had reduced death & </li></ul><ul><li>dependency </li></ul><ul><li>problems with heterogeneity in the study </li></ul>
  26. 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
  27. 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)
  28. 30. Pharmacological & Interventional Therapies
  29. 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
  30. 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
  31. 33. Pharmacological & Interventional Therapies <ul><li>ANTICOAGULANT THERAPY ???? </li></ul><ul><li>No efficacy has been established </li></ul><ul><li>Stroke Treatment – Aspirin </li></ul><ul><ul><ul><li>Two important trials: </li></ul></ul></ul><ul><ul><ul><li>International Stroke Trial (IST) </li></ul></ul></ul><ul><ul><ul><li>Chinese Acute Stroke Trial (CAST) </li></ul></ul></ul><ul><ul><ul><li>Combined analysis (n=40,090) </li></ul></ul></ul><ul><ul><ul><li>Death / nonfatal strokes reduced 11% </li></ul></ul></ul><ul><ul><ul><li>Reduces the subsequent stroke in TIA </li></ul></ul></ul><ul><ul><ul><li>160 – 300mg within 48 hours reduces recurrent </li></ul></ul></ul><ul><ul><ul><li>  </li></ul></ul></ul>
  32. 34. Pharmacological & Interventional Therapies <ul><li>ANTICOAGULANT THERAPY ???? </li></ul><ul><li>Stroke Treatment – Heparinoids </li></ul><ul><ul><ul><li>Two important trials: </li></ul></ul></ul><ul><ul><ul><li>International Stroke Trial (IST) </li></ul></ul></ul><ul><ul><ul><li>TOAST (Trial of ORG 10172) </li></ul></ul></ul><ul><ul><ul><li>Decreased recurrent ischemic strokes </li></ul></ul></ul><ul><ul><ul><li>Increased hemorrhagic events </li></ul></ul></ul><ul><ul><ul><li>No net stroke benefit </li></ul></ul></ul><ul><li>  </li></ul>
  33. 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
  34. 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
  35. 37. <ul><li>CONCLUSIONS </li></ul><ul><li>Public & pre-hospital providers must be taught to </li></ul><ul><li>identify features of stroke </li></ul><ul><li>Early hospital consultations is required </li></ul><ul><li>Stroke can be ischemic or hemorrhagic </li></ul><ul><li>Ischemic stroke can be treated with fibrinolytics if presented within 3 hours of onset </li></ul><ul><li>Stroke is “Brain Attack” & should be considered as acute myocardial infarcton </li></ul><ul><li>Pre-hospital care involves early detection and stabilization </li></ul><ul><li>ED care involves early confirmation & further stabilization and complications recognition </li></ul>
  36. 38. THANK YOU
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