Emergency Care Of Stroke
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Emergency Care Of Stroke

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    Emergency Care Of Stroke Emergency Care Of Stroke Presentation Transcript

    • PREHOSPITAL & ED MANAGEMENT OF STROKE
    •       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%
    • 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”
    • 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)
    • 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
    • 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
    • DETECTION – PH Cincinnati Stroke Scale
    • 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 !!!
    • ED Management of Acute Stroke
    • 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
      • 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)
      • 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
      • 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
      • 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
    •  
    •  
    • ED Management of Acute Stroke
    • 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
      • 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)
    • 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
    • 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
    • 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)
    • 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
    • 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
    • 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
    • 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
      • 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
    • 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
    • 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)
    • Pharmacological & Interventional Therapies
    • 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
    • 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
    • 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
          •  
    • 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
      •  
    • 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
    • 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
      • 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
    • THANK YOU