Time for a case discussion. Think about what your response to this patient will be. Check if they know ambulance codes. (note: change of modes to maintain interest)
References: 1. American Stroke Association. Impact of Stroke. Available at: www.strokeassociation.org. Accessed June 21, 2002. 2. Albers GW, Easton JD, Sacco RL, Teal P. Antithrombotic and thrombolytic therapy for ischemic stroke. Chest. 1998;119(suppl):683S-698S. Additional Reference: Rosamond WD, Folsom AR, Chambless LE, et al. Stroke incidence and survival among middle-aged adults: 9-year follow-up at the Atherosclerosis Risk in Communities (ARIC) cohort. Stroke. 1999;30:736-743. Cerebrovascular disease is a heterogeneous disease. A stroke occurs when a blood vessel that supplies oxygen and nutrients to the brain becomes blocked or ruptures. A portion of the brain dependent on blood flow from this vessel becomes deprived of oxygen. Within minutes, nerve cells begin to die, which results in permanent disability. 1 Strokes can be categorized as either hemorrhagic or ischemic. 1 Hemorrhagic strokes occur as a result of bleeding into the brain caused by an injury to the head or a ruptured aneurysm. Although less common than ischemic strokes, hemorrhagic strokes produce more fatalities. Hemorrhagic strokes are further categorized as intracerebral or subarachnoid. An intracerebral hemorrhage occurs when a defective artery in the brain ruptures and the surrounding area of the brain fills with blood. A subarachnoid hemorrhage occurs when a blood vessel on the surface of the brain ruptures and bleeds into the subarachnoid space between the skull (but not within the tissues of the brain). 1 Ischemic strokes can be further divided into subcategories. A cerebral embolism is a result of a clot or embolus that forms in another portion of the body such as the heart (in the case of atrial fibrillation) and is carried through the bloodstream, becomes lodged in an artery that supplies blood to the brain, and blocks the flow of blood. Atherosclerotic cerebrovascular disease results in stroke when there is an impediment to normal blood perfusion as a result of severe arterial stenosis or occlusion due to atherosclerosis and coexisting thrombosis. 2 Lacunar infarcts result from microatheroma, lipohyalinosis, and other occlusive diseases of the small penetrating arteries of the brain; these are sometimes referred to as subcortical infarcts. Cryptogenic infarcts refer to ischemic strokes in which the underlying etiology remains obscure. 1,2
Time is Brain! • Every second 32,000 neurons die • every minute 1.9 million neurons die • every hour 120 million neurons die • completed stroke: loss of 1.2 billion neurons • blockage of one blood vessel will cause ischemia within 5 minutes
The Four R’s of Stroke Care Rapid Recognition & Reaction to warning signs Rapid Use of 911 Rapid Transport / Treatment to a stroke receiving hospital Rapid Diagnosis & Treatment at the hospital
Date of operation: 3/1/03 Diagnostic cerebral angiogram and clot retrieval from left cerebral artery. Diagnosis: 30-year-old woman, with sudden onset of aphasia and right-sided hemiparesis. An MRI study demonstrated ischemia and proximal left middle cerebral artery occlusion. An indication for clot retrieval was made. Procedure time: 1 hour 52 minutes Thrombus origin location: Left M1 Concentric balloon guide catheter positioning: ICA Type of guidewire used with microcatheter: Bentson Microcatheter crossed the target site: Yes Maximum inflation volume of Balloon guide catheter: 0.8ml Concentric Retriever(s) successfully retrieved the clot: Yes Number of passes with Concentric X6 Retriever: 2 Number of fragments removed: 4 1x1x1 mm 1x1x1 mm 1x1x1 mm 2x1x1 mm Site: UCLA Physicians: Gary Duckwiler, M.D. and Alois Zauner, M.D.
Stroke & The EMS Response 07/08/2009 Troy W. Pennington DO, MSHPE, FAAEM EMS Director- ARMC, Mercy Air, San Bernardino County FD, Barstow FD
Risks “may be increased…and should be weighed against the anticipated benefits…”
Stroke Treatment In The Emergency Department < 3 Hrs = Hyperacute therapy when nearly all patients have penumbra
The Ischemic Penumbra Core Infarct Ischemic Penumbra: zone of salvageable tissue surrounding core infarct
Strategies to Identify Patients with Salvageable Ischemic Penumbra < 3 Hrs = > 3 Hrs Hyperacute therapy when nearly all patients have penumbra Time From Onset (Hours) % Patients with Penumbra Imaging required to assess pathophysiology
Provent Strategies in Acute Ischemic Stroke Therapy
Prevent Clot Propagation
Early Implementation of Secondary Prevention
Early Supportive Acute Stroke Care 5-15% Increase in Good Outcomes in Acute Stroke Unit Controlled Trials
Continuous pulse oximetry, supplemental oxygen as needed
An 83 yo RH woman with sudden speech difficulty and right body weakness
Last known well @ 5:00 PM
911 call @ 7 min
Field NP study drug @ 33 min
PSC ED arrival @ 49 min
IV TPA @ 1 hr 54 min
CSC ED arrival @ 3 hr 17 min
Multimodal MRI @ 3 hr 39 min
1 st Merci pass @ 4 hr 22 min
Recanalization @ 4 hr 51 min
Acute Ischemic Stroke Care in the 21 st Century Symptoms Primary Stroke Center Neuroprotectants EMS 911 Comp Stroke Center EMS IV Lytic Imaging Imaging IA Mechanical or Lytic Angiogram Cath Lab Neuroprotectants Stroke Unit
• EMS play a critical role in the emergency care of acute stroke patients. • Over 400,000 acute stroke patients are being transported annually by EMS providers. • Just over half of all stroke patients use EMS, but those who do comprise the majority of patients presenting within the 3 hour window for acute treatment. • EMS use decreases time to hospital arrival, physician exam, CT imaging, neurologic evaluation, and ability to implement acute stroke intervention Key Points
• There are more than 750,000 strokes per year. • 163,000 die from stroke every year in america • stroke is the third leading cause of death • stroke is the leading cause of disability in adults • 4.4 million survivors; only 50-75% of stroke survivors regain functional independence • estimated direct/indirect costs for 2007- $62.7 billion • 14% of persons who survive a first stroke or TIA will have another within one year The Impact of Stroke
A pea sized piece of brain dies for every 12 minutes that treatment is delayed. Each minute you wait you lose close to 2 million brain cells. Time is Brain
TPA For Stroke 3 hours of symptom onset (NINDS trial) 4.5 hours of symptom onset (ECASS 3) 7 D’s detection, dispatch deliverly, door, data, decision, drug Stroke & The EMS Response
Use of TPA for acute stroke 1999-2004 treatment rates for ischemic stroke: 1% Schumacher C et al: use of thrombolysis in Acute Ischemic Stroke. ANN Emerg Med. 2007;50:99-107 Stroke & The EMS Response
Stroke mimics cortical vs noncortical stroke cranial nerves awake breathing Stroke & The EMS Response
Left side right side at threshold of new therapies that require us as an EP to statify…in the same way we do with mi patients Stroke & The EMS Response
For the first time in a decade it will matter what type of stroke syndrome they have lacunar or cortical cortex..Big vessels mca, cath lab get rid of clot language involved you have just localized to the cortex… angiogram, cta, mra ventriculosotomy massive territory stroke do they need a ventriculostomy risk stratification…language on the left sensory exam more likely to be cortical lacunar infarcts characterized small vessel disease less likely to get edema Stroke & The EMS Response
Lacunar different treatment arm lacunar vs cortical You only have one ICU bed, which is more likely to have complications the cortical is! Stroke mimics dissection, infective endocarditis, ekg, vegitations, intermittent afib, cardiac cerebral axis… Stroke & The EMS Response
Mimics: Encephalopathy Endocrine Dissection Endocarditis MRI What do the Neurologist want? What is the right risk stratification test noncontrast ct Stroke & The EMS Response
Types of Specialized Studies: Tissue Groups ct perfusion studies…contast studies with special protocols that show blood flow, be able top ick out the dead the core infarct vs the pneumbra poor The Vessels diffusion weighted- MRI picks up a dead core of an infarct, picks up early changes in cell death dead core of an infarct perfusion weighted- shows us the blood flow… will help us hone our therapies Stroke & The EMS Response
CT…about the vasculature, can we see where the obstruction is CTA vs MRA MR…. Stroke & The EMS Response
ABC’s, tube em, what if they have a fever should we cool em fever associated with poorer outcomes, increase temp increase metabolic demmand, so do we cool them, tylenol, whats causing the fever ? Pneumonia one of the biggest killer of people having a stroke, keep patients NPO…is the fever because they aspirated… TPA candidate Blood pressure control under 185/110 220/120 it could be harmful to lower the blood pressure in these individuals acclimated to the higher blood pressures Stroke & The EMS Response
Stroke remains the third leading cause of death and a leading cause of long-term disability among Americans.
Approximately 700,000 individuals suffer a new or recurrent stroke each year.
BP Control Nipride less popular toxicity concern difficult to use problem in renal failure dilates cerebral vessels steal phenomenon with some Labetolol 10mg iv….up to about 300mg longer half life no concern about cocaine Nicardipine titratable less toxic effects Stroke & The EMS Response
Hyperglycemia trend towards tighter control trauma, sepsis, stroke most of this literature of an association type 80-140 UK study flies in the face of that should we use heparin, doesn’t appear to have any of the benefits of TPA not indicated in acute ischemic stroke…so if you have a cardio embolic source they have been waiting 72 hours to a week to put them on anticoagualtion. hypotension Stroke & The EMS Response
Don’t combine the ASA with TPA what about plavix? 7mg 5 days to steady state many are loading 300mg….jury still out moderate hypothermia does it work for stroke, most neuroprotective therapies have failed in human trials vasodilators…no carotid endarectomy…no doesn’t work, its too late endovascular interventions…look promising up to 8 to 9 hours Neuroprotective agents…don’t really have a good one yet 2007 Stroke & The EMS Response
Attention to the basics swallow eval, pneumonia, dvt, sepsis, head of the bed up, npo in the ed. Treatment of acute neurological complications lie at the nexus between medical and surgical disease, dense hemiparesis cortical- sensory, language, spatial, perception problem along with it. Get drowsy likely to go down hill. Cerebellar infarct- posterior strokes, bleed is a surgical emergency, infarct may also be surgical patient need decompression, your swelling in a confined space. Stroke & The EMS Response
Malignant MCA syndrome Roy was attached by montecue the tiger hemicraniectomy, they realized that he would die without it. Venticulostomy to relieve pressure hemorrhagic transformation seizures- treat them, they generally don’t recommend prophylaxis, latter with scaring they then tend to generate the epilogenic foci. Stroke & The EMS Response
Stokes Mimics 24 hour cardiac monitoring from time of onset think about the heart brain axis cortical vs noncortical vs lacunar imaging noncontrast dead vs not quite dead is there an ischemic pneumbra that would could save treat pain, drain bladder, npo, keep hob elevated good BP control get all your specialist involved tight glycemic control ? What do we want to do? Stroke & The EMS Response
Important Role of EMS & EMSS in optimizing stroke care
EMS - Emergency Medical Services
Full scope of pre-hospital services, including:
9-1-1 activation and dispatch
emergency medical response
triage & stabilization in the field
transport by ground or air ambulance to a hospital or between facilities.
EMSS - Emergency Medical Service Systems
Delivery systems organized on a local, regional, statewide, or nationwide basis using public or private resources.
The successful integration of one (and often multiple) EMSS is critical to ensuring the effectiveness of a stroke system of care.
Ensure that 100% of EMSS use validated pre-hospital stroke screening tools to identify stroke patients.
Ensure that when EMS responders screen patients for stroke, they err on the side of over-identification. Initially, EMSS should establish a goal of over-triage of 30% for the pre-hospital assessment of acute stroke.
As part of the CQI process, EMS responders’ stroke screening assessment should be compared against final patient diagnoses to identify failures to identify patients who were experiencing a stroke (under-triage).
These data should be used to develop and adjust EMS responder training and protocols for the use of stroke screening forms.
Ensure pre-arrival notification of hospitals is provided for all suspected stroke patients.
Ensure that 100% of EMS providers complete a minimum of 2 hours of instruction on stroke assessment and care as part of their required CME for certification and re-licensure.
Ensure the total EMSS contact time (from the receipt of the 9-1-1 call or presentation at a non-stroke center hospital to arrival at a stroke center) is measured for 100% of stroke patients. EMSS should consistently strive to decrease this time.
Ensure on-scene time is <15 minutes before transport, unless there are extenuating circumstances. This also applies to emergent interfacility transportation of stroke patients. EMSS & hospitals should develop policies & procedures to streamline paperwork and equipment issues.
Ensure EMS response time to reach a stroke patient for emergent interfacility transfer is the same as the time from dispatch to transport (less than 9 minutes at least 90% of the time or as determined appropriate by the local EMSS).
Ensure that 100% of stroke patients are included in CQI activities and that EMSS receives feedback from the hospital on all confirmed & suspected stroke patients they provided pre-arrival hospital notification for.
Implement continuous monitoring of standard measures as part of the CQI process including:
stroke history obtained
stroke assessment using validated screening tools
stroke history checklists that document eligibility for acute therapies properly completed
whether on-scene time was appropriate
whether the hospital transport destination decision was appropriate.
Patients should be transported to the nearest Stroke Center for evaluation & care if located within a reasonable transport distance & transport time.
The determination needs to take into account regional issues such as the availability of Stroke Centers & geography and whether transportation to a Stroke Center is possible within the appropriate time for acute therapeutic interventions.