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The Continuum of Stroke Care
The Continuum of Stroke Care
The Continuum of Stroke Care
The Continuum of Stroke Care
The Continuum of Stroke Care
The Continuum of Stroke Care
The Continuum of Stroke Care
The Continuum of Stroke Care
The Continuum of Stroke Care
The Continuum of Stroke Care
The Continuum of Stroke Care
The Continuum of Stroke Care
The Continuum of Stroke Care
The Continuum of Stroke Care
The Continuum of Stroke Care
The Continuum of Stroke Care
The Continuum of Stroke Care
The Continuum of Stroke Care
The Continuum of Stroke Care
The Continuum of Stroke Care
The Continuum of Stroke Care
The Continuum of Stroke Care
The Continuum of Stroke Care
The Continuum of Stroke Care
The Continuum of Stroke Care
The Continuum of Stroke Care
The Continuum of Stroke Care
The Continuum of Stroke Care
The Continuum of Stroke Care
The Continuum of Stroke Care
The Continuum of Stroke Care
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The Continuum of Stroke Care

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  • 1. The Continuum of Stroke Care Justin A. Sattin, M.D. Assistant Professor UW Department of Neurology Medical Director UW Health Comprehensive Stroke Program
  • 2. The Chain of Survival • Healthful Choices • Public Recognition • EMS Access • ED Recognition • Radiology / Lab • Neurologist • Pharmacy • ICU Nursing Care • General RN Care • More Radiology / Lab • Inter-D Care • Rehabilitation • Re-Integration
  • 3. Stroke Symptoms
  • 4. Cincinnati Prehospital Stroke Scale Facial Droop Instruction: Ask patient to smile  Normal: Both sides of face move equally  Abnormal: One side of face does not move as well Arm Drift Instruction: Ask patient to close eyes and extend both arms straight out for 10 seconds  Normal: Both arms move the same or not at all  Abnormal: One arm does not move or drifts down Speech Instruction: Ask patient to say “You can’t teach an old dog new tricks.”  Normal: Patient says correct words without slurring  Abnormal: Patient slurs words, says wrong words, or is unable to speak Kothari RU, et al. Cincinnati Prehospital Stroke Scale: reproducibility and validity. Ann Emerg Med. 1999;33:373-8.
  • 5. Ischemic or Hemorrhagic?
  • 6. Ischemic or Hemorrhagic?
  • 7. NINDS tPA Trial 0 5 10 15 20 25 30 35 t-PA Placebo Death Hemorrhage The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. N Eng J Med. 1995;333:1588–1593.
  • 8. 39 – 26 = 13 13 ---- = 50% relative benefit 26 39 – 26 = 13% absolute difference 100 ----- = 8 needed to treat 13
  • 9. Hacke W, et al. Association of outcome with early stroke treatment: pooled analysis of ATLANTIS, ECASS, and NINDS rt-PA stroke trials. Lancet 2004;363:768-74. Time is of the Essence
  • 10. Furlan A, Higashida R, Wechsler L, et al. Intra-arterial prourokinase for acute ischemic stroke. The PROACT II Study: A randomized controlled trial. JAMA. 1999;282:2003-2011.
  • 11. Mechanical Embolectomy Leary MC, et al. Beyond tissue plasminogen activator: mechanical intervention in acute stroke. Ann Emerg Med. 2003;41:838- 46.
  • 12. Courtesy of Concentric Medical, Inc.
  • 13. Mechanical Embolectomy
  • 14. Annual Stroke Mortality 2001-2004 <10 (64) 10-50 (1,033) 50-100 (1,067) >100 (1,186) Avg# of deaths per county per year (total for all counties in group) Yuan, H. and Brue, C. Wisconsin Heart Disease and Stroke Surveillance Summary Update – 2007 – PPH 43040 (01/07). Wisconsin Department of Health and Family Services, Division of Public Health. The Joint Commission. Available at: http://www.jointcommission.org/CertificationPrograms/Disease- SpecificCare/DSCOrgs/ Accessed 10/14/07
  • 15. General Management Principles • Hypoxic pts. should receive O2 – SpO2 > 92% • Cardiac monitoring for at least 24 hrs. • Treat HTN conservatively for 24 hrs. – Ischemic: SBP < 220 mmHg – Hemorrhagic:SBP < 160 mmHg
  • 16. General Management Principles • Minimize urinary catheterization • Fevers should be evaluated and treated • Hyperglycemia should be treated – Optimal threshold is not established – < 140 mg/dL?< 185 mg/dL?
  • 17. General Management Principles • Dysphagia screening • Early mobilization • DVT prophylaxis – LMWH
  • 18. Stroke Hemorrhagic ICH SAH Ischemic Cardioembolic Large artery athero. Small vessel dz. Other Unknown Adams HP Jr, Bendixen BH, Kappelle LJ, Biller J, Love BB, Gordon DL, Marsh EE 3rd. Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST. Trial of Org 10172 in Acute Stroke Treatment. Stroke. 1993;24(1):35-41.
  • 19. Stroke Ischemic Cardioembolic Large artery athero. Small vessel dz. Other Unknown http://www.florida-oxygen.com/treatment.htm
  • 20. Stroke Ischemic Cardioembolic Large artery athero. Small vessel dz. Other Unknown http://www.cardioliving.com/consumer/Stroke/AF_Causes.shtm
  • 21. Cardioembolic Stroke
  • 22. Stroke Ischemic Cardioembolic Large artery athero. Small vessel dz. Other Unknown http://biocomp.stanford.edu/3dreconstruction/movies/haveri/stenosis_ica_angio%26ssd.jpg
  • 23. Stroke Ischemic Cardioembolic Large artery athero. Small vessel dz. Other Unknown
  • 24. Stroke Ischemic Cardioembolic Large artery athero. Small vessel dz. Other Unknown http://bbh.hhdev.psu.edu/courses/368/slide.21.(164).htm
  • 25. Stroke Ischemic Cardioembolic Large artery athero. Small vessel dz. Other Unknown
  • 26. Risk Factor Modification • Hypertension • Diabetes • Dyslipidemia • Metabolic Syndrome • Tobacco Dependence
  • 27. Antithrombotic Therapies • Aspirin • Aspirin/Dipyridamole (Aggrenox) • Clopidogrel (Plavix) • Warfarin (Coumadin)
  • 28. Important Collaborators • PT • OT • Speech • Swallow • Rehab • Neuro Ψ • Health Ψ • Case Managers! • Social Work • Pastoral Care • Palliative Care • ACE Team
  • 29. Discharge Dispositions • Home – often with outpt. or home health therapies) • Acute Rehab • Subacute Rehab • Skilled Nursing Facility • Hospice • (Celestial Discharge)
  • 30. Vascular Cognitive Impairment
  • 31. How to Reach Us Emergent Referrals UW Access Center Phone: 800-472-0111 Office Referrals UW Stroke Clinic Phone: 608-265-8899 Fax: 608-265-1753

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