Stroke & the ems response final


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  • 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: 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 final

    1. 1. Stroke & The EMS Response 07/08/2009 Troy W. Pennington DO, MSHPE, FAAEM EMS Director- ARMC, Mercy Air, San Bernardino County FD, Barstow FD
    2. 2. <ul><li>Acute Stroke: US Societal Impact </li></ul><ul><li>1 st leading cause of adult disability </li></ul><ul><li>2 nd leading cause of dementia after alzheimers </li></ul><ul><li>3 rd leading cause of death (2 nd worldwide) </li></ul><ul><li>~800,000 new strokes each year </li></ul><ul><li>>6 million stroke survivors </li></ul><ul><li>$70 billion per year in the United States </li></ul><ul><li>1 in 6 Americans will be affected </li></ul><ul><li>Of those who survive, 90% have deficit </li></ul>
    3. 3. What is a Stroke? <ul><li>Injury to the brain from blockage or rupture of a blood vessel </li></ul><ul><ul><li>Ischemic stroke </li></ul></ul><ul><ul><ul><li>Blockage of a blood vessel </li></ul></ul></ul><ul><ul><ul><li>Brain cells deprived of oxygen/nutrients </li></ul></ul></ul><ul><ul><ul><li>83% of strokes in US, 65% of strokes in Asia </li></ul></ul></ul><ul><ul><li>Hemorrhagic stroke </li></ul></ul><ul><ul><ul><li>Rupture of a blood vessel </li></ul></ul></ul><ul><ul><ul><li>Bleeding into the brain </li></ul></ul></ul><ul><ul><ul><li>17% of strokes in US, 35% of strokes in Asia </li></ul></ul></ul>
    4. 4. Acute Ischemic Stroke
    5. 5. Hemorrhagic Stroke Intracerebral Hemorrhage Subarachnoid Hemorrhage
    6. 6. Warning Signs of Stroke “The Five Suddens” <ul><li>Sudden weakness or numbness </li></ul><ul><li>Sudden change in vision </li></ul><ul><li>Sudden difficulty speaking or understanding </li></ul><ul><li>Sudden dizziness or loss of balance </li></ul><ul><li>Sudden headache </li></ul>
    7. 7. Cerebrovascular Disease Pathogenesis Cardioembolic (30%) Lacunar (25%) (small vessel disease) Ischemic Stroke (83%) Hemorrhagic Stroke (17%) Subarachnoid Hemorrhage (30%) Cryptogenic (5%) Atherothrombotic Cerebrovascular Disease (30%) Intracerebral Hemorrhage (70%) Other (vasculitiis, dissection, hypercoagulable, etc (10%)
    8. 8. <ul><li>Ischemic Stroke </li></ul><ul><ul><li>None </li></ul></ul><ul><li>Intracerebral Hemorrhage </li></ul><ul><ul><li>None </li></ul></ul><ul><li>Subarachnoid Hemorrhage </li></ul><ul><ul><li>Nimodipine </li></ul></ul><ul><li>Intraventricular Hemorrhage </li></ul><ul><ul><li>None </li></ul></ul>Acute Stroke Care 1990 Therapies with FDA Approval or Positive Trials
    9. 9. <ul><li>Ischemic Stroke </li></ul><ul><ul><li>Stroke Unit Care </li></ul></ul><ul><ul><li>PO Aspirin < 48 hrs </li></ul></ul><ul><ul><li>IV TPA < 3 hrs </li></ul></ul><ul><ul><li>IV TPA 3-4.5 hrs </li></ul></ul><ul><ul><li>IA fibrinolysis < 6 hrs </li></ul></ul><ul><ul><li>IA Merci Retriever < 8 hrs </li></ul></ul><ul><ul><li>IA Penumbra System < 8 hrs </li></ul></ul><ul><ul><li>Endovascular temperature control </li></ul></ul><ul><li>Intracerebral Hemorrhage </li></ul><ul><ul><li>Stroke Unit Care </li></ul></ul><ul><ul><li>Endovascular temperature control </li></ul></ul>Acute Stroke Care 2010 Therapies with FDA Approval or Positive Trials <ul><li>Subarachnoid Hemorrhage </li></ul><ul><ul><li>Stroke Unit Care </li></ul></ul><ul><ul><li>GDC coil, Matrix coil, stent assisted coiling </li></ul></ul><ul><ul><li>Endovascular temperature control </li></ul></ul><ul><ul><li>Nimodipine </li></ul></ul><ul><ul><li>Magnesium sulfate </li></ul></ul><ul><ul><li>Statins </li></ul></ul><ul><ul><li>IA angioplasty for vasospasm </li></ul></ul><ul><li>Intraventricular Hemorrhage </li></ul><ul><ul><li>Intraventricular TPA and drainage </li></ul></ul><ul><ul><li>Endovascular temperature control </li></ul></ul>
    10. 10. <ul><li>In a typical acute ischemic stroke, every minute the brain loses </li></ul><ul><li>1.9 million neurons </li></ul><ul><li>14 billion synapses </li></ul><ul><li>7.5 miles myelinated fibers </li></ul><ul><li>-- Saver, Stroke 2006 </li></ul>
    11. 11. Stroke and the Golden Hour <ul><li>Narrow therapeutic time window </li></ul><ul><li>Early intervention critical for stroke care </li></ul><ul><li>Prehospital personnel </li></ul><ul><ul><li>35-70% of stroke patients arrive by ambulance </li></ul></ul><ul><ul><li>Unique position: first medical professional to come in contact with stroke patient </li></ul></ul>
    12. 12. Emergent Stroke Care & The Chain of Survival Patient Calling EMS ED Stroke Stroke Knowledge 911 System Staff Team Unit
    13. 13. Stroke Systems Two Tier US Model <ul><li>EMS </li></ul><ul><ul><li>--Trained dispatchers, high priority triage </li></ul></ul><ul><ul><li>--Paramedics trained in stroke recognition (e.g. LAPSS) </li></ul></ul><ul><ul><li>--Deliver patients to nearest stroke capable hospital </li></ul></ul><ul><ul><li>--Pre-arrival notification </li></ul></ul><ul><li>Primary Stroke Centers - Spokes </li></ul><ul><li>--Able to provide initial, acute care </li></ul><ul><li>--Able to use rt-PA and other acute therapies in a safe and efficient manner </li></ul><ul><li>--Can admit patients if they have a Stroke Unit </li></ul><ul><li>Comprehensive Stroke Centers - Hubs </li></ul><ul><li>-- Able to care for complex patients </li></ul><ul><li>--Advanced treatments (i.e. coils, stents, etc) </li></ul><ul><li>--Trained specialists in key areas (Vascular neurology, Neurointerventional procedures, Neurocritical Care, Vascular Neurosurgery) </li></ul>
    14. 14. Certified Primary Stroke Centers in the United States (5/09) <ul><li>Joint Commission 545 </li></ul><ul><li>HFAP (Osteopathic) </li></ul><ul><li>15 </li></ul><ul><li>Dept of Health/EMS 290 </li></ul><ul><li>Total 850 </li></ul>
    15. 15. Primary Stroke Center Coverage of US Population in 2009 <ul><li>States </li></ul><ul><ul><li>Delaware </li></ul></ul><ul><ul><li>Florida </li></ul></ul><ul><ul><li>Georgia </li></ul></ul><ul><ul><li>Illinois </li></ul></ul><ul><ul><li>Maryland </li></ul></ul><ul><ul><li>Massachusetts </li></ul></ul><ul><ul><li>Missouri </li></ul></ul><ul><ul><li>New Jersey </li></ul></ul><ul><ul><li>New Mexico </li></ul></ul><ul><ul><li>New York </li></ul></ul><ul><ul><li>Oklahoma </li></ul></ul><ul><ul><li>Texas </li></ul></ul><ul><ul><li>Virginia </li></ul></ul><ul><li>Counties </li></ul><ul><ul><li>Alabama </li></ul></ul><ul><ul><ul><li>7 counties </li></ul></ul></ul><ul><ul><li>Arizona </li></ul></ul><ul><ul><ul><li>Maricopa-Phoenix </li></ul></ul></ul><ul><ul><li>California </li></ul></ul><ul><ul><ul><li>Alameda </li></ul></ul></ul><ul><ul><ul><li>Kern </li></ul></ul></ul><ul><ul><ul><li>Los Angeles (partial) </li></ul></ul></ul><ul><ul><ul><li>Orange </li></ul></ul></ul><ul><ul><ul><li>Sacramento </li></ul></ul></ul><ul><ul><ul><li>San Diego </li></ul></ul></ul><ul><ul><ul><li>San Francisco </li></ul></ul></ul><ul><ul><ul><li>San Mateo </li></ul></ul></ul><ul><ul><ul><li>Santa Clara </li></ul></ul></ul>13 states, multiple additional counties
    16. 16. California Stroke Systems Status <ul><li>California </li></ul><ul><ul><li>64 JC Certified Primary Stroke Centers </li></ul></ul><ul><ul><li>9 of 58 County EMS Stroke Systems </li></ul></ul><ul><li>Primary Stroke Center systems </li></ul><ul><ul><li>Alameda </li></ul></ul><ul><ul><li>Kern </li></ul></ul><ul><ul><li>Los Angeles (partial) </li></ul></ul><ul><ul><li>Sacramento </li></ul></ul><ul><ul><li>San Diego </li></ul></ul><ul><ul><li>San Francisco </li></ul></ul><ul><li>Two Tier Primary and Comprehensive Stroke Center systems </li></ul><ul><ul><li>Santa Clara </li></ul></ul><ul><ul><li>San Mateo </li></ul></ul><ul><li>Pure Comprehensive Stroke Center system </li></ul><ul><ul><li>Orange County – 9 (6) of 26 hospitals </li></ul></ul>
    17. 17. Primary Stroke Center Coverage of US Population in 2009 <ul><li>Live in jurisdictions with direct routing to Stroke Centers </li></ul><ul><ul><li>154 million Americans </li></ul></ul><ul><ul><ul><li>51% of US population </li></ul></ul></ul><ul><ul><li>23 million Californians </li></ul></ul><ul><ul><ul><li>63% of California population </li></ul></ul></ul><ul><li>Live in jurisdictions with routing to nearest hospital, not PSCs </li></ul><ul><ul><li>150 million Americans </li></ul></ul><ul><ul><li>16 million Californians </li></ul></ul>
    18. 18. The 6 Major Stroke Clinical Syndromes Syndrome Symptoms/Signs Cerebral Hemisphere Ischemia Contralateral hemiparesis, hemisensory Contralateral visual field defect Aphasia (left) / Hemispatial neglect (right) Brainstem Ischemia Decreased LOC Unilateral or bilateral weakness, sensory Dysconjugate gaze, dysarthria, dysphagia, vertigo Cerebellar Ischemia Ataxia, nystagmus Lacunar (small vessel) Ischemia Motor/sens/ataxia without language, neglect, visual Intracerebral Hemorrhage One of above focal syndromes, plus Headache, N/V, decreased LOC Subarachnoid Hemorrhage Thunderclap headache Neck stiffness Decreased LOC
    19. 21. How Did we Get Here? The NINDS Trail
    20. 22. IV TPA FOR STROKE 3-4.5 HR’s? ECASS 3
    21. 23. Prehospital Trails- Fast-Mag
    22. 24. NIH Stroke Scale <ul><li>Designed for acute ischemic stroke trials </li></ul><ul><li>Relatively quick (5-10 min) and reproducible </li></ul><ul><li>Requires speech-&-language cards, safety pin </li></ul><ul><li>Quantifies stroke deficit </li></ul><ul><ul><li>11 items, 0-42 point scale (0 = nl) </li></ul></ul><ul><li>Valid, reproducible, assists in patient selection, facilitates communication </li></ul><ul><li>Certification available from AHA website </li></ul>
    23. 25. NIH Stroke Scale: “Traditional” order of items <ul><li>1a. LOC </li></ul><ul><li>1b. LOC questions </li></ul><ul><li>1c. LOC commands </li></ul><ul><li>2. Best gaze </li></ul><ul><li>3. Visual fields </li></ul><ul><li>4. Facial palsy </li></ul><ul><li>5a. Right arm motor </li></ul><ul><li>5b. Left arm motor </li></ul><ul><li>6a. Right leg motor </li></ul><ul><li>6b. Left leg motor </li></ul><ul><li>7. Limb ataxia </li></ul><ul><li>8. Sensory </li></ul><ul><li>9. Best language </li></ul><ul><li>10. Dysarthria </li></ul><ul><li>11. Extinction/ </li></ul><ul><li>inattention </li></ul>
    24. 26. NIH Stroke Scale: Modified arrangement of items <ul><li>Mental Status </li></ul><ul><li>LOC </li></ul><ul><li>Questions </li></ul><ul><li>Commands </li></ul><ul><li>Language </li></ul><ul><li>Neglect </li></ul><ul><li>Cranial Nerves </li></ul><ul><li>Visual fields </li></ul><ul><li>Horizontal gaze </li></ul><ul><li>Face strength </li></ul><ul><li>Dysarthria </li></ul>Limbs R/L arm motor R/L leg motor Coordination Sensation
    25. 27. Stroke Scales <ul><li>NIH stroke scale 0-42 </li></ul><ul><ul><li>0-5 mild (in most patients) </li></ul></ul><ul><ul><li>6-10 moderate </li></ul></ul><ul><ul><li>11-20 severe </li></ul></ul><ul><ul><li>> 20 very severe </li></ul></ul><ul><ul><li>underestimates volume of infarct in non-dominant (R) hemispheric strokes </li></ul></ul>
    26. 28. The NIHSS and Patient Selection for TPA <ul><li>No lower limit </li></ul><ul><ul><li>But most patients 4 or more </li></ul></ul><ul><li>No upper limit </li></ul><ul><ul><li>But FDA/AHA caution when NIHSS > 22 </li></ul></ul><ul><ul><li>Risks “may be increased…and should be weighed against the anticipated benefits…” </li></ul></ul>
    27. 29. Stroke Treatment In The Emergency Department < 3 Hrs = Hyperacute therapy when nearly all patients have penumbra
    28. 30. The Ischemic Penumbra Core Infarct Ischemic Penumbra: zone of salvageable tissue surrounding core infarct
    29. 31. 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
    30. 32. Provent Strategies in Acute Ischemic Stroke Therapy <ul><li>Supportive Care </li></ul><ul><li>Recanalization </li></ul><ul><li>Prevent Clot Propagation </li></ul><ul><li>Early Implementation of Secondary Prevention </li></ul>
    31. 33. Early Supportive Acute Stroke Care 5-15% Increase in Good Outcomes in Acute Stroke Unit Controlled Trials <ul><li>Treat hypoxemia </li></ul><ul><ul><li>Continuous pulse oximetry, supplemental oxygen as needed </li></ul></ul><ul><li>Maintain normothermia </li></ul><ul><ul><li>Early antipyretics/antibiotics </li></ul></ul><ul><li>Avoid hyperglycemia </li></ul><ul><ul><li>Avoid glucose infusions/use SSI/maintain glucose < 200 mg/dl </li></ul></ul><ul><li>Early parental fluid to support collaterals </li></ul><ul><ul><li>Maintenance normotonic IV fluids (IV NS 75-100 cc/h) </li></ul></ul><ul><li>Permissive hypertension to support collaterals </li></ul><ul><ul><li>Treat only if >220/120 </li></ul></ul><ul><li>DVT prophylaxis </li></ul><ul><ul><li>Compression boots/hep/LMWH </li></ul></ul><ul><ul><li>Early mobilization </li></ul></ul><ul><li>Early swallow assessment to guide oral feeding </li></ul>
    32. 34. Preventing Clot Propagation Antithrombotics and Acute Stroke <ul><li>Aspirin </li></ul><ul><ul><li>9 trials, 41,399 patients (Cochrane 2004) </li></ul></ul><ul><ul><li>Minimally beneficial, OR = 0.94 (95%CI 0.91-0.98) </li></ul></ul><ul><ul><li>13 more per 1000 alive and independent </li></ul></ul><ul><ul><li>NNT: 77 </li></ul></ul><ul><li>Heparin/LMWHs </li></ul><ul><ul><li>21 trials, 23,427 patients (Cochrane 2004) </li></ul></ul><ul><ul><li>No net benefit </li></ul></ul><ul><ul><li>“ [H]eparin/heparinoids are not recommended for…acute ischemic stroke” AAN/AHA Joint Guideline 2002 </li></ul></ul>
    33. 35. Currently Available Recanalization Therapies in Acute Cerebral Ischemia <ul><li>Intravenous </li></ul><ul><ul><li>IV TPA under 3 hours </li></ul></ul><ul><ul><ul><li>FDA approved, guideline endorsed, RCT supported </li></ul></ul></ul><ul><ul><li>IV TPA 3-.4.5 hours </li></ul></ul><ul><ul><ul><li>RCT supported, guideline endorsement highly likely, FDA approval likely </li></ul></ul></ul><ul><ul><li>IV lytics 4.5-9 hours in advanced imaging selected patients </li></ul></ul><ul><ul><ul><li>Weakly RCT supported, not guideline endorsed or FDA approved </li></ul></ul></ul><ul><li>Catheter </li></ul><ul><ul><li>Mechanical embolectomy ≤ 8 h (Merci devices) </li></ul></ul><ul><ul><ul><li>FDA approved for clot clearance, no RCTs </li></ul></ul></ul><ul><ul><li>Mechanical aspiration ≤ 8 h (Penumbra device) </li></ul></ul><ul><ul><ul><li>FDA approved for clot clearance, no RCTs </li></ul></ul></ul><ul><ul><li>Mechanical angioplasty/stenting </li></ul></ul><ul><ul><ul><li>FDA approved for secondary prevention, no RCTs </li></ul></ul></ul><ul><ul><li>IA fibrinolytics ≤ 6 h </li></ul></ul><ul><ul><ul><li>Off label, 1.5 positive RCTs, weakly guideline endorsed </li></ul></ul></ul>
    34. 36. IV TPA Under 3 Hours – Changes in Outcome Due to Treatment <ul><li> Outcome NNTB </li></ul><ul><li>Nl/Near Normal 8.3 </li></ul><ul><li>Improved 3.1 </li></ul><ul><li>For every 100 patients treated with tPA, 32 benefit, 3 harmed </li></ul><ul><li>--Saver, Arch Neurol 2004; 61:1066-1070; Stroke 2007; 38:2279-2283 </li></ul><ul><li>--AAN/ACEP/AHA Patient Educational Tool 2008 </li></ul>
    35. 37. Intravenous Treatment Beyond 3 Hours: Pooled Analysis of Initial IV TPA Trials (Lancet 2004) <ul><li>6 trials, 4 with > 3h data </li></ul><ul><ul><li>ECASS 1, ECASS 2 </li></ul></ul><ul><ul><li>ATLANTIS A, ATLANTIS B </li></ul></ul><ul><ul><li>NINDS Trial 1, NINDs Trial 2 </li></ul></ul><ul><li>2775 patients </li></ul><ul><li>OR favorable outcome </li></ul><ul><ul><li>Time (hrs) OR </li></ul></ul><ul><ul><li>1.0-1.5 2.8* </li></ul></ul><ul><ul><li>1.5-3.0 1.6* </li></ul></ul><ul><ul><li>3.0-4.5 1.4* </li></ul></ul><ul><ul><li>4.5-6.0 1.2 </li></ul></ul>
    36. 38. Intravenous TPA in the 3-4.5 Hour Window <ul><li>Outcome NNTB </li></ul><ul><li>Normal/Near Normal 14 </li></ul><ul><li>Improved 7.1 </li></ul><ul><li>For every 100 patients treated with tPA, </li></ul><ul><li>16 benefit, 3 harmed </li></ul><ul><li>--Saver et al, Neurology (submitted) </li></ul>
    37. 39. Using tPA in Routine Clinical Practice <ul><li>Overall only about 3%-4% of stroke patients receive tPA — mostly due to time delays </li></ul><ul><li>Efficacy similar to NINDS trial </li></ul><ul><li>Rate of ICH: 4%-6% </li></ul><ul><li>Risk of ICH increases with protocol violations </li></ul><ul><ul><li>Time >3 hours </li></ul></ul><ul><ul><li>Poor blood pressure control </li></ul></ul><ul><ul><li>Using prohibited agents </li></ul></ul><ul><ul><li>Wrong dose </li></ul></ul><ul><ul><ul><li>0.9 mg/kg </li></ul></ul></ul><ul><ul><ul><li>Maximum dose: 90 mg </li></ul></ul></ul><ul><ul><li>Elevated blood sugar also increases risk </li></ul></ul>Adams HP, et al. ASA Stroke Council. Stroke. 2003;34:1056-1083.
    38. 40. Monitoring the Stroke TPA Patient <ul><li>Blood pressure </li></ul><ul><ul><li>Goal ≤ 180/105 x 24 hours </li></ul></ul><ul><li>Monitor for complications </li></ul><ul><ul><li>Bleeding complications </li></ul></ul><ul><ul><ul><li>Symptomatic intracranial (2-3%) </li></ul></ul></ul><ul><ul><ul><ul><li>Headache, sudden BP increase, increased focal deficits, N/V, decreased LOC </li></ul></ul></ul></ul><ul><ul><ul><li>Systemic (Uncommon) - Gums, IV sites </li></ul></ul></ul><ul><ul><li>Orolingual angioedema (1-2%) </li></ul></ul><ul><ul><ul><li>Typically mild, transient, contralateral </li></ul></ul></ul><ul><ul><ul><li>Rx: benadryl, H2 blockers </li></ul></ul></ul><ul><ul><ul><li>Severe: steroids, epinephrine, intubation </li></ul></ul></ul>
    39. 41. Intra-arterial Recanalization Therapies
    40. 42. Intra-arterial Recanalization Approaches Thrombolytics Mechanical Techniques
    41. 43. Mechanical Endovascular Recanalization Devices in Acute Stroke <ul><li>Endovascular Thrombectomy </li></ul><ul><ul><li>Clot Retrieval Devices </li></ul></ul><ul><ul><ul><li>Merci Retriever </li></ul></ul></ul><ul><ul><ul><li>Phenox Retriever </li></ul></ul></ul><ul><ul><ul><li>Catch Device </li></ul></ul></ul><ul><ul><ul><li>Microsnare </li></ul></ul></ul><ul><ul><li>Suction Thrombectomy </li></ul></ul><ul><ul><ul><li>Syringe suction </li></ul></ul></ul><ul><ul><ul><li>Angiojet/Neurojet </li></ul></ul></ul><ul><ul><ul><li>Penumbra system </li></ul></ul></ul><ul><li>Mechanical Disruption </li></ul><ul><ul><li>Laser </li></ul></ul><ul><ul><ul><li>EPAR Device </li></ul></ul></ul><ul><ul><ul><li>LaTIS Device </li></ul></ul></ul><ul><ul><li>Primary Angioplasty/Stenting </li></ul></ul><ul><ul><li>Augmented Fibrinolysis </li></ul></ul><ul><ul><ul><li>Microwire passage </li></ul></ul></ul><ul><ul><ul><li>Endovascular ultrasound </li></ul></ul></ul>
    42. 44. Merci Retriever Devices X5, X6 Five helical loops, conical, X6 more resistant to stretching L5, L6 Helical loops, cylindrical, arcading filaments K-mini Helical loops with counter-twist, cylindrical, smaller diameter V-Series 7 helical loops (2 small distal loops), filaments, variable spring rate
    43. 45. Merci ® Retrieval System Balloon Guide Flexible, helical shaped, tapered tip made of nitinol wire Merci = mechanical embolus retrieval in cerebral ischemia
    44. 46. Find it, Engage it, Retrieve it
    45. 47. UCLA – MCA Occlusion 30-Year-Old Female – Baseline NIHSS 24 Symptom Onset to Final Angiogram – 5:37 NIHSS 24 hours 1 mRS 5 days post 0 30 days post 0 90 day post 0
    46. 50. Penumbra System: Registration Trial <ul><li>125 patients </li></ul><ul><li>NIHSS 17.6 </li></ul><ul><li>Recanalization (TIMI 2-3) </li></ul><ul><ul><li>Reported “82%” </li></ul></ul><ul><ul><li>Likely lower using standard ratings </li></ul></ul><ul><li>SICH 11.2% </li></ul><ul><li>Nondisabled (mRS 0-2) outcome 90 d 25% </li></ul><ul><li>Death 90 d 33% </li></ul>
    47. 51. Penumbral Imaging and Mechanical Embolectomy <ul><li>23 patients treated with Concentric Clot Retriever </li></ul><ul><li>Mean age 62 (range 28-90) </li></ul><ul><li>Median pretreatment NIHSSS 19 (range 10-26) </li></ul><ul><li>14 patients (54%) demonstrated pretreatment penumbral MRI pattern* </li></ul><ul><li>Partial or complete recanalization 70% </li></ul><ul><li>*(PWI - DWI diameter  20%) </li></ul>
    48. 52. Multimodal Diffusion-Perfusion MRI Tissue Status Bioenergetic Compromise Perfusion Status Hemodynamic Compromise Vessel Status Occlusions or Stenoses DWI PWI MRA
    49. 53. Multimodal CT Imaging Tissue Status Bioenergetic Compromise Perfusion Status Hemodynamic Compromise Vessel Status Occlusions or Stenoses CT PCT CTA
    50. 54. Intracerebral Hemorrhage Therapies BP control Ventriculostomy for Hydrocephalus Hemorrhage evacuation Cerebellar, cortical
    51. 55. Subarachnoid Hemorrhage Therapies                                                                                                                                                                                                                                                                                                                                     With this approach, surgery is done to clip the aneurysm. First a window is made in the skull. This is called a   <ul><li>Prevent rebleed </li></ul><ul><ul><li>Aneurysm coiling, clipping </li></ul></ul><ul><li>Ventriculostomy for hydrocephalus </li></ul><ul><li>Treated delayed vasospasm </li></ul>
    52. 56. History <ul><li>83 yo RH woman </li></ul><ul><li>7:05 PM – acute onset wobbling gait, slurred speech, right body weakness </li></ul><ul><li>911 called </li></ul>
    53. 57. EMS Evaluation <ul><li>Pulse 75, BP 170/75 </li></ul><ul><li>Right weakness </li></ul><ul><li>LAPSS positive for stroke </li></ul><ul><li>Neurologist by phone confirms history and orders start of FAST-MAG neuroprotective trial study agent in ambulance </li></ul>
    54. 58. Primary Stroke Center <ul><li>BP 172/70 </li></ul><ul><li>Aphasic – says “hi” repetitively </li></ul><ul><li>Severe right hemiparesis </li></ul><ul><li>NIHSS 24 </li></ul><ul><li>H/o HTN, hypercholesterolemia </li></ul><ul><li>Medications: Pravastatin, carvedilol, losartan, pantoprazole, levothyroxine </li></ul>
    55. 59. Noncontrast CT – L MCA hyperdense sign
    56. 60. Noncontrast CT – L MCA hyperdense sign
    57. 61. Primary Stroke Center <ul><li>IV TPA 0.9 mg/kg </li></ul><ul><li>Transfer to UCLA CSC </li></ul>
    58. 62. <ul><li>An 83 yo RH woman with sudden speech difficulty and right body weakness </li></ul><ul><li> Last known well @ 7:05 PM </li></ul><ul><li> 911 call @ 7 min </li></ul><ul><li>Field NP study drug @ 33 min </li></ul><ul><li>PSC ED arrival @ 49 min </li></ul><ul><li>IV TPA @ 1 hr 54 min </li></ul>
    59. 67. DWI PWI MRA
    60. 76. DWI PWI Day 5 Pre
    61. 77. <ul><li>An 83 yo RH woman with sudden speech difficulty and right body weakness </li></ul><ul><li> Last known well @ 5:00 PM </li></ul><ul><li> 911 call @ 7 min </li></ul><ul><li>Field NP study drug @ 33 min </li></ul><ul><li>PSC ED arrival @ 49 min </li></ul><ul><li>IV TPA @ 1 hr 54 min </li></ul><ul><li>CSC ED arrival @ 3 hr 17 min </li></ul><ul><li>Multimodal MRI @ 3 hr 39 min </li></ul><ul><li>1 st Merci pass @ 4 hr 22 min </li></ul><ul><li>Recanalization @ 4 hr 51 min </li></ul>
    62. 78. 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
    63. 79. • 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
    64. 80. • 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
    65. 81. 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
    66. 82. 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
    67. 83. 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
    68. 84. Stroke mimics cortical vs noncortical stroke cranial nerves awake breathing Stroke & The EMS Response
    69. 85. 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
    70. 86. 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
    71. 87. 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
    72. 88. Mimics: Encephalopathy Endocrine Dissection Endocarditis MRI What do the Neurologist want? What is the right risk stratification test noncontrast ct Stroke & The EMS Response
    73. 89. 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
    74. 90. CT…about the vasculature, can we see where the obstruction is CTA vs MRA MR…. Stroke & The EMS Response
    75. 91. 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
    76. 92. Background & Importance <ul><li>Stroke remains the third leading cause of death and a leading cause of long-term disability among Americans. </li></ul><ul><li>Approximately 700,000 individuals suffer a new or recurrent stroke each year. </li></ul>
    77. 93. 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
    78. 94. 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
    79. 95. 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
    80. 96. 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
    81. 97. 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
    82. 98. 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
    83. 99. Important Role of EMS & EMSS in optimizing stroke care <ul><li>EMS - Emergency Medical Services </li></ul><ul><ul><li>Full scope of pre-hospital services, including: </li></ul></ul><ul><ul><ul><li>9-1-1 activation and dispatch </li></ul></ul></ul><ul><ul><ul><li>emergency medical response </li></ul></ul></ul><ul><ul><ul><li>triage & stabilization in the field </li></ul></ul></ul><ul><ul><ul><li>transport by ground or air ambulance to a hospital or between facilities. </li></ul></ul></ul><ul><li>EMSS - Emergency Medical Service Systems </li></ul><ul><ul><li>Delivery systems organized on a local, regional, statewide, or nationwide basis using public or private resources. </li></ul></ul><ul><ul><li>The successful integration of one (and often multiple) EMSS is critical to ensuring the effectiveness of a stroke system of care. </li></ul></ul>
    84. 100. Recommendation One <ul><li>Stroke Systems should Require Appropriate Processes that ensure Rapid access to EMS for Acute Stroke Patients </li></ul><ul><ul><li>Ensure: </li></ul></ul><ul><ul><li>Access to enhanced landline & wireless 9-1-1 (W-E911). </li></ul></ul><ul><ul><li>EMS communicators recognize stroke signs & symptoms reported by callers. </li></ul></ul><ul><ul><li>Stroke patients are dispatched at the highest level of care available in the shortest time possible. </li></ul></ul><ul><ul><ul><li>ensuring use of emergency medical dispatch guidelines reflecting the current ASA/AHA guidelines. </li></ul></ul></ul>
    85. 101. Measurement Parameters (cont.) <ul><li>100% of 911 call centers use dispatch guidelines that prioritize stroke patients at the highest care level available. </li></ul><ul><li>Ensure that the time period between the receipt of the call and the dispatch of the response team is less than 90 seconds for 90% of calls involving stroke. </li></ul><ul><li>EMS communicators correctly identify a max % of callers experiencing stroke and dispatch EMS responders at the highest priority for these calls. </li></ul>
    86. 102. Recommendation Two <ul><li>For EMS responders, EMSS should use protocols, tools and training that meet current AHA/ASA guidelines for stroke care . </li></ul><ul><ul><li>Identify acute stroke patients rapidly by ensuring that EMS responders use validated screening algorithms effectively. </li></ul></ul><ul><ul><li>Establish goals for the EMSS response time for suspected stroke patients. The EMSS response time comprises the dispatch time, the turnout time, and the travel time. </li></ul></ul>
    87. 103. Measurement Parameters <ul><li>Ensure that 100% of EMSS use validated pre-hospital stroke screening tools to identify stroke patients. </li></ul><ul><li>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. </li></ul><ul><li>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). </li></ul><ul><ul><li>These data should be used to develop and adjust EMS responder training and protocols for the use of stroke screening forms. </li></ul></ul>
    88. 104. Measurement Parameters (cont.) <ul><li>Ensure EMSS response time is <9 minutes for at least 90% of acute stroke patients. </li></ul><ul><ul><li>Response time reflects the amount of time elapsed from the receipt of the call by the dispatch entity to the arrival on the scene of a properly equipped and staffed ambulance. </li></ul></ul><ul><li>Ensure that dispatch time is <1 minute, turnout time is <1 minute, and travel time is equivalent to trauma or acute myocardial infarction calls. </li></ul><ul><li>Ensure that the on-scene time is <15 minutes (unless extenuating circumstances or extrication difficulties). </li></ul><ul><li>Report all times using the fractile method (e.g. 90th percentile). For accurate data collection, all clocks capturing these times in the EMSS should be synchronized. </li></ul>
    89. 105. Potential Solution Samples <ul><li>Integrate EMS within ED stroke care & CQI activities for stroke. </li></ul><ul><li>Collaborate with state or local coalition of healthcare providers, experts, and regulators to develop improved EMSS processes & protocol enhancements. </li></ul><ul><li>Advocate for funding of professional education training for pre-hospital providers. </li></ul><ul><li>Collaborate with state or local coalition of healthcare providers, experts, and regulators to develop improved EMSS point-of-entry (transport destination) plans. </li></ul>
    90. 106. Measurement Parameters <ul><li>Ensure pre-arrival notification of hospitals is provided for all suspected stroke patients. </li></ul><ul><li>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. </li></ul><ul><li>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. </li></ul>
    91. 107. Measurement Parameters (cont.) <ul><li>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. </li></ul><ul><li>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). </li></ul>
    92. 108. Measurement Parameters (cont.) <ul><li>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. </li></ul><ul><li>Implement continuous monitoring of standard measures as part of the CQI process including: </li></ul><ul><ul><li>stroke history obtained </li></ul></ul><ul><ul><li>stroke assessment using validated screening tools </li></ul></ul><ul><ul><li>stroke history checklists that document eligibility for acute therapies properly completed </li></ul></ul><ul><ul><li>whether on-scene time was appropriate </li></ul></ul><ul><ul><li>whether the hospital transport destination decision was appropriate. </li></ul></ul>
    93. 109. Recommendation Four <ul><li>Patients should be transported to the nearest Stroke Center for evaluation & care if located within a reasonable transport distance & transport time. </li></ul><ul><ul><li>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. </li></ul></ul>
    94. 110. Recommendation Four (cont.) <ul><ul><li>Assess stroke patient eligibility for acute stroke therapies using a stroke history checklist or algorithm consistent with AHA/ASA guidelines. </li></ul></ul><ul><ul><li>Establish EMSS transport destination protocols that reflect optimal patient care with transport to a certified Stroke Center. </li></ul></ul><ul><ul><li>Establish protocols for the transfer of stroke patients from non-stroke center hospitals to certified Stroke Centers. </li></ul></ul><ul><ul><li>Transport stroke patients to stroke-ready hospitals regardless of the patients’ geopolitical location. </li></ul></ul>
    95. 111. Potential Solution Samples <ul><li>Ensure the use of stroke triage & transport protocols that reflect current recommendations for assessing stroke patients for eligibility for acute stroke therapies, including thrombolytic therapy. </li></ul><ul><li>Ensure that EMS responders have adequate education & training to screen patients accurately for acute therapies. </li></ul><ul><li>Advocate for a statewide plan for EMS protocols to ensure stroke patients receive high-priority care at recognized certified Stroke Centers. </li></ul><ul><li>Advocate for the development of a public statewide hospital identification system identifying hospitals that meet the criteria for Primary or Comprehensive Stroke Centers. </li></ul>
    96. 112. Measurement Parameters <ul><li>Ensure that stroke history checklists are completed for at least 90% of all suspected stroke patients. </li></ul><ul><li>Ensure that the amount of time EMS responders spend collecting the clinical history at the scene is < 10 minutes. Total on-scene time should not exceed 15 minutes. </li></ul><ul><li>Work within existing coalitions with representatives of the emergency medicine, political, and pre-hospital communities. </li></ul><ul><li>Establish model policies & regulations for patient transportation protocols that are consistent with AHA/ASA guidelines and can be adopted at state, regional, & local levels. </li></ul>
    97. 113. THANK YOU <ul><li>Questions? </li></ul><ul><li>You can contact me at: </li></ul><ul><li>[email_address] </li></ul><ul><li>1-951-544-5433 </li></ul>