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Stroke Management Chemeketa Community College Peggy Andrews.

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Presentation on theme: "Stroke Management Chemeketa Community College Peggy Andrews."— Presentation transcript:

1 Stroke Management Chemeketa Community College Peggy Andrews

2 2 The "Golden Hour" of Acute Ischemic Stroke  > A Look at Current Stroke Treatment What's Changed in 2000? “EMS systems should implement a prehospital stroke protocol to evaluate and rapidly identify patients who may benefit from fibrinolytic therapy, similar to the protocol for chest pain patients” (Class IIb). “Patients who may be candidates for fibrinolytic therapy should be transported to hospitals identified as capable of providing acute stroke care, including 24-hours availability of CT scan and interpretation.” (Class IIb). “Stroke presenting with 3 hours should be triaged on an emergent basis with urgency similar to acute ST-elevation myocardial infarction.”

3 3 Acute Stroke Where are we today?  Public poorly informed  Response time too slow  Presentation too late  Hospitals ill prepared

4 4 Models for the "Golden Hour" Trauma  Times studied/defined  Centralized trauma center system  Mortality Low AMI  Similar door-drug/groin benchmarks for reperfusion  Decentralized system  Treatment data strongly supports

5 5 AMI - example The paradigm has shifted  Chest pain - patients know to call 911  Rapid access to EMS –Early recognition  ECG  S/S  Rapid Transport  Team, protocols, drugs in the ED  “Door to Drug” in 30 Minutes

6 6 Why Care? Impact of Stroke  3rd leading cause of death in U.S.  Leading cause of adult disability  750,000 new cases/year in U.S. –150,000 deaths/year –1/3 Under age 65

7 7 Forces of Change 1.Public expectations –Aware of “Draino for the Braino” 2.Medical - legal pressures 3.Managed care cost concerns - Long term vs Short Term 4.New/better treatments 5.Physicians‘ willing/able to treat - Evidenced based medicine

8 8 Organized Stroke Care Saves Lives  21% reduction in early mortality  18% reduction in 12 month mortality  Decreased length of hospital stay  Decreased need for institutional care Source: Jorgenson, Stroke, 1994 Jorgenson, Stroke, 1994Jorgenson, Stroke, 1994

9 9 What are we talking about here?  Ischemic Stroke (84%)  Hemorrhagic Stroke (16%) –These have very different needs –Philosophy in treatment takes a different direction  Traumatic Brain Injury (TBI) –Not talking about today – PHTLS

10 10 Ischemic Stroke  HYPOperfusion  Embolic (20% had a-fib)  Thromboembolic  GOAL of Treatment –1. Restore Circulation –2. Stop Ischemia

11 11 What is this rt-PA  Recombinant Tissue Plasminogen Activator  Review of clotting cascade –Collagen Exposed  Vessel injury  Damage  Long term wear  Embolus –Clotting factors aggregate –Fibrin Repair (Bond-O) –FIBRINOLYSIS

12 12 Intra-venous fibrinolysis for acute ISCHEMIC stroke  Class I IV - t-PA within 3 hours of onset  Class Indeterminate IV - t-PA between 3 and 6 hours of onset

13 13 Intra-arterial thrombolysis  TPA, Urokinase, Anti-platelet –All experimental in the 3-6 hour window –Lower doses, delivered right to clot  Snare devices –Reach in and grab it –Vessels sometimes too small to get into  Mechanical devices –Angiojet – rotating blade –Ultrasound –Lasers

14 14 With rt-PA, considering 1,000 eligible patients:  Hospitalization costs = $1.7 million more  Rehabilitation costs = $1.4 million less  Nursing home costs = $4.8 million less  564 quality-adjusted life-years saved Source: Fagan, Neurology 1998Fagan, Neurology 1998

15 15 NIH National Symposium Recommendations  Door-to-MD:> 10 minutes  Door-to-Neurologic Expertise: > 15 minutes  Door-to-CT scan:> 25 minutes  Door-to-CT Interpretation: > 45 minutes  Door-to-Drug:(80% compliance) > 60 minutes  Door-to-Admission:> 3 hours

16 16 Stroke Chain of Survival & Recovery  Detection: Early recognition  Dispatch: Early EMS activation  Delivery: Transport & management  Door: ED triage  Data: ED evaluation & management  Decision: Specific therapies  Drug: Thrombolytic & future agents

17 17 Dispatch & Delivery: Transport & Management  ABC’s  Stroke recognition  Establish time of onset  Perform neurological evaluation  Check glucose  Early hospital notification  Rapid transport

18 18 Cincinnati Pre-Hospital Stroke Scale Facial Droop  Normal: Both sides of face move equally  Abnormal: One side of face does not move at all

19 19 Cincinnati Pre-Hospital Stroke Scale Arm Drift  Normal: Both arms move equally or not at all  Abnormal: One arm drifts compared to the other

20 20 Cincinnati Pre-Hospital Stroke Scale Speech  Normal: Patient uses correct words without slurring  Abnormal: Slurred or inappropriate words or mute

21 21 NIH Stroke Scale ItemDescriptionRange 1aLOC 0 – 3 1b LOC Questions 0 – 2 1c LOC Commands 0 – 2 2 Best Gaze 0 – 2 3 Best Visual 0 – 3 4 Facial Palsy 0 – 3 5 Motor Arm Left 0 – 4 6 Motor Arm Right 0 – 4 7 Motor Leg Left 0 – 4 8 Motor Leg Right 0 – 4 9 Limb Ataxia 0 – 2 10Sensory 11Neglect 12Dysarthria 13 Best Language 0 – 3

22 22 12 cranial nerves check  Ismell  IIvision  IIIpupil constriction, eye movement  IVdownward gaze  Vfacial sensation  VIlateral eye movement  VIItaste, frown, smile  VIII hearing, balance  IXtaste, gag, swallowing  Xvoice  XIshoulder shrug  XIItongue movement

23 23 Preparation Know your stroke team before you need them  Check glucose  Two large IV lines  Oxygen as needed  Cardiac monitor  Continuous pulse-ox  Stat non-contrast CT scan  ECG  CXR  Get rt-PA > Prepare to mix > Have pharmacy alerted  Discuss options with patient and family  Contact primary care provider

24 24 American Heart Association Recommendations Oxygen  Use to correct hypoxia  Suggestion that supernormal levels may hurt > one year survival 69% 3L NC vs 73% control Glucose  Maintain euglycemia  Treat glucose > 300 mg/dl with insulin Source: Rønning, Stroke 1999Rønning, Stroke 1999

25 25 True Time of Onset How normal were they?  What are they like at baseline?  Who saw them last?  Clearly no symptoms? Times of reference  Television  The time the basketball game started

26 26 Stroke Risk Factors Modifiable risk factors  High blood pressure  Cigarette smoking  Transient ischemic attacks  Heart disease  Diabetes mellitus  Hypercoagulopathy  Carotid stenosis –Bruits  Other Non-modifiable risk factors  Age  Gender  Race  Prior stroke  Heredity

27 27 Differential Diagnosis  Intracerebral hemorrhage  Hypoglycemia / Hyperglycemia  Seizure  Migraine headache  Hypertensive crisis  Epidural / Subdural  Meningitis / Encephalitis / Brain abscess  Tumor

28 28 What are the Options? No thrombolytics  Nothing  Aspirin  Heparin Intravenous rt-PA Other  Intra-arterial thrombolytics  Investigative procedure

29 29 Exclusions to Thrombolytics  Bleeding concerns –Stroke/head trauma in 3 mos –Major surgery<14 days –Hx of intracranial hemorrhage  Seizures at the onset of stroke –SBP > 185 mm Hg –DBP > 110 mm Hg –Symptoms suggestive of hemorrhage –GI hemorrhage within 21 days –Urinary tract hemorrhage within 21 days –Arterial puncture at non- compressible site < 7 days –Rx anticoagulants  Possibly not indicated or wrong diagnosis –Rapidly improving or minor symptoms –Glucose 400 mg/dl  Possible Setup for DIC/other metabolic disorders –Heparin within 48 hours –PTT High –PT High –INR High –Platelet count low

30 30 Let’s talk about blood pressure  MAP – Mean Arterial Pressure (70-90 Normal)  ICP – Intracranial Pressure –Normally about 0-15mmHg –>20 = Bad  CPP – Cerebral Perfusion Pressure –CPP=MAP-ICP –CPP must be above 70mmHg for cerebral perfusion  You do the math

31 31 IF CPP=MAP-ICP  And we know that the body autoregulates pressures to preserve itself –80-90% of ischemic strokes present with elevated BP –ICP may have risen because of Edema

32 32 Studied: –Multicenter Study – 372 patients –Compared Neuro outcome vs BP changes in first 24 hours –If Diastolic BP decreased by >25% (even once)  Poorer outcomes regardless of baseline diastolic BP levels, Stroke location or use of HTN agents –NO EVIDENCE THAT LOWERING BP HELPS  Remember we’re still talking about ischemic strokes –FAIR Evidence that it harms

33 33 BP Treated in extreme cases “Gentle” management if thrombolytic candidate:  SBP > 180 mm Hg  DBP > 110 mm Hg Choices:  Labetalol  Enalapril  Nitropaste

34 34 Treatment Considerations: Who will benefit from rt-PA?  Patient age  Co-morbid factors –Medical history  Risks of treatment –Odds of Presenting  Benefits of Treatment –Odds of surviving

35 35 Treatment considerations (cont’d)  Time from onset (Remember 3 hours)  Stroke severity  Stroke subtype –Data driven here too  CT findings –Assymetry = Bad –Density image – Tissue/fluid ratio  Charcoal=Normal  Dark = Higher density (more tissue than fluid) –Ischemia  Light = Lower density (More fluid than tissue) –Hemorrhage –Tumor

36 36 Which one is which?

37 37 Factors Associated with Increased Risk of ICH  Treatment initiated > 3 hours  Increased thrombolytic dose  Elevated blood pressure  NIHSS > 20 *  Acute hypodensity or mass effect * * Even though increased r/o ICH, still with benefit vs. placebo

38 38 Stroke Treatment – Aspirin  Two important trials: > International Stroke Trial > Chinese Acute Stroke Trial  Combined analysis (n=40,090)  Death / nonfatal strokes reduced 11%  Don’t forget to check swallowing  Local protocol driven

39 39 Stroke Treatment – Heparinoids  Decreased recurrent ischemic strokes  Increased hemorrhagic events  No net stroke benefit

40 40 The "Golden Hour" of Acute Ischemic Stroke > Case Study  History:  A 61 year old male, with acute aphasia, right facial droop, and right sided weakness.

41 41 12:30 Sudden onset while working in yard. 12:45 Family calls :05 Advanced squad evaluates neurologic deficits and glucose. 13:15 Squad notifies receiving hospital of possible stroke patient 13:30 ED arrival. Initial evaluation by E.D. physician. 13:45 Stroke Team arrives. NIHSS :00 CT scan performed. 14:15 Discuss with family and PMD. 14:20 Labs back: gluc 97. BP remains 150/70’s. 14:20 CT reading back. No hemorrhage or early signs of ischemia

42 42

43 43 14:25 Checklist done. No exclusion criteria met. 14:30 Decision time. 14:35 IV rt-PA given. 0.9 mg/kg total > 10% bolus - 9 mg > 90% over 1 hr - 81 mg 15:45 Patient goes to ICU. Report personally given to ICU staff. 15:50 Pathway actions begin (HOB, BP parameters, aspiration precautions).

44 44 24 Hour Follow-up  A 61 year old male, with acute stroke, treated with rt-PA.  Repeat NIHSS = 3:  VF intact  No gaze palsy  Mild facial palsy  Mild right arm drift  Mild dysarthria

45 45 Hemorrhagic Stroke  Treatment Goals – (Different) –1. Reduce the risk of re-bleed –2. Reduce risk of continued bleeding

46 46 Hemorrhagic Stroke (16%)  Bleeding into or surrounding the brain  Intracerebral Hemorrhage (ICH) –HTN –Tumor/Lesions –Venous sinus thrombosis  Drains from the dura mater –Amyloid angiopathy  Starch-like deposits on vessel walls- precursor

47 47 Hemorrhagic Stroke (16%)  Bleeding into or surrounding the brain  Sub-arachnoid hemorrhage (SAH) –Blood in arachnoid space, basal cisterns & often intraventricular  Aneurysm rupture  Trauma  Arteriovenous malformation (AVM)

48 48 Some Skull Ground Rules  Monroe-Kellie Hypothesis –Intracranial space/volume constant –Three components = ICP  CSF – 100mL –Production/absorption is pressure driven  Blood – 150mL –Here lies the problem  Brain – 1250mL (or grams) –Relatively constant (IS H 2 O minimally displaceable)

49 49 Head Bleeds  Still assuming a closed system (non-trauma)  ICP will rise  BP will rise –Remember autoregulation (compensatory)  If SBP>230 & DBP > 120 –Sodium Nitroprusside 0.5mcg/kg/min  If SBP>180 & DBP >105 –Labetolol 10mg/1-2min – Double q10 to 300mg  If Hypertensive, but not extremely high –LEAVE IT ALONE

50 50 Benefits of playing with BP  Decrease Edema  Limit size of damaged area  Limit further vascular damage  Might actually need a fluid bolus –1 Hypotensive episode-mortality 30+ %

51 51 Risks of playing with BP  TOO MUCH  TOO FAST –Can extend stroke by eliminating tamponade –Expose patients to medication reactions  Goal –SBP < 160 –DBP < 100  Sometimes use a 20% of original rule

52 52 Respiratory Management  Intubate patients with GCS < 8  Paralyze & Heavily Sedate –11 th commandment  Causes of Increased ICP –Gagging –Puking –Stress –Respiratory distress  Cause increased intra-thoracic pressure  Decreases cerebral drainage

53 53 Respiratory Management  Post-intubation – Use LA paralytic  Watch BP Carefully for hypotension

54 54 Respiratory Management  Hyper-oxygenate  DO NOT hyperventilate –CO 2 is POTENT vasodilator –Hypocarbia causes cerebral vasoconstriction  Vasoconstriction causes edema  ICP’s may rise  CPP will drop  Loss of autoregulation … Brain death

55 55 Adjuncts  SpO 2 Monitoring (Volume) –Bag to keep sat’s at % –(This might be VERY slow) –5-7mL/kg  CO 2 Monitoring (Rate) –Bag slow enough to keep EtCO 2   (40ish is normal)

56 56 Other treatments considered  Osmotic Diuretics –Mannitol (comes in and out of favor)  Anticonvulsant’s –Prevent seizures  Anti-emetics  May operate on bleeders –Often too late by the time it is diagnosed

57 57 Questions

58 58 Some pictures, Just for fun

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