1. Melissa Duchene, rn-stroke program administrator
Trends in stroke care
Melissa Duchene, rn-stroke program administrator
Jan baker-apn-bc

2. statistics 5th leading cause of death in the united states
80% of strokes can be prevented
About 795,000 people have a stroke every year
Every 40 seconds someone in the us is having a stroke
37% of all Americans can not accurately identify even one warning sign of a stroke
Stroke is the leading cause of serious long term disability with total cost estimated at over 34 billion
Stroke kills almost 130,000 Americans every year ( 1out of 20 deaths)
Source: American Heart association: heart disease and stroke statistics-2015 update

3. Two types of stroke Ischemic (Blockage) 87%
Caused by a blockage in the blood vessels to
The brain

4. Ischemic strokes:
Thrombus: a blood clot forms at a fatty deposit
Source: American Heart association
Embolus: a traveling particle, usually a blood clot, that gets stuck in a blood vessel.

5. Two types of strokes cont.
Hemorrhagic (Bleeding) 13%
Caused by a burst or leaking blood vessels in
the brain

6. Hemorrhagic stroke:
Aneurysms: ballooning of a weakened spot of a blood vessel
Arteriovenous malformations: a cluster of abnormal blood vessels ( avms)

7. Two types of hemorrhagic strokes
Intraparenchymal (within the brain tissue, also know as intracerebral) Hemorrhage: A vessel bursts and leaks blood into the tissue of the brain
Subarachnoid Hemorrhage: this occurs when a vessel near the surface of the brain bursts and leaks blood into the outside portion of the brain, between the skull and the brain

8. tia transient ischemic attack
Blood flow to arteries is briefly blocked symptoms are temporary
A Tia is a Warning that a stroke may happen
You are 9.5 times more likely to have a stroke if you have had a tia
A tia is a medical emergency
Patients that have had a tia fail to report them to healthcare providers
Approximately 200,000 to 500,000 tia’s are reported in the us EVERY YEAR

9. Why is the Ems role so important ?
TREATMENT STARTS RIGHT AWAY
Rapid transport to nearest stroke center
PRE-NOTIFICATION TO THE HOSPITAL
PATIENT ARRIVES TO ED faster FOR QUICKER TREATMENT
TRIAGE TO STROKE CENTERS FOR APPROPRIATE TREATMENT
Ems can bypass hospital without stroke resources
Obtain blood glucose level
Establish a last known well time/symptom onset –very important
Source :genentech stroke4ems

10. Three types of stroke hospitals
1-Stroke ready
2-Primary stroke center
3-Comprehensive stroke center
Source: the joint commission; facts about joint commission stroke certification

11. 1-Stroke ready
Provide timely stroke care but can not meet all the needs to be certified( drip & ship)
have 24/7 access to stroke expertise (in person or telemedicine)
Have transfer agreements with other facilities established
Collect and submit data
Have stroke protocols
Qualified medical staff that are trained in stroke care
Diagnostic imaging/laboratory testing capabilities

12. 2-primary stroke center
stabilize and treat acute stroke patient
use standardized methods of delivering care
Administer IV thrombolytics (tpa) if needed
demonstrate applications of and compliance with clinical practice guidelines
Stroke data and process improvements
Neurosurgical expertise available
protocols

13. 3-comprehensive stroke center
Significant resources in infrastructure, staff and training to provide state- of- the -art care
complex stroke patients
coils and stents to the brain and specialized staff available
advanced intervention capabilities; such as coiling, surgical clipping and iv tpa
continuous research plan
Source: the joint commission.org 2016

14. Treatment for stroke patients

15. Stroke treatments IV tPA IA (intra-arterial) tpa Thrombectomy:
penumbra-suction like device
solitaire-stent retriever

16. Iv tpa (alteplase) Tissue plasminogen activator
Gold standard for treatment
Weight based medication
Works by dissolving the clot in return improving blood flow
Given with onset of symptoms of 0-3hours ( may give up to 4.5 hours in some cases)
Is currently the only thrombolytic

17. Intra –arterial tpa This is given is smaller doses
Patients that do not qualify for iv tpa
Given in cath lab or ir suite
Accessed through the groin similar to cardiac catheterization
Given up to 6 hours of symptom onset

18. endovascular procedures
Mechanical thrombectomy –
trained physicians remove the blood clot by deploying a stent retriever device to the area of blockage in the brain. The physicians thread the device through an artery in your groin with a catheter, the stent opens up and grabs the clot. The clot retrieving stent is then removed. They can also use a suction device.

19. endovascular procedures
Solitaire: stent retrieval device used to remove clot
Penumbra- Suction like device used to remove clot.

20. telemedicine
This is primarily used in rural hospitals where they have limited neuro expertise available
Use smart phones, computers, ipads and digital video to connect to physicians
Uses teleconferencing to connect stroke patients with neurologists that are off site. Allowing them to examine and interpret brain scan results, there by helping to make treatment decisions

22. Risk factors Modifiable:
High Blood pressure
Diabetes
Smoking/alcohol usage
Sedentary lifestyle
Coronary artery disease
Atrial fibrillation

23. Risk factor cont… Non-modifiable:
Age
Gender
Family history
Previous stroke or tia
race

24. Care expectations Hga1c level 48 hour telemetry monitoring
Lipid profile
Tee
Carotids
Follow up ct/cta/mri/mra
Npo until dysphagia screen
Physical/occupational therapy consult
Stroke education
Hga1c level
48 hour telemetry monitoring

26. references www.heart.org/idc/groups/heartpublic/@wcm/@fda/documents/
(2016)