1. Stroke 2006 Debate Optimizing ED Stroke Patient Care: Clinical Questions

2. Stroke 2006 Debate Thank you to AstraZeneca for their support of this stroke educational meeting

3. Stroke 2006 Debate Case Presentation 62 year-old professor has an apparent stroke while teaching at the local community college.62 year-old professor has an apparent stroke while teaching at the local community college. Contact to the local EMS base station occurs within 15 minutes of the onset of symptoms.Contact to the local EMS base station occurs within 15 minutes of the onset of symptoms. He arrives at the closest ED within 30 minutes of symptom onset.He arrives at the closest ED within 30 minutes of symptom onset.

4. Stroke 2006 Debate Case Presentation VS 178/80 RR 18 P 96 Temp 98.6VS 178/80 RR 18 P 96 Temp 98.6 Cardiopulmonary exam OKCardiopulmonary exam OK Mental Status OKMental Status OK Neurological ExamNeurological Exam Awake and alertAwake and alert R facial weaknessR facial weakness Slurred speechSlurred speech Right visual field neglectRight visual field neglect Unable to purposefully move RUE / RLEUnable to purposefully move RUE / RLE

5. Stroke 2006 Debate Question: TIA ED Visit Had this patient presented to the ED two weeks earlier with dizziness and numbness in his R upper extremity, what would be your approach?

6. Stroke 2006 Debate Question: TIA ED Visit A. A. I admit all TIA patients regardless of the severity of the symptoms.

7. Stroke 2006 Debate Question: TIA ED Visit B. I only admit those patients who have clear motor weakness or visual symptoms (amaurosis fugax) because of a greater stroke risk.

8. Stroke 2006 Debate Question: TIA ED Visit C. I might consider sending this patient home, but only if I have completed a cranial CE and an evaluation of the carotids (Doppler, CTA, MRA).

9. Stroke 2006 Debate Question: TIA ED Visit D. I would send this patient home with aspirin therapy and arrange that a physician complete a TIA work-up as an outpatient.

10. Stroke 2006 Debate Question: TIA ED Visit E. I don’t really have an opinion on what to do with this TIA patient, and so would depend on my neurologist for a disposition decision.

11. Stroke 2006 Debate Question: TIA ED Visit A. A. I admit all TIA patients. B. B. I only admit those patients who have clear motor weakness or visual symptoms. C. C. Send home after a cranial CT and a carotid evaluation. D. D. Send home, outpatient TIA workup. E. E. No opinion, ask the neurologist.

12. Stroke 2006 Debate Question: EMS Triage Regarding EMS triage, should this patient be:

13. Stroke 2006 Debate Question: EMS Triage A. A.Transported to the closest hospital?

14. Stroke 2006 Debate Question: EMS Triage B. Diverted to the closest primary stroke center?

15. Stroke 2006 Debate Question: EMS Triage C. Diverted to the closest tertiary center with 24/7 interventional radiology?

16. Stroke 2006 Debate Question: EMS Triage D. Diverted to the closest comprehensive stroke center?

17. Stroke 2006 Debate Question: EMS Triage A. A.Closest hospital B. B.Closest primary stroke center C. C.Closest 24/7 IR tertiary center D. D.Closest comprehensive stroke center

18. Stroke 2006 Debate Question: Inter-hospital Transfer If this patient is transported to the closest ED of a hospital with no specific stroke team or protocol, which of the following best describes circumstances when transfer to a tertiary or stroke center should take place for this stroke patient?

19. Stroke 2006 Debate Question: Inter-hospital Transfer A. A. There are no indications for inter-hospital transfer to take place.

20. Stroke 2006 Debate Question: Inter-hospital Transfer B. B. The patient should be transferred after IV tPA is administered.

21. Stroke 2006 Debate Question: Inter-hospital Transfer C. C. Transfer should take place only if IV tPA is not indicated and CNS intra-arterial thrombolytic therapy or thrombus removal is likely.

22. Stroke 2006 Debate Question: Inter-hospital Transfer D. Transfer should take place for all patients if the time from symptom onset is between three and ten hours in order to allow advanced diagnostics to be provided acutely.

23. Stroke 2006 Debate Question: Inter-hospital Transfer E. Transfer to a primary stroke center should take place for all stroke patients, regardless of the time of symptom onset, whether IV tPA has been provided, and whether an acute clot intervention is contemplated

24. Stroke 2006 Debate Question: Inter-hospital Transfer F. I have no idea when inter- hospital transfer should take place for patients such as this one.

25. Stroke 2006 Debate Question: Inter-hospital Transfer A. A.No indications B. B.After IV tPA is administered. C. C.IV tPA is not indicated and CNS intra-arterial thrombolytic therapy or thrombus removal is likely D.Symptoms 3-10 hours, diagnostics E.Transfer all stroke patients F.I have no idea

26. Stroke 2006 Debate Question: Use of the NIHSS Which of the following describes your views regarding the use of the NIHSS in evaluating stroke severity and the indications for various stroke therapies?

27. Stroke 2006 Debate Question: Use of the NIHSS A. A. Every emergency physician should know how to calculate the NIHSS for patients such as this one, since it is the standard of care for determining stroke severity and the need for any and all stroke therapies.

28. Stroke 2006 Debate Question: Use of the NIHSS B. It is obvious how severe this patient’s stroke is, and the need for all potential stroke therapies can be determined clinically without actually calculating the NIHSS.

29. Stroke 2006 Debate Question: Use of the NIHSS C. The NIHSS can be reliably estimated by determining symptom severity in four categories: motor, speech, mental status, and visual/neglect.

30. Stroke 2006 Debate Question: Use of the NIHSS D. The NIHSS is a research tool that can be calculated retrospectively as needed as long as the neurological exam in the ED is documented appropriately.

31. Stroke 2006 Debate Question: Use of the NIHSS E. When I am considering IV tPA, I just quickly calculate the NIHSS using Internet tools.

32. Stroke 2006 Debate Question: Use of the NIHSS F. What does NIHSS stand for, anyways?

33. Stroke 2006 Debate Question: Use of the NIHSS A. A.NIHSS is the standard of care B. B.Determine Rx clinically, no NIHSS C. C.Estimate NIHSS in 4 clinical areas D.Calculate retrospectively from exam E.Quickly calculate NIHSS with Internet F.What does NIHSS stand for?

34. Stroke 2006 Debate Question: Patient NIHSS What is the approximate NIHSS of this patient?What is the approximate NIHSS of this patient?  Awake and alert  R facial weakness  Slurred speech  Right visual field neglect  Unable to purposefully move his RUE / RLE

35. Stroke 2006 Debate Question: Patient NIHSS A. A.0-5 B. B.5-10 C. C.10-15 D.15-20 E.Greater than 20

36. Stroke 2006 Debate Question: Use of Scales Regarding the use of stroke outcome scales such as the Modified Rankin Scale (MRS) or the Barthel Index (BI), which of the following is your clinical approach?Regarding the use of stroke outcome scales such as the Modified Rankin Scale (MRS) or the Barthel Index (BI), which of the following is your clinical approach?

37. Stroke 2006 Debate Question: Use of Scales A. I use these scales in assessing stroke patient severity in the ED.

38. Stroke 2006 Debate Question: Use of Scales B. I understand the MRS and the BI, and I use them to help in assessing the effectiveness of new stroke therapies from published clinical trials.

39. Stroke 2006 Debate Question: Use of Scales C. I do not have any idea how these outcome scales are utilized, either in the ED or after hospital disposition.

40. Stroke 2006 Debate Question: Use of Scales D. These scales correlate with the NIHSS, making their use superfluous.

41. Stroke 2006 Debate Question: Use of Scales E. I have not ever heard of these scales, let alone use them.

42. Stroke 2006 Debate Question: Use of Scales A. A.I use these scales in the ED B.Scales assess the effectiveness of new stroke therapies C.No idea how these outcome scales are utilized D.Scales correlate with the NIHSS, making their use superfluous E.I have never heard of these stroke scales

43. Stroke 2006 Debate Question: Use of IV tPA This patient’s stroke is deemed to be moderate to severe in its severity and is a suitable candidate for thrombolytic therapy with IV tPA. Which of the following is your viewpoint regarding the use of IV tPA given the published efficacy data?This patient’s stroke is deemed to be moderate to severe in its severity and is a suitable candidate for thrombolytic therapy with IV tPA. Which of the following is your viewpoint regarding the use of IV tPA given the published efficacy data?

44. Stroke 2006 Debate Question: Use of IV tPA A. If IV tPA is indicated, I use it because the clinical data supports its use and I am adequately supported in its use.

45. Stroke 2006 Debate Question: Use of IV tPA B. Although I am not opposed to the use of tPA, I do not use it often because patients rarely meet the criteria for use in the ED.

46. Stroke 2006 Debate Question: Use of IV tPA C. I try not to use tPA because the published efficacy data does not adequately support its use and because I am not well supported to use it.

47. Stroke 2006 Debate Question: Use of IV tPA D. I simply am so concerned about the risk of a symptomatic ICH that I cannot bear to use this drug when treating stroke patients such as this one.

48. Stroke 2006 Debate Question: Use of IV tPA E. I leave the tPA use decision to the stroke team or neurology consultant.

49. Stroke 2006 Debate Question: Use of IV tPA A. A.Clinical data supports its use B.Patients rarely meet the criteria C.Published efficacy data does not adequately support its use D.Concerned about the risk of a symptomatic ICH E.Decided by the stroke team

50. Stroke 2006 Debate Question: Clinical Guidelines Regarding ischemic stroke patients, what is your understanding and use of clinical guidelines?Regarding ischemic stroke patients, what is your understanding and use of clinical guidelines?

51. Stroke 2006 Debate Question: Clinical Guidelines A. I am not aware of any clinical guidelines that direct my care of ischemic stroke patients.

52. Stroke 2006 Debate Question: Clinical Guidelines B. I am sure that there are guidelines that exist from organizations such as the American Stroke Association, but I do not use them because primarily my neurology consultants utilize these guidelines.

53. Stroke 2006 Debate Question: Clinical Guidelines C. I am familiar with guidelines that direct stroke patient care, and I refer to them on occasion in order to optimize my acute care.

54. Stroke 2006 Debate Question: Clinical Guidelines D. I follow clinical guidelines and protocols in my ED because our hospital has integrated them into clinical policies for the institution.

55. Stroke 2006 Debate Question: Clinical Guidelines E. I wish that there were guidelines that would direct my treatment of stroke complications such as elevated blood pressure.

56. Stroke 2006 Debate Question: Clinical Guidelines A. A.Not aware of any clinical guidelines. B.My neurology consultants utilize these guidelines. C.I refer to them on occasion. D.Our hospital has integrated them. E.I wish that there were guidelines.

57. Stroke 2006 Debate Question: Neuroprotection Regarding neuroprotection in acute ischemic stroke patients, what is your understanding of current optimal therapies?Regarding neuroprotection in acute ischemic stroke patients, what is your understanding of current optimal therapies?

58. Stroke 2006 Debate Question: Neuroprotection A. I am not aware of any specific neuroprotection therapies for ischemic stroke patients.

59. Stroke 2006 Debate Question: Neuroprotection B. I believe that the only useful therapies involve ASA use and blood pressure and glucose management in the majority of ischemic stroke patients.

60. Stroke 2006 Debate Question: Neuroprotection C. Besides BP and glucose control, I consider optimal cerebral blood flow to be another critical neuroprotectant, and I pursue aggressive thrombolysis and clot retrieval of the target vessel in order to achieve it.

61. Stroke 2006 Debate Question: Neuroprotection D. I am aware of the trials of specific neuroprotectants, and I utilize them in my clinical practice.

62. Stroke 2006 Debate Question: Neuroprotection E. I do not believe that neuroprotection is possible. Once the initial damage is done, there is no way to protect the infarct zone or ischemic penumbra.

63. Stroke 2006 Debate Question: Neuroprotection A. A.Not aware of any therapies. B.Only useful therapies involve ASA use and blood pressure and glucose management. C.Optimal cerebral blood flow is another critical neuroprotectant. D.I utilize them. E.I do not believe that neuroprotection is possible.

64. Stroke 2006 Debate Question: CT & LP in SAH What is your approach to the use of CT and LP in patients who present to your emergency department with headache and suspected SAH?What is your approach to the use of CT and LP in patients who present to your emergency department with headache and suspected SAH?

65. Stroke 2006 Debate Question: CT & LP in SAH A. A.I simply perform a lumbar puncture in all of these patients without a prior CT.

66. Stroke 2006 Debate Question: CT & LP in SAH B. After a negative non-contrast CT head, I perform an LP in nearly all of these suspicious headache patients.

67. Stroke 2006 Debate Question: CT & LP in SAH C. Because CT is so sensitive for the detection of blood such as with SAH, I do not perform an LP unless the patient is very high risk for SAH.

68. Stroke 2006 Debate Question: CT & LP in SAH D. I not only perform a CT head and LP in these patients, I also perform a CT angiogram or other test prior to discharge from the emergency department.

69. Stroke 2006 Debate Question: CT & LP in SAH A. Perform an LP without a head CT. B. I CT and LP all of these patients. C. If the CT is negative, I rarely perform an LP due to no indication. D. I perform a CT, LP and also some other advanced diagnostic test.

70. Stroke 2006 Debate Question: Delayed LP in SAH It is suggested that in some cases of suspected SAH that the lumbar puncture should be delayed until the symptoms have persisted for at least 6-12 hours. What is your practice regarding delayed LP?It is suggested that in some cases of suspected SAH that the lumbar puncture should be delayed until the symptoms have persisted for at least 6-12 hours. What is your practice regarding delayed LP?

71. Stroke 2006 Debate Question: Delayed LP in SAH A. A.I do not delay LP in any circumstances in suspect SAH patients. I perform the LP right after the CT is done regardless of the symptom duration.

72. Stroke 2006 Debate Question: Delayed LP in SAH B. I perform the LP in the ED after the patients has had symptoms for at least 6 hours.

73. Stroke 2006 Debate Question: Delayed LP in SAH C. I delay the LP in most cases until the patient has been admitted to the neurology or another clinical service.

74. Stroke 2006 Debate Question: Delayed LP in SAH D. I don’t know what the clinical indication is for any delay in performing the LP in suspected SAH patients.

75. Stroke 2006 Debate Question: Delayed LP in SAH A. Perform the LP right away. B. LP after 6 hours of HA symptoms. C. Delay all LPs until after admission. D. I don’t know why to delay LP in suspected SAH patients.

76. Stroke 2006 Debate Question: Surgery for ICH What is your approach to the operative intervention for ICH patients who present to your emergency department?What is your approach to the operative intervention for ICH patients who present to your emergency department?

77. Stroke 2006 Debate Question: Surgery for ICH A. A.I would consult neurosurgery for their assessment of operative need.

78. Stroke 2006 Debate Question: Surgery for ICH B. I would transfer this patient to another hospital because I don’t have neurosurgery coverage and/or it is our institution’s protocol.

79. Stroke 2006 Debate Question: Surgery for ICH C. I have an understanding of the need for operative intervention and can assess this need with neurosurgery.

80. Stroke 2006 Debate Question: Surgery for ICH D. I am aware of the results of the STICH trial and feel that operative intervention is not indicated in most cases.

81. Stroke 2006 Debate Question: Surgery for ICH A. Consult neurosurgery. B. Transfer for neurosurgery care. C. I understand when operative intervention in indicated. D. I know from the STICH trial that operative intervention in most ICH patients is not indicated.

82. Stroke 2006 Debate Question: ICH and Warfarin Consider if this patient had been on warfarin and had an intracerebral hemorrhage of the left temporal lobe of 3 cm diameter associated with moderate edema and mass effect. What might be your management of this ICH patient?Consider if this patient had been on warfarin and had an intracerebral hemorrhage of the left temporal lobe of 3 cm diameter associated with moderate edema and mass effect. What might be your management of this ICH patient?

83. Stroke 2006 Debate Question: ICH and Warfarin A. A.I would admit this patient to neurosurgery for further orders.

84. Stroke 2006 Debate Question: ICH and Warfarin B. I would transfer this patient to another hospital because I don’t have neurosurgery coverage and/or it is our institution’s protocol.

85. Stroke 2006 Debate Question: ICH and Warfarin C. I would be able to manage BP, ICP, the airway, and ICH complications in the ED prior to disposition to another service for admission.

86. Stroke 2006 Debate Question: ICH and Warfarin D. Not only would I manage the patient as in (C.) above, I would also discuss the use of Factor VIIa and other therapies with neurosurgery in this ICH patient’s care.

87. Stroke 2006 Debate Question: ICH and Warfarin A. Admit to neurosurgery. B. Transfer for neurosurgery care. C. I can manage this ICH pt prior to transfer, but don’t know how to manage elevated INR in this pt. D. I also know how to manage elevated INR in ICH pts who are on warfarin.

88. Stroke 2006 Debate Questions? Thank you! ferne@ferne.org edsloan@uic.edu www.ferne.org ferne_eusem_2006_strokequestions_brief_100606_finalcd 2/10/2016 7:44 AM