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Rapid Response - STROKE

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Rapid Response - STROKE Theresa Rohrs, PA-C Stroke Program Coordinator Franklin Square Hospital Center * Found on rounds down? Is patient a reliable historian and ... – PowerPoint PPT presentation

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Title: Rapid Response - STROKE


1
Rapid Response - STROKE
  • Theresa Rohrs, PA-C
  • Stroke Program Coordinator
  • Franklin Square Hospital Center

2
Disclosures Credentials
  • Disclosures NONE
  • Background PA in clinical practice since 1992
    Emergency Medicine, Hospital Medicine, Critical
    Care, Neurology

3
Objectives Participants will
  • Recognize stroke as an emergency, requiring the
    same emergent evaluation as heart attack
  • Identify symptoms, risk factors and mortality
    associated with stroke types
  • Be familiar with interventions which can reduce
    in-hospital mortality and long term disability
    associated with stroke
  • Be better prepared to respond to calls for
    patients with suspected stroke

4
Case 1
  • 76F admitted 1 day prior with SOB, cough, fever
    Dx Pneumonia
  • Rapid Response is CTSP with right sided weakness
    and confusion

5
Stroke STATs
  • Nearly 800,000 strokes in U.S. annually
  • Additional 200-500,000 TIA each year
  • 3 cause of death
  • Leading cause of disability

6
Risk Factors for Stroke
  • Hypertension
  • Diabetes
  • Smoking
  • h/o Stroke or TIA
  • Advancing Age
  • Gender
  • CAD
  • Hyperlipidemia
  • Hormone therapy
  • Atrial fibrillation
  • Carotid Stenosis
  • Interruption of medications
  • Cancer
  • Infection
  • Hypercoagulable state
  • Pregnancy

7
Stroke Types
  • Ischemic 85
  • Thrombotic
  • Embolic
  • Intracerebral Hemorrhage 11
  • Subarachnoid Hemorrhage 4
  • Up to 17 of all strokes occur in hospitalized
    patients

8
Mortality by Stroke Type
  • Intracerebral hemorrhage 25
  • Subarachnoid hemorrhage 20
  • Ischemic 5.5
  • Afib is the strongest predictor of mortality
    associated with ischemic stroke, due in part to
    the size of embolic strokes.

9
Characteristics of Stroke
  • Usually acute onset
  • May be maximal at onset, progressive or
    fluctuating
  • May be obvious, but can be subtle
  • Symptoms be mistaken for confusion
  • Seizure may be a presenting symptom of stroke /
    may mimic stroke
  • Rarely a cause for LOC, typically not associated
    with syncope

10
Symptoms of Stroke
  • Weakness of arm and/or leg
  • Slurred speech
  • Facial Droop
  • Vision loss
  • Severe headache
  • Dizziness, often vertigo
  • Loss of sensation
  • Loss of balance
  • Loss of coordination
  • Inability to speak or understand speech

11
Case 1 first impression
  • Elderly female, lying in bed, obvious right
    facial droop and right sided weakness, having
    difficulty speaking

12
Acute Ischemic Stroke Time is Brain
  • Recanalization Thrombolysis
  • IV tPA up to 4.5 hours
  • At 90 days post stroke, those who received IV tPA
    were 15-30 more likely to have minimal to no
    deficit compared with those who did not
  • Hemorrhage 6 with tPA
  • SICH approximately 3

13
Time is Brain
  • Odds ratios for four treatment groups to recover
    following tPA
  • 0-90 minutes 2.8
  • 91-180 minutes 1.6
  • 181-270 minutes 1.4
  • 271-360 minutes 1.2

Thrombolysis with Alteplase 3 to 4.5 hours after
Acute Ischemic Stroke Hacke NEJM
20083591317-1329
14
Beyond IV tPA
  • Intra-Arterial Thrombolysis?
  • Option in selected patients who have major stroke
    lt 6 hours due to occlusion of MCA
  • Rescue IA tPA following IV tPA
  • Treatment requires an experienced stroke center
    with immediate access to cerebral angiography and
    qualified interventionalists

15
Clot Retrieval?
  • Reasonable intervention for the extraction of IA
    thrombi in carefully selected patients, the
    utility in improving outcomes after stroke
    remains unclear
  • Clinical trials continue
  • Posterior Circulation strokes (basilar artery)
  • up to 12 hours after onset
  • MCA occlusions up to 6 hours after onset

16
Know your Institution
  • Primary Stroke Center (640 in US)
  • Joint Commission or State certification
  • Initiate IV tPA
  • Neurology
  • Neurosurgery
  • Tele-stroke
  • Post tPA care
  • Drip and Ship

17
Comprehensive Stroke Center
  • New level of Joint Commission certification
    anticipated in 2011-12
  • Endovascular treatment
  • (interventional neuroradiology)
  • Neurosurgical expertise
  • Higher risk patients s/p tPA

18
Acute Stroke Response Times THE GOLDEN
HOUR
  •  Patients with symptoms of acute ischemic stroke
    lt 3.5 hours of duration
  • lt10 minutes Initial evaluation
  • (history, NIHSS, labs and CT orders)
  • lt25 minutes CT Head should be complete
  • lt 45 minutes Lab results back and CT has been
    read by Radiologist
  • lt 15 minutes Consult with Stroke Neurologist
  • lt 60 minutes tPA should be administered to
    eligible patient
  • Door-to-Needle lt 60 minutes

19
Inclusion Criteria for tPA
  • Age gt 18
  • Treatment must be initiated before 4.5 hours
  • Symptoms suggestive of acute ischemic stroke with
    measurable neurologic deficit hemiplegia,
    hemiparesis, aphasia, brainstem signs

20
Exclusion Criteria for tPA
  • Stroke within prior 3 months
  • Significant trauma in past 3 months
  • Major surgery within last 14 days
  • History of Intracranial Hemorrhage
  • Suspected Subarachnoid Hemorrhage
  • Intracranial neoplasm, AV malformation or
    aneurysm
  • Myocardial infarction in past 3 months

21
Exclusion Criteria continues
  • Symptoms suggestive of endocarditis or
    pericarditis
  • Evidence of active bleeding or acute trauma
    (fracture)
  • GI or GU hemorrhage within 21 days
  • Seizure on presentation with postictal residual
    neurologic impairment
  • Persistent blood glucose lt 50 or gt 400

22
Exclusion Criteria continues
  • INR 1.7, if taking anticoagulants
  • Dabigatran (Pradaxa) for Afib
  • Heparin in prior 48 hours with ? ? PTT
  • Platelet count lt 100,000
  • Any evidence of hemorrhage, edema or severe
    stroke on CT (hypodensity gt 1/3 cerebral
    hemisphere)
  • Arterial puncture at a non-compressible site lt 7
    days

23
Exclusion Criteria - relative
  • Persistent SBP gt 185, DBP gt 110
  • Awoke with symptoms
  • Rapidly resolving symptoms
  • Minor or isolated stroke (NIHSS lt 4)
  • Severe stroke (NIHSS gt 25)

24
Expanding the Window 4.5 hrs
  • ECASS-3 efficacy and safety of tPA administered
    between 3-4.5 hours
  • Half the benefit compared with lt 3 hour group
    (15)
  • No difference in mortality
  • ICH rate similar 6
  • Additional Exclusions Criteria

25
tPA 3 4.5 hours
  • Study excluded
  • Age gt 80
  • History of both Diabetes Stroke (with residual
    disability)
  • Oral anticoagulants, regardless of INR

26
ABCs of Stroke
  • Airway
  • Breathing
  • Circulation
  • Mental status
  • Blood sugar
  • Cardiac Monitor

27
Case 1 Primary Assessment
  • Alert, no respiratory distress
  • RR 16, O2 Sat 94
  • BP 165/90 P 86 irregular
  • FS 180
  • Atrial fibrillation on monitor

28
Acute Stroke Labs
  • CBC, PT/PTT, BMP, CK, Troponin
  • Assess risk of hemorrhage
  • Results should be available within 45 minutes

29
Timeline
  • Time of onset reliable historian able to
    identify when symptoms began
  • Last Known Well when was this patient last seen
    at baseline

30
History
  • Last Known Well / Time of Onset
  • Past medical history risk factors
  • Medications current, recent, omitted
  • Review of the Inclusion Exclusion criteria

31
Case 1 continues
  • Last seen at baseline 30 minutes prior when nurse
    was in room to administer IV antibiotics
  • Patient is unable to provide further details
    about onset of symptoms

32
Case 1 PMH Meds
  • PMH HTN, DM and Afib not on warfarin therapy
    because patient refusal
  • Current Medications Avelox, glipizide,
    lisinopril, vesicare and acetaminophen

33
Neurological Exam its complicated
  • Paralysis
  • Plegia
  • Flaccid
  • Dysarthria
  • Aphasia
  • Dysphagia
  • Neglect
  • Ataxia
  • Dysmetria
  • Dysrhythmia
  • Quadrantanopia
  • Homonomous hemianopia
  • Gaze preference

34
Physical Exam
  • NIH Stroke Scale
  • - standardized exam
  • - quantifies impairment
  • - easy to communicate results
  • - early prognosis
  • - no special tools needed
  • - 10 minutes to perform

35
NIH Stroke Scale
  • 1a level of consciousness
  • 1b answers questions accurately
  • 1c follows commands
  • 2 best gaze
  • 3 - visual fields
  • 4 facial palsy
  • 5 motor arms
  • 6 motor legs
  • 7 limb ataxia
  • 8 sensory
  • 9 best language
  • 10 dysarthria
  • 11 extinction / inattention
  • Score 0-42

36
NIHSS Aphasia / Dysarthria
  • TIP-TOP
  • FIFTY-FIFTY
  • THANKS
  • HUCKLEBERRY
  • BASEBALL PLAYER

37
NIHSS Dysarthria / Aphasia Screening
  • NIHSS Sentences

You know how. Down to earth. I got home from
work. Near the table in the dining room. They
heard him speak on the radio last night.
38
Case 1 - NIHSS
  • 1a alert 0
  • 1b none correct 2
  • 1c both correct0
  • 2 normal gaze 0
  • 3 visual fields 0
  • 4 partial facial palsy 2
  • 5a Lt arm 0
  • 5b Rt arm no effort against gravity 3
  • 6a Lt leg 0
  • 6b Rt leg drift 1
  • 7 no ataxia 0
  • 8 no sensory loss 0
  • 9 severe aphasia 2
  • 10 mild to moderate dysarthria 1
  • 11 no extinction or
  • inattention 0
  • NIHSS score 11

39
Case 1 - Imaging
  • STAT CT Head, no contrast
  • Indication Acute Stroke
  • STAT reading requested

40
Acute Stroke Imaging
  • Non-contrast CT of the Brain
  • Gold standard to identify ICH / SAH
  • Fast 1-2 minutes
  • Readily available
  • Identifies early signs of ischemic brain injury
    (loss of gray-white differentiation)
  • Arterial occlusions (hyperdense vessel sign)

41
MRI
  • More sensitive and specific than CT
  • DWI allows visualization of ischemic region
    within minutes of symptoms onset
  • Time consuming
  • Lack of availability at most institutions on an
    emergency basis

42
Vascular Imaging
  • CTA
  • MRA
  • Aid in the decision to select best therapy (IV v.
    IA tPA v. clot retrieval)
  • CTA higher accuracy for aneurysm
  • Access is limited for urgent evaluation

43
Imaging Benchmarks
  • Initial imaging (CT or MRI) should be completed
    within 25 minutes of patient arrival / order
  • Image should be interpreted by a physician with
    expertise within 45 minutes of patient arrival /
    order

44
Neurology Consultation
  • Telemedicine
  • Neurology expertise on-site
  • Neurology consultant should respond within 15
    minutes of request

45
Case 1 Neuro Consult
  • 76F with h/o HTN, DM, Afib not on ACT admitted 1
    day prior with PNA LKW 65 minutes ago, now with
    Rt sided facial droop, Rt arm gt leg weakness,
    aphasia and dysarthria, NIHSS 11.
  • CT shows no evidence of hemorrhage or acute
    infarct
  • No thrombocytopenia, INR 1.3
  • No exclusion criteria
  • Family spokesperson has been contacted and is
    available to discuss thrombolytic options

46
Treatment Decision
  • IV tPA
  • BP monitoring / management
  • Close neurological assessments
  • Monitoring for signs of hemorrhage
  • Angioedema surveillance
  • ICU monitoring
  • Neurosurgical availability
  • Drip and Ship

47
Case 1 alternative ending
  • CT suggests loss of grey-white differentiation /
    large MCA infarct / age of infarct maybe longer
    than initial reported
  • tPA is excluded

48
Case 1 CT Scan
49
Not a Thrombolytic Candidate
  • Antiplatelet agent within 24-48 hours
  • Anticoagulation NO, in most circumstances
  • Avoid hypotension - perfuse the brain
  • Gradual lowering of elevated BP but not too
    fast
  • Treat BP immediately
  • if gt 220/120
  • Treat hyperthermia
  • Treat hyperglycemia
  • Initiate Statin therapy
  • Prevent aspiration swallow screen prior to PO
  • Prevent VTE within 48 hours of admit
  • Cardiac monitoring

50
Case 2
  • 78F h/o Afib, HTN, breast CA, hyperlipidemia
  • Found by family in morning, LKW 9 pm when she
    went to bed
  • Lt hemiparesis, facial droop, slurred speech
  • BP 170/85
  • NIHSS 22
  • No tPA - gt 4.5 hours, large infarct by CT
  • INR 1.4

51
Case 2 Day 3
  • CTSP with ?MS
  • BP 180/90 P 60
  • Repeat CT-Large RT MCA infarct, marked edema,
    mass effect, early hydrocephalus

52
Malignant MCA Infarcts
  • Predictors
  • NIHSS gt 20
  • Early involvement gt 50 of MCA territory ACA
    and/or PCA

53
Hemicraniectomy
  • Surgical decompression significantly reduces
    mortality
  • Survivors likely to have moderate-severe
    disability
  • Early decompression (lt48 hours) most benefit

54
Case 3
  • CTSP with MS change
  • 70 male admitted 1 day prior to cardiac telemetry
    unit
  • Admit Dx CHF

55
ABCs of Stroke
  • Airway
  • Breathing
  • Circulation
  • Mental status
  • Blood sugar
  • Cardiac Monitor

56
Case 3
  • Drowsy elderly male, not moving left side, speech
    is slurred
  • BP 220/110 P 58
  • RR 12 O2 sat 94
  • FS 200
  • Cardiac Monitor sinus bradycardia

57
Case 3 PMH / Meds
  • LKW 1 hour ago
  • PMH HTN, Diabetes, hyperlipidemia, tobacco
    abuse, Afib
  • Current Meds warfarin, metoprolol, metformin,
    sliding scale insulin
  • Potential Exclusions OAC

58
Acute Stroke Labs
  • CBC, PT/PTT, BMP, CK, Troponin

59
Case 3 - NIHSS
  • 1a alert 1 drowsy
  • 1b one correct 1
  • 1c both correct0
  • 2 normal gaze 0
  • 3 visual fields 0
  • 4 partial facial palsy 2
  • 5a Lt arm no drift 2 cant resist gravity
  • 5b Rt arm 0
  • 6a Lt leg 1 drift
  • 6b Rt leg 0
  • 7 no limb ataxia 0
  • 8 no sensory loss 0
  • 9 severe aphasia 0
  • 10 Dysarthria 1 mild to moderate dysarthria
  • 11 no extinction or
  • inattention 0
  • NIHSS score 8

60
Case 3 - Imaging
  • STAT CT Head, no contrast
  • Indication Acute Stroke
  • STAT reading requested

61
Case 3 CT Scan Labs
  • RT posterior parietal hematoma
  • Surrounding edema
  • Extends into occipital lateral horns
  • INR 4.0

62
Intracerebral Hemorrhage
  • Early deterioration is common
  • 20 will experience ? in GCS
  • Severe HA, vomiting, decreased LOC
  • Markedly ? BP
  • Progression over minutes to hours
  • 28-38 will have hematoma expansion which
    correlate to ? mortality

63
ICH Risk Factors
  • Hypertension
  • Anticoagulation therapy
  • Antiplatelet agents
  • Stimulants cocaine, diet pills decongestants
  • Recent Ischemic CVA
  • Carotid surgery / stenting ?hyperperfusion
  • Dementia
  • (amyloid angiopathy)
  • Liver disease
  • Renal insufficiency
  • hyperglycemia

64
ICH Treatment
  • ? ? INR due to OACs
  • Discontinue OACs
  • IV Vitamin K (warfarin) FFP
  • Severe thrombocytopenia ? platelets
  • Platelets probably not useful with history of
    anti-platelet use
  • rFVIIa not recommended, except in hemophilia /
    ICH

65
Blood Pressure and ICH
  • Ongoing clinical trails of BP intervention in ICH
    are incomplete
  • In patients with SBP 150-220, acute lowering of
    SBP to 140 mm Hg is probably safe

66
Management of ICH
  • ICU monitoring
  • Hyperglycemia should be treated
  • Avoid hypoglycemia
  • Maintain normothermia
  • Seizures should be treated with AED
  • EEG is indicated in patients with ?MS out of
    proportion of ICH r/o subclinical seizures
  • Seizure prophylaxis is not recommended
  • Prevent aspiration VTE

67
Case 4
  • 49M found unresponsive by spouse LKW 2 hours PTA
  • PMH HTN, polysubstance abuse
  • GCS 4 BP 195/118
  • CT- RT parietal hemorrhage into lateral,
    occipital, 3rd 4th ventricles with diffuse
    edema
  • Tox Screen cocaine
  • No coagulopathy or thrombocytopenia

68
Glasgow Coma Scale
69
Intraventricular Hemorrhage
  • IVH 45 of spontaneous ICH
  • Hypertensive hemorrhage
  • Ventricular catheterization
  • ?MS and hydrocephalus
  • Difficult to maintain patency
  • Intraventricular tPA likely safe
  • Benefit uncertain

70
Surgical Treatment of ICH
  • Controversial
  • Early surgery risk of rebleed
  • Usefulness of surgery is uncertain
  • Cerebellar hemorrhage with brainstem compression
    / hydrocephalus require emergent removal of
    hemorrhage ventricular drainage alone is
    insufficient

71
Case 5
  • 44F cardiac arrest at home resuscitated in ED
  • GCS 3
  • Likely PComm aneurysm rupture

72
SAH Risk Factors
  • 75-80 - ruptured aneurysm
  • 4-5 - AV malformation
  • HTN
  • Smoking
  • Heavy ETOH
  • Situations which cause sudden ?BP
  • Stimulants cocaine
  • Polycystic kidney disease
  • Ehlers-Danlos syndrome

73
Clinical Presentation
  • Worst headache of my life - 74
  • Nausea / vomiting - 77
  • Stiff neck / nuchal rigidity - 35
  • Brief LOC - 53
  • 12 die before receiving medical attention
  • Focal neurologic symptoms (including isolated
    cranial nerve palsies)
  • Most aneurysms are asymptomatic until they rupture

74
Diagnosis of SAH
  • CT positive gt 98-100 within 12 hrs
  • Sensitivity ? 57-85 by day 6
  • LP if CT non-diagnostic
  • Xanthochromia SAH

75
Management of SAH
  • Prevent REBLEED
  • BP lt 150/90
  • Detect aneurysm / AVM (MRA or CTA or angiogram)
  • Clip or coil
  • Prevent VASOSPASM
  • Volume expansion
  • CA Channel Blockers (Nimodipine)
  • Prevent / treat complications
  • Airway management / mechanical ventilation
  • VTE prophylaxis / Aspiration prevention

76
SAH Severity
Hunt Hess Severity Scale
77
Learn the NIH Stroke Scale
  • www.learn.heart.org
  • www.nihss.net
  • www.nihstrokescale.org
  • FREE, online, 3 hours CME, learn at your own
    pace, annual recertification recommended

78
More Stroke Information
  • Complete list of Primary Stroke Centers
    http//www.strokecenters.org/strokecenters.index.a
    spx
  • Neuro Toolkit 2.99 for iPhone includes NIHSS,
    Coma scales, ABCD2 scale for TIAs, CHADS2 score
    for Afib

79
Stroke is NOT a Common Causes of Coma
  • Head trauma
  • Brainstem ischemia
  • Diffuse anoxia
  • Intracranial hemorrhage
  • Status epilepticus
  • Diffuse cerebral edema
  • Drug or ethanol toxicity
  • Hypoglycemia
  • CNS infection (meningitis, encephalitis, brain
    abcess)

80
References
  • Guidelines for the Early Management of Adults
    with Ischemic Stroke Stroke 200738
  • Expansion of the Time Window for Treatment of
    Acute Ischemic Stroke with IV Tissue Plasminogen
    Activator, Stroke 200940
  • Guidelines for the Management of Spontaneous
    Intracerebral Hemorrhage, Stroke 201041
  • Guidelines for the Management of Aneurysmal
    Subarachnoid Hemorrhage, Stroke 200940
  • Quality of Care for In-Hospital Stroke Analysis
    of a Statewide Registry, Stroke 201142
  • Recommendations for Imaging of Acute Stroke A
    Scientific Statement from the AHA, Stroke
    200940
  • Neuroanatomy through Clinical Cases Blumenfeld,
    H. 2002 Sinauer Associates, Inc.

81
Case 6
  • 36M with untreated HTN, presents to ED with HA
  • BP 210/115
  • NIHSS 0
  • Pontine hemorrhage
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