Acute Stroke Management Using HANDi Stroke Rx: A Palm-based Education and Treatment Aid

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Acute Stroke Management Using HANDi Stroke Rx A
Palm-based Education and Treatment Aid

• Kevin Baumlin, MD, FACEP
• Jason Shapiro, MD, and Michael Bessette, MD
• Mount Sinai School of Medicine
• Department of Emergency Medicine

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Introduction

• 1-2 of all ED charts from acute stroke patients
  have a documented NIHSS
• Using NIHSS as a measure allows Neurologists and
  EPs to follow stroke severity
• Handi Stroke Rx is a palm-based handheld computer
  program designed to assist clinicians in their
  management of acute ischemic stroke patients.
  The public release version is available for free
  from the FERNE website at www.ferne.org

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Why the NIHSS?

• NINDS NIHSS Severity median score 14
• NIHSS 42 point scale, 11 categories
• Mild facial paralysis NIHSS 1
• Complete r hemiplegia with aphasia, gaze
  deviation, visual field deficit, dysarthria,
  sensory loss NIHSS 25
• NIHSS severity is critical to pt selection

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Objective

• Primary Objective
• To create an easy to use clinical assessment and
  educational tool for emergency department
  evaluation of acute ischemic stroke patients.
  The tool includes
• 1) A National Institutes of Health Stroke Scale
  Calculator (NIHSS)
• 2) An interactive checklist of inclusion and
  exclusion criteria
• 3) A r-TPA dose calculator
• 4) Reference materials such as sets of sample
  orders, a list of sequence of events in
  management of these patients, and suggestions
  for documentation of consent and management of
  hypertension and intracerebral hemorrhage.

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Objective

• Secondary Objective
• To develop this tool on a forms/database platform
  for use as a data collection tool in future
  clinical studies. The goal of this objective is
  to have data literally streaming from the point
  of care through data base software and
  statistical analysis software, leaving little or
  no room for human error.

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Methods

• Satellite Forms version 4.1 from Puma Technology
  was chosen as the design platform for this
  project.. Advantages of this platform included
• A WYSIWIG (What You See Is What You Get) PC
  environment for handheld forms creation.
• Ability to add large amounts of content and
  powerful functionality using visual basic
  scripting and embedded third-party extensions.
• Pumatech's Enterprise Intellisync Server
  software which allows data to be synced over the
  internet from each user to a server-based
  database program.

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Description

• The program is set up in a linear fashion
  allowing users to go sequentially through an
  NIHSS calculator followed by inclusion criteria,
  absolute contraindications and relative warnings
  for rt-PA therapy, followed by an rt-PA dose
  calculator based on patient weight.

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Description

• Alternatively the user can chose the Jump
  buttons located throughout the program to use
  individual components of the program from a table
  of contents or Jump menu.

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Description

• The NIHSS portion of the program includes the
  standard 11 questions with full explanations
  available by tapping the i in the upper right
  hand corner of each screen. Standard NIHSS
  images are included in-line and a final score
  reporting screen with a scale relating risk of
  symptomatic intracranial hemorrhage to NIHSS
  score is included at the end.

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NIHSS
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NIHSS
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NIHSS
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NIHSS
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NIHSS
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NIHSS
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Inclusion Criteria and Contraindications

• The inclusion criteria, absolute
  contraindications and relative warnings are set
  up as interactive check boxes.

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tPa Dose Calculator

• The rt-PA dose calculator includes a simple input
  of the patients weight in kg, and a second screen
  that gives both bolus and infusion doses.

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Sequence of Events
This section allows users to be reminded of the
appropriate protocol for treatment
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Sample Orders
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Management of ICH
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Blood Pressure Control
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Current Progress

• The primary objectives have all been reached and
  we are currently in the process of developing the
  program for use in data collection in order to
  satisfy our secondary objective. Specifically we
  are retooling the program to gather important
  patient information such as laboratory and CT
  findings, as well as working on the back-end
  database and conduit to allow direct syncing of
  data from end users. Additionally we are
  planning a validation study comparing the use of
  this new handheld NIHSS with traditional paper
  and pencil.

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Conclusion

• HandiStroke is a palm based stroke education and
  treatment aid. This free application will be an
  effective tool for clinicians in their management
  of acute ischemic stroke in the emergency
  department and in stroke units. It should
  facilitate further understanding of the current
  guidelines for management of the acute stroke
  patient.

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Case One

• 44 yo Male h/o HTN, BIBEMS at 200pm post
  notification, for acute change in his ability to
  speak. EMS reports CSS 3
• According to his co-workers he was talking on the
  phone at 115 when a colleague noticed slurred
  speech.
• Pt. Arrived. Code Stroke was called and the
  patient was immediately evaluated, labs were sent
  and CT was performed at 235.

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Case One (cont.)

• BP 195/120, HR67, RR14, Temp 37
• Medications aspirin qd, HCTZ (? Taking)
• On examination the patient was alert but had
  difficulty with speech. He was able to say
  okay yes and appeared frustrated with being
  unable to communicate. He had a partial right
  facial droop. Exam also revealed a pronator
  drift on the right with normal strength. .
• NIHSS was performed using HandiStroke demo

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Results

• NIHSS 9 (1b2, 42,5a1,92,102)
• Lab and EKG were within normal limits
• CT ....

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CT Scan

• Image.

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Treatment

• Labatelol 10 mg IV was given
• (see HTN guidelines)
• t-PA--
• Demo bolus and drip

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tPa Dose Calculator

• The rt-PA dose calculator includes a simple input
  of the patients weight in kg, and a second screen
  that gives both bolus and infusion doses.

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Outcome

• Follow up
• His aphasia and right hemi improved by day 3.
  Carotid duplex showed no stenosis.
• The patient was discharged on Clopidogrel.
  (Plavix)
• Three months later he was back to work
• As a paramedic

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Discussion

• Giving tPA to a patient on Aspirin is okay.
• The protocol prohibits the use of aspirin AFTER
  thrombolytics for 24hours..
• The original NINDS trial 1/3 of the patients had
  taken aspirin prior to stroke no harmful
  interaction was noted.
• If stroke scale was 5-6 would you still have
  thrombolysed?
• Yes. It depends on what the deficit is. If the
  deficit was speech alone tPa would still be
  considered.