Emergency Care Of Stroke

1 Heart Diseases & Diseases of Pulmonary Circulation 15.99%

2 Septicemia 14.51%

3 Malignant Neoplasm 9.16%

4 Accident 6.76%

5 Perinatal Conditions 5.56%

6 Pneumonia 4.98%

7 Cerebrovascular Diseases 4.48%

8 Diseases of Digestive Systems 4.38%

9 Kidney Diseases 3.72%

10 Ill-Defined Conditions 2.74%

Principal Causes of Deaths In Government Hospitals Malaysia in 2002

The Era of Reperfusion: Guideline 2000

I. Intravenous tPA for patients with ischemic stroke- Within 3 hours of onset of symptoms (Class I)- Between 3 and 6 hours of onset of symptoms (Class Indeterminate)

II. Intra-arterial fibrinolysis may be beneficial (Class IIb)

““Time is brain”Time is brain”

Basic life support (BLS) role in

stroke management

• “Phone first” for unresponsive adults (Class Indeterminate)

• Prehospital identification of stroke victims (Class 1)

• Rapid transport & notification (Class1)• Rapid /early dispatch of stroke victims like MI

(Class1)• Transport to center capable of starting rapid

fibrinolytic (Class IIb)

Stroke Chain of Survival and Recovery (7D's)

1. Detection - note the onset of signs and symptoms

2. Dispatch - call 999/991 and have EMS dispatched

immediately

3. Delivery - transport patient to hospital with assessment

and care

4. Door - immediate emergency department triage

5. Data - prompt laboratory and CT diagnostic studies

6. Decision - diagnosis and decision about appropriate

therapy

7. Drug - administration of appropriate drugs or other

intervention

DETECTION

DISPATCH

DELIVERY

DOOR

DATA

DECISION

DRUG

Recognizing signs & symptoms

Calling for help (999/991)

Initial assessment & stabilization

Appropriate hospital delivery

Initial investigation

Treatment modality

Choosing appropriate drugs

DETECTION – PH Cincinnati Stroke Scale

Pre-hospital Management of Stroke

Initial assessment & management:

I. Airway,Breathing,CirculationII. Vital signs check – BP, PR, Respiratory RateIII. Capillary blood sugarIV. Determine time of onsetV. En route – an IV, O2, Cardiac MonitoringVI. Notify receiving appropriate hospitalVII. Transport ASAP – TIME IS BRAIN !!!

ED Management of Acute Stroke

ED Management of Acute Stroke

The completion of 4 D’s………

Door - immediate emergency department triage

Data - prompt laboratory and CT diagnostic studies

Decision - diagnosis and decision about appropriate therapy

Drug - administration of appropriate drugs or other intervention

What concern us in the ED………

I. Triage, primary survey & initial stabilization (Door)

II. History, general & neuro assessment (Door)

III. Determine whether ischemic or hemorrhagic stroke(Data)

IV. Initial treatment & supportive care (Decision)

V. Early referral for definitive treatment (Drug)

Immediate general assessment (<10 min from arrival)

Assess ABCs, vital signs Oxygen provision Obtain IV access, blood investigations (FBC, BUSE, coagulation profiles Blood sugar Obtain 12-lead ECG Alert neurology team

Immediate neurological assessment…

Review history Establish time of onset (< 3 hours ?) Physical examination Determine GCS/NIH stroke scale/Hunt & Hess Urgent non-contrast CT scan (door to CT < 25 minutes from arrival) Read CT scan (door to CT read < 45 minutes from arrival Rule out trauma/other causes

Is it ischemic or hemorrhagic stroke???

CT scan is the most important diagnostic test Do without contrast Increased density suggest bleed Be aware that SAH may present with normal CT If suspicious, do LP MRI is NOT ROUTINE (not superior to CT) Though MRI detect early bleed & more sensitive

ED Management of Acute Stroke

ED Management of Acute Stroke

Initial treatment & supportive care

I. General Emergency Therapy

- Maintain adequate tissue oxygenation- Prevent hypoxia- Risk of airway compromise in stroke patient- Airway obstruction, hypoventilation, aspiration atelectasis- Consider elective intubation- Routine O2 supplement is not recommended unless hypoxic

Initial treatment & supportive care

II. Management of Elevated Blood Pressure

- Hypertension may occur after the insult- BP elevated from the stress of stroke, full bladder, hypoxia, raised ICP- Optimal management is controversy- DO NOT treat aggressively- Little scientific basis & no clinically proven benefit for lowering BP- Treat urgently in hypertensive encephalopathy, acute pulmonary edema, renal failure/AMI

ED Management of Acute Stroke

(Circulation,2000;102(suppl I):I-204-I-216)

ED Management of Acute Stroke

Management of Elevated Blood Pressure

No data to define for level of treatment

From CONCENCUS (NOT EVIDENCE BASE) treat only if

- DBP > 120 mmHg

- SBP > 220 mmHg

Lower BP cautiuosly

- Use IV antihypertensive (i.e labetolol)

- Avoid oral short acting agent (i.e nifedipine)

(Stroke, 2003;34:1056-1083)

(Circulation,2000;102(suppl I):I-204-I-216

ED Management of Acute Stroke

III. Management of seizures

- Life-threatening complication if recurs- Anticonvulsant recommended- Prophylaxis is not indicated- A,B,C, O2, Normothermia- Benzodiazepine, phenytoin, phenobarbitone

Adams HJ et al. Stroke. 1994;25:1901-1914

ED Management of Acute Stroke

IV. Management of Raised ICP

- Cerebral edema & raised ICP are common cause of death after stroke (10-20%)- Goals of therapy:

reduction of elevated ICPmaintenance of cerebral perfusion(CPP=MAP-ICP)

ED Management of Acute Stroke

IV. Management of Raised ICP (Cont.)

- If suspect:fluid restrictionhead elevation (20-30%)support of ventilationcontrol of agitation

- Optimal PaCO2 30 to 35 mmHg (immediate effect)- Normoventilation vs Hyperventilation- Avoid aggressive tracheal suctioning- Pharmacological therapy:

hyperosmolar therapy (0.5g/kg per dose over 20 min)

diureticshypertonic salineacetazolamidebarbiturates (1 to 5 mg/kg)

- ICP monitoring (guide therapy, worsening condition)

Broderick JP et al. Stroke. 1999;30:905-915Adams HJ et al. Stroke. 1994;25:1901-1914

ED Management of Acute Stroke

V. Fever

- Poor neurological outcome with fever- A recent meta-analysis suggested marked increase in mortality & morbidity- Find source of fever- Issue of modestly induced hypothermia in treating stroke (neuroprotective)

Azzimondi G et al. Stroke. 1995;26:2040-2043Jorgensen HS et al. The Copenhagen Stroke Study. Stroke 1999;30:2008-2012

ED Management of Acute Stroke

VI. Cardiac Rhythm

- MI & cardiac arrhythmias are potential complications - Disturbances in autonomic nervous systems- ECG changes:

ST depressionQT interval prolongationinverted T waveAcute MI (release of cathecolamine)

- Most common arrhythmia is atrial fibrillation- Sudden death can occur

Myers MG et al. Sroke.1982;13:838-842Kolin A. Stroke. 1984;15:990-993

ED Management of Acute Stroke

VII. Blood sugar

- Always check blood sugar!- Diabetes is a well known risk factor- Detrimental effects of both hypo & hyperglycemia

anaerobic glycolysisincrease blood brain barrier

- No relation between HbA1C & stroke outcome- No database evidence showing euglycemia change the impact of stroke

Bruno A et al. Neurology.1999;52:280-284Scot JF et al. Stroke. 1999;30;793-799Weir CJ et al. BMJ.1997;314:1303-1306

Pharmacological & Interventional Therapies

I. Ischemic Stroke

Fibrinolytic Therapy- Intraarterial & intravenous fibrinolytics in ischemic stroke- The Cochrane Stroke Review group

17 trials with > 5000 patients, > 50% receivedrtPApatients treated < 3 hours had reduced death &dependency

problems with heterogeneity in the study

Pharmacological & Interventional Therapies

The National Institute of Neurological Disorders & Stroke rtPA Stroke Trial

prospective,blinded RCT

< 3 hours of stroke onset

use of IV rtPA (0.9mg/kg 10% bolus over 1 min & the rest

over 1 hour infusion)

30% more likely no/minimal disability

BUT 10X more likely to get intracranial bleed

overall mortality NOT increased

Pharmacological & Interventional Therapies

The National Institute of Neurological Disorders & Stroke rtPA Stroke Trial

Based on part I & II:

IV administration of rtPA is recommended

for carefully selected patients with acute

ischemic stroke with no contraindications to

fibrinolytic therapy & given within 3 hours of

stroke onset (Class I)

Pharmacological & Interventional Therapies

Pharmacological & Interventional Therapies

Characteristics of patients with ischemic stroke whoCould be treated with rtPA:

Diagnosis of ischemic stroke Measurable neurological deficitHemorrhagic stroke excludedOnset of symptoms < 3 hoursSBP<185mmHg & DBP<110mmHgCT does not show a multilobular infarctionThe patient & family understand the risk & benefits

Pharmacological & Interventional Therapies

WHY LESS THAN 3 HOURS ????????

The ATLANTIS Trial: Recombinant Alteplase for ischemic stroke 3 to 5hours after symptom onset (A RCT)

No significant end points differencesThe benefit was not maintained at 30 daysIncreased rate of intracranial bleedRoutine use of IN rtPA > 3 hours is not recommended(Class indeterminate)

Clark W et al. Recombinant Alteplase for ischemic stroke 3 to 5 hoursAfter symptom onset: the ATLANTIS study: a RCT. JAMA. 1999;282:2019-2026

Pharmacological & Interventional Therapies

ANTICOAGULANT THERAPY ????

No efficacy has been establishedStroke Treatment – Aspirin

Two important trials: •International Stroke Trial (IST) •Chinese Acute Stroke Trial (CAST) •Combined analysis (n=40,090) •Death / nonfatal strokes reduced 11% •Reduces the subsequent stroke in TIA•160 – 300mg within 48 hours reduces recurrent  

Pharmacological & Interventional Therapies

ANTICOAGULANT THERAPY ????

Stroke Treatment – Heparinoids

Two important trials: •International Stroke Trial (IST) •TOAST (Trial of ORG 10172) •Decreased recurrent ischemic strokes •Increased hemorrhagic events •No net stroke benefit

Pharmacological & Interventional Therapies

LOW MOLECULAR WEIGHT HEPARIN ????

Norwegian TrialCompare deltaparin & aspirinNo significant differences in outcomes & recurrentHigher rate of bleeding in deltaparin groupAspirin group has fewer second stroke

German TrialUse 4 different doses of certoparinNo favourable outcome among the four groupsHigh incidence of spontaneous bleed

Berge E et al. Lancet;2000;355:1205-1210Diener HC et al. Stroke;32:22-29

Pharmacological & Interventional Therapies

OTHER TREATMENTS ????

Ca2+ channel blockersVolume expanderHemodilutionLow molecular weight dextran

NO FAVOURABLEOUTCOME

Clark WM et al. Stroke.1999;31:2592-2597

CONCLUSIONS

I. Public & pre-hospital providers must be taught toidentify features of stroke

II. Early hospital consultations is requiredIII. Stroke can be ischemic or hemorrhagicIV. Ischemic stroke can be treated with

fibrinolytics if presented within 3 hours of onset

V. Stroke is “Brain Attack” & should be considered as acute myocardial infarcton

VI. Pre-hospital care involves early detection and stabilization

VII. ED care involves early confirmation & further stabilization and complications recognition

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