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a. yes b. no

ACUTE STROKE IDENTIFICATION AND TREATMENT (“TIME IS BRAIN”) Andy Jagoda, MD, FACEP Department of Emergency Medicine Mount Sinai School of Medicine New York, New York.

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a. yes b. no

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  1. ACUTE STROKEIDENTIFICATION AND TREATMENT (“TIME IS BRAIN”)Andy Jagoda, MD, FACEPDepartment of Emergency MedicineMount Sinai School of MedicineNew York, New York

  2. A 58 yo man experiences one half hour of numbness and weakness in his left arm. When he arrives in the ED his symptoms have resolved. PMH: positive for CAD. Meds: Enalapril. PE: no focal deficits. ECG: NSR.Should this patient be admitted to the hospital? a. yes b. no

  3. The patient is discharged for an outpatient workup. Three weeks later he develops left face and arm weakness. EMS is called. Which of the following is the best choice? a. He should be taken to the closest hospital b. He should be taken to the closest hospital with a designated stroke team

  4. The patient arrives in the ED, one hour after onset of symptoms, with no improvement. Blood pressure since EMS arrived has remained 170/100. Which of the following is the best blood pressure management? a. sl nitroglycerin b. po clonidine c. iv labetolol d. no treatment

  5. A CT is obtained within 90 minutes of symptom onset: It is read by a neuroradiologist and shows no signs of edema, infarct, or hemorrhage. Which of the following would you recommend? a. t-PA b. aspirin c. heparin d. a plus b or c e. supportive care

  6. INTRODUCTION • Stroke is the 3ird most common cause of death • Second most common cause for patient to be in a nursing home • 500,000 - 700,000 strokes / year • 80 - 90% Ischemic • 10 - 20% Hemorrhagic or SAH • 30% Mortality within 3months • Leading cause of disability • 3 million with stroke related disability • Estimated $ 40 billion annual heath care cost * * TAYLOR ET AL. STROKE 1996;27:1459

  7. The Facts • TIAs • 20% of stroke patients have a preceding TIA • 75% resolve in <15 minutes; 97% <3 hours • Stroke • 5.4% recurrent symptomatic stroke within 1 year • 28% mortality within 1 year (40-60% related to stroke) • Acute stroke • ICH within 36 hours: 1% symptomatic, 4% asymptomatic • 25% have little or no disability at 3 months • 25% have mild to moderate disability at 3 months • 30% have severe disability • 20% dead at 3 months

  8. Transient Ischemic Attack • Cerebrovascular event with deficit <24 hours • Symptoms in a vascular territory • Risk of stroke: • 25% by 5 years • 15% by 1 year • 10% at 3 months • 5% at 48 hours • Anticoagulation indicated in atrial fibrillation, patent foramen ovale, carotid / vertebral artery stenosis • Endarterectomy reduces risk by 10% at 2 years

  9. Transient Ischemic Attack • Benefits of hospitalization • Facilitates diagnostic evaluation • Allows observation and rapid management for stroke • Hospitalization indicated for: • Suspected cardio-embolism • Patients > 60 • Diabetes • Symptom duration > 10 minutes • Weakness • Speech impairment • Initiate anti-platelet therapy (aspirin, clopidigrel)

  10. SUBTYPES OF STROKE • HEMORRHAGIC • INTRACEREBRAL HEMORRHAGE • SUBARACHNOID HEMORRHAGE • ISCHEMIC LARGE ARTERY ATHEROSCLEROSIS WITH THROMBOEMBOLISM • SMALL VESSEL DISEASE • CARDIOEMBOLISM • NONARTHEROSCLEROTIC VASCULOPATHIES • HYPERCOAGULABLE STATES

  11. GOALS IN STROKE MANAGEMENT • DEFINE ETIOLOGY • CONSIDER CONDITIONS THAT MASQUERADE AS STROKE: COMPLICATED MIGRAINE, TODD’S PARALYSIS, HYPOGLYCEMIA, FUNCTIONAL • DO NO HARM • DO NOT OVERTREAT BLOOD PRESSURE • MANAGE BLOOD SUGAR • LIMIT INFARCT SIZE • ROLE OF THROMBOLYTICS • NEUROPROTECTIVE AGENTS • PREVENT COMPLICATIONS • INITIATE EARLY REHABILITATION

  12. NINDS PROCEEDINGS: 1997 • PUBLIC EDUCATION • PREHOSPITAL EMERGENCY RESPONSE • DESIGNATED STROKE CENTERS • EMERGENCY DEPARTMENTS • HOSPITAL STROKE UNITS • REHABILITATION

  13. PUBLIC EDUCATION • NINDS STROKE TRIAL, 17,000 PATIENTS, ONLY 3.6% WERE ELIGIBLE FOR TREATMENT • AGGRESSIVE PUBLIC CAMPAIGNS HAVE DECREASED TIME OF ONSET TO TIME OF ED ARRIVAL TO < 3 HOURS IN 50% OF PATIENTS * • FACTORS ASSOCIATED WITH DELAY • NO SYMPTOM RECOGNITION • LIVING ALONE • NIGHTTIME ONSET • CALL TO MD MORRIS ET AL. ACAD EMERG MED 1996;3:539 BARSAN ET AL. ARCH INT MED 1993;153:2558

  14. CHAIN OF RECOVERY • MI: TRAUMA: STROKE • RAPID ON-SCENE IDENTIFICATION OF LIFE-THREATENING PROBLEMS • RAPID EVACUATION TO APPROPRIATE FACILITY WITH PRENOTIFICATION • RAPID DIAGNOSIS • RAPID DEFINITIVE INTERVENTIONS • SPECIALIZED IN-PATIENT MANAGEMENT • REHABILITATION

  15. THE PUBLIC MESSAGE • WEAKNESS OR NUMBNESS ON ONE SIDE OF THE BODY • DIFFICULTY WITH VISION • DIFFICULTY WITH SPEECH OR UNDERSTANDING • UNUSUALLY SEVERE HEADACHE • DIZZINESS OR UNSTEADINESS

  16. STROKE IS A BRAIN ATTACK.CALL 911*PUBLIC SERVICE ANNOUNCEMENT. JANUARY 1998

  17. EMS DISPATCH IN ACUTE STROKE • PRIORITY DISPATCH SYSTEMS • GOAL: TO SEND THE RIGHT THINGS TO THE RIGHT PEOPLE AT THE RIGHT TIME IN THE RIGHT WAY “ (NHAAP, NIH, 1994) • 911 • STILL NOT AVAILABLE TO 15% OF POPULATION • BASIC 911 REQUIRES PATIENT PARTICIPATION • ADVANCED 911, CALLER ID • EMS DISPATCHERS IDENTIFY ONLY 51% OF STROKES (KOTHARI. STROKE 1996;27:171) • ARRIVAL TO ED FROM SYMPTOM ONSET • 7% WITHIN 1 HR (JORGESEN. NEUROLOGY 1996;47:383) • 2.6 HOURS (BARSAN. ARCH INT MED 1993;153:2558)

  18. PREHOSPITAL CARE IN STROKE • UP TO 25% OF PATIENTS WITH ACUTE STROKE REQUIRE ADVANCED CARE DURING TRANSPORT: • AIRWAY MANAGEMENT • SEIZURE CONTROL • RECOGNITION OF MI AND DYSRHYTHMIAS KOTARI ET AL. STROKE 1995;26:937

  19. PREHOSPITAL STROKE SCALE FOCUSED EXAM TO MINIMIZE FIELD TIME AND TO ACTIVATE STROKE TEAM • FACIAL DROOP • SYMMETRICAL MOVEMENT • ASYMMETRIC MOVEMENT • MOTOR WEAKNESS • NO MOVEMENT OR PRONATOR DRIFT • SPEECH: REPEAT A PHRASE • SLURS WORDS, USES INAPPROPRIATE WORDS, OR IS UNABLE TO SPEAK KOTARI ET AL. ACAD EMERG MED 1997;4:986

  20. THE STROKE TEAM / STROKE CENTERS • GOAL: • To provide comprehensive, coordinated care • To identify candidates for thrombolytics within 3 hours • TEAM: • Physicians with expertise in stroke • Nurse • CT personnel • AVAILABILITY: • 24 hours / day / 7 days a week Alberts et al. Recommendations for the establishment of primary stroke centers. JAMA 2000; 283:31-2-3109

  21. IDEAL RESPONSE TIMES • ED arrival within one hour of symptoms • Evaluation within 10 minutes of arrival • Stroke team notification within 15 min • CT within 25 minutes • CT interpretation within 45 minutes • Thrombolytics for eligible patients within 60 minutes • Transfer to a stroke unit within 3 hours or arrival

  22. THE STROKE TEAM • EMS NOTIFICATION • TEAM ACTIVATION • STANDING ORDERS: • VITAL SIGN MONITORING • RAPID GLUCOSE DETERMINATION • NEUROLOGICAL MONITORING • ECG / CARDIAC MONITORING • IV ACCESS • LABORATORY STUDIES: CBC, LYTES, PT/PTT, TYPE AND SCREEN • PORTABLE CXR • HEAD CT

  23. EMERGENCY DEPARTMENT APPROACH TO STROKE: HISTORY • TIME OF ONSET • HEAD TRAUMA • SEIZURE • MEDICATIONS: USE OF ANTICOAGULANTS • SYMPTOMS SUGGESTIVE OF MI • CHEST PAIN, PALPITATIONS, SOB • SYMPTOMS SUGGESTIVE OF HEMORRHAGE • SEVERE HEADACHE • NECK STIFFNESS / PAIN • NAUSEA / VOMITING

  24. ED APPROACH TO STROKE: PHYSICAL • ABC’S • Vital signs (BP both arms; presence of fever) • LOC (when depressed, consider other diagnoses) • Trauma exam • Neck exam • Cardiopulmonary exam • Neurologic exam • Glasgow coma scale • NIHSS: 15 Item measure: 42 Points • < 4 Not a candidate for thrombolytics • > 22 Increased risk for hemorrhage

  25. Level of consciousness Orientation (month and age) Follow commands Best gaze Visual fields Facial palsy Motor arm Motor leg Limb ataxia Sensory Best language Dysarthria Extinction and inattention (neglect) NIH Stroke Scale

  26. Stroke Mimics • Todd’s paralysis • Complicated migraine • Nonconvulsive status epilepticus • Neuropathy • Hypoglycemia • Hyperglycemia

  27. Stroke Localization Pearls • Aphasia usually corresponds to left hemispheric stroke (right sided weakness) • Neglect (hemi-attention) usually indicates right hemispheric stroke • Patients usually look towards the lesion • Crossed signs indicated brainstem involvement • Vertigo of central origin almost always is associated with other cranial nerve deficits • Vertical nystagmus is posterior circulation ischemia until proven otherwise

  28. CONTROVERSIES IN STROKE MANAGEMENT • USE OF DEXTROSE • MANAGEMENT OF BLOOD PRESSURE • USE OF THROMBOLYTICS • USE OF HEPARIN

  29. BLOOD PRESSURE MANAGEMENT IN ISCHEMIC STROKE • Loss of autoregulation in ischemic brain: CBF depends on arterial BP to maintain cerebral perfusion • Most ischemic stroke patients have a history of hypertension and need higher CPP • In general, there is a spontaneous decline in BP over time • Lowering BP may exacerbate brain ischemia ADAMS ET AL. STROKE 1994;25:1901 STRANDGAARD. CIRCULATION 1976;53:720

  30. BLOOD PRESSURE MANAGEMENT IN ISCHEMIC STROKE • Systolic 185 - 220, Diastolic 105 - 120; Do not treat for the first hour (consider benzodiazepines); if persists, IV Labetolol, 10 mg. • Systolic > 220 mm Hg or diastolic 121 - 140; 2 readings 20 min apart: Start Labetolol 10 MG IV. Patients requiring more than 2 doses are not candidates for t-PA • Diastolic > 140 mm Hg; 2 readings 5 minutes apart: Start Nitroprusside. Patient is not a candidate for t-PA

  31. BLOOD PRESSURE MANAGEMENT IN ISCHEMIC STROKE • HYPOTENSION IN ACUTE STROKE • DEHYDRATION • ARRHYTHMIA • DIMINISHED CARDIAC OUTPUT • TREAT UNDERLYING CAUSE • FLUIDS • RHYTHM CONTROL • PRESSORS

  32. BLOOD PRESSURE MANAGEMENT IN HEMORRHAGIC STROKE • NO STUDIES TO SHOW LOWERING BP DECREASES RISK OF REBLEEDING OR IMPROVES OUTCOME • NINDS RECOMMENDS INTERVENTION WHEN THE SYSTOLIC > 180, DIASTOLIC > 130 • GOAL IS TO LOWER THE BP TO A MAP OF 130 mm Hg (10 - 20%) • NITROPRUSSIDE OR LABETOLOL

  33. Use of Thrombolytics: Review of the literature

  34. NINDS • Randomized, double blind study; 624 patients • t-PA .9 mg/kg (max 90 mg) within 3 hours onset • Statistically significant benefit in outcome at 3 and 12 months • No change in mortality and a decrease in LOS

  35. Alpers et al. The standard treatment with Alteplase to reverse stroke study (STARS). JAMA 2000; 283:1145-1150 • Prospective, multi-center phase IV study: 2/97 - 12/98 • Designed to assess safety profile and outcome findings. • 57 or 83 centers in ATLANTIS participated • 389 patients • median time of tx 2 hours and 44 minutes • median NIHSS score 13 (vs 14 in NINDS) • 19% NIHSS score >20 (vs 20% in NINDS) • 6% with cerebral edema on initial CT (vs 4% NINDS) • 3 day rate ICH: • 3.3% symptomatic (vs 6.4% NINDS) • 7% asymptomatic • 1.5% major systemic bleeding

  36. Alpers et al. The standard treatment with Alteplase to reverse stroke study (STARS). JAMA 2000; 283:1145-1150 • 35% violations of the NINDS protocol • 13% treated beyond the 3 hour window • 9% received anticoagulants within 24 hours • 7% treated with BPs > 185 mm Hg • Symptomatic ICH occurred in 3.9% (vs 3.1%; trend towards significance) • 30 day outcome (NINDS measured at 90 days) • 13% mortality • 35 % very favorable outcome; Rankin <1 • 8% functionally independent: Rankin 1-2 • 12% moderate disability: Rankin 3 • 31% moderate to severe disability: Rankin 4

  37. Alpers et al. The standard treatment with Alteplase to reverse stroke study (STARS). JAMA 2000; 283:1145-1150 • Predictors of favorable outcome: • NIHSS score of 10 or less • Absence of specific abnormalities on the baseline CT (hypodensity > 1/3 MCA associated with ICH) • Age < 86 • Odds of recovery (OCD) • For every 5 point increase in baseline NIHSS score, patients had a 22% decrease in the OCD • NIHSS scores greater than 10 had a 75% decrease in the OCD • Every 10 point increase in baseline mean BP decreased the OCD by 19% • Results replicated the NINDS study

  38. Katzan et al. Use of t-PA: The Cleveland experience. JAMA 2000; 283:1151-1158 • Retrospective review of Cleveland experience using data from stroke registry from 29 hospitals,over a one year period, 1997-1998 • Stroke patients identified using ICD-9 codes • 4345 ischemic strokes • 17% admitted within 3 hours • 70 patients received t-PA: 1.8% of all stroke patients, 10.4% of eligible patients • 16 of 29 hospitals used t-PA • 669 matched patients who did not receive t-PA

  39. Katzan et al. Use of t-PA: The Cleveland experience. JAMA 2000; 283:1151-1158 • In-hospital mortality: 16% t-PA vs 7.1% no t-PA • 5% mortality in the general stroke population • ICH rate 22%; 15.7% symptomatic • 50% of deaths were in the symptomatic ICH group • Patients treated with t-PA were discharged home significantly less often than those not treated

  40. Katzan et al. Use of t-PA: The Cleveland experience. JAMA 2000; 283:1151-1158 • 50% violation of treatment guidelines • 37% treated with antithrombotics • 13% treated outside of 3 hours • 7% SBP > 185 or DBP >110 • NIHSS score not documented in 60% • median score of 12 • Deviation in BP treatment / monitoring 86%

  41. Katzan et al. Use of t-PA: The Cleveland experience. JAMA 2000; 283:1151-1158 • Limited data on stroke severity • 50% receiving treatment had deviations from the NINDS treatment standards • no significant correlation between deviations and symptomatic ICH • Neurologic outcomes were not tracked

  42. DECIDING TO USE THROMBOLYTICS • UP TO 20% OF PATIENTS ARE INCORRECTLY DIAGNOSED AS HAVING A STROKE • EXPERTISE IN STROKE MANAGEMENT NEEDED • EXCLUSION: • CT SIGNS OF HEMORRHAGE OR INFARCTION • UNDETERMINED TIME OF ONSET • UNCONTROLLED HYPERTENSION • RAPIDLY RESOLVING NEURO DEFICITS • UNRESOLVING NEURO DEFICIT LASTING > 90 MIN, LESS THAN 3% ARE TIAs

  43. STROKE UNITS • IMPROVES OUTCOME * • OPTIMIZES CHANCE OF RECOVERY • MINIMIZES COMPLICATIONS • DECREASE LENGTH OF HOSPITAL STAY • PROVIDES ONGOING MONITORING • NEUROLOGIC DETERIORATION (4-8% SEIZURE) • CARDIAC DYSRHYTHMIAS (CARDIAC ETIOLOGY IN 14% OF POST-STROKE DEATHS) • DECREASES INCIDENCE OF PE, PNEUMONIA (30% OF STROKE DEATHS) • FACILITATES DIAGNOSTIC WORK-UP • ENSURES EARLY REHABILITATION, PATIENT AND FAMILY EDUCATION * LANGHORNE ET AL. LANCET 1993;342:395

  44. CONCLUSIONS • New treatment for stroke makes rapid diagnosis critical • Chain of survival begins with public education and rapid access to definitive care • Identification of hospitals prepared to provide comprehensive care is fundamental • Stroke teams are critical to ensure efficient stroke management • Continuous quality improvement programs are needed to assess effectiveness and identify needs

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