Stroke Management Chemeketa Community College Peggy Andrews The

Stroke Management Chemeketa Community College Peggy Andrews The "Golden Hour" of Acute Ischemic Stroke > A Look at Current Stroke Treatment What's Changed in 2000? EMS systems should implement a prehospital stroke protocol to evaluate and rapidly identify patients who may benefit from fibrinolytic therapy, similar to the protocol for chest pain patients (Class IIb).

Patients who may be candidates for fibrinolytic therapy should be transported to hospitals identified as capable of providing acute stroke care, including 24-hours availability of CT scan and interpretation. (Class IIb). Stroke presenting with 3 hours should be triaged on an emergent basis with urgency similar to acute ST-elevation myocardial infarction. 2 Acute Stroke Where are we today? Public poorly informed

Response time too slow Presentation too late Hospitals ill prepared 3 Models for the "Golden Hour" Trauma Times studied/defined Centralized trauma center system Mortality Low

AMI Similar door-drug/groin benchmarks for reperfusion Decentralized system Treatment data strongly supports 4 AMI - example The paradigm has shifted Chest pain - patients know to call 911 Rapid access to EMS Early recognition

ECG S/S Rapid Transport Team, protocols, drugs in the ED Door to Drug in 30 Minutes 5 Why Care? Impact of Stroke

3rd leading cause of death in U.S. Leading cause of adult disability 750,000 new cases/year in U.S. 150,000 deaths/year 1/3 Under age 65 6 Forces of Change 1. Public expectations Aware of Draino for the Braino

2. Medical - legal pressures 3. Managed care cost concerns - Long term vs Short Term 4. New/better treatments 5. Physicians willing/able to treat - Evidenced based medicine 7 Organized Stroke Care

Saves Lives 21% reduction in early mortality 18% reduction in 12 month mortality Decreased length of hospital stay Decreased need for institutional care Source: Jorgenson, Stroke, 1994 8 What are we talking about here? Ischemic Stroke (84%) Hemorrhagic Stroke (16%)

These have very different needs Philosophy in treatment takes a different direction Traumatic Brain Injury (TBI) Not talking about today PHTLS 9 Ischemic Stroke

HYPOperfusion Embolic (20% had a-fib) Thromboembolic GOAL of Treatment 1. Restore Circulation 2. Stop Ischemia 10 What is this rt-PA Recombinant Tissue Plasminogen Activator

Review of clotting cascade Collagen Exposed Vessel injury Damage

Long term wear Embolus Clotting factors aggregate Fibrin Repair (Bond-O) FIBRINOLYSIS 11 Intra-venous fibrinolysis for acute ISCHEMIC stroke Class I IV - t-PA within 3 hours of onset

Class Indeterminate IV - t-PA between 3 and 6 hours of onset 12 Intra-arterial thrombolysis TPA, Urokinase, Anti-platelet All experimental in the 3-6 hour window Lower doses, delivered right to clot Snare devices Reach in and grab it

Vessels sometimes too small to get into Mechanical devices Angiojet rotating blade Ultrasound Lasers 13 With rt-PA, considering 1,000 eligible patients: Hospitalization costs = $1.7 million more Rehabilitation costs = $1.4 million less Nursing home costs = $4.8 million less

564 quality-adjusted life-years saved Source: Fagan, Neurology 1998 14 NIH National Symposium Recommendations Door-to-MD:> 10 minutes Door-to-Neurologic Expertise: > 15 minutes Door-to-CT scan:> 25 minutes Door-to-CT Interpretation: > 45 minutes Door-to-Drug:(80% compliance)

> 60 minutes Door-to-Admission:> 3 hours 15 Stroke Chain of Survival & Recovery Detection: Early recognition Dispatch: Early EMS activation Delivery: Transport & management Door: ED triage Data: ED evaluation & management Decision: Specific therapies Drug: Thrombolytic & future agents

16 Dispatch & Delivery: Transport & Management ABCs

Stroke recognition Establish time of onset Perform neurological evaluation Check glucose Early hospital notification Rapid transport 17 Cincinnati Pre-Hospital Stroke Scale Facial Droop Normal: Both sides of face move equally

Abnormal: One side of face does not move at all 18 Cincinnati Pre-Hospital Stroke Scale Arm Drift Normal: Both arms move equally or not at all Abnormal: One arm drifts compared to the other 19

Cincinnati Pre-Hospital Stroke Scale Speech Normal: Patient uses correct words without slurring Abnormal: Slurred or inappropriate words or mute 20 NIH Stroke Scale Item

1a 1b 1c 2 3 4 5 6 7 8 9 10 11

12 13 Description LOC LOC Questions LOC Commands Best Gaze Best Visual Facial Palsy Motor Arm Left Motor Arm Right Motor Leg Left

Motor Leg Right Limb Ataxia Sensory Neglect Dysarthria Best Language Range 03 02 02 02 03

03 04 04 04 04 02 02 02 02 03 21

12 cranial nerves check I smell II vision III pupil constriction, eye movement IV downward gaze V facial sensation VI lateral eye movement

VII taste, frown, smile VIII hearing, balance IX taste, gag, swallowing X voice XI shoulder shrug XII tongue movement 22

Preparation Know your stroke team before you need them Check glucose Two large IV lines Oxygen as needed Cardiac monitor Continuous pulse-ox Stat non-contrast CT scan ECG CXR Get rt-PA > Prepare to mix > Have pharmacy alerted

Discuss options with patient and family Contact primary care provider 23 American Heart Association Recommendations Oxygen Use to correct hypoxia Suggestion that supernormal levels may hurt > one year survival 69% 3L NC vs 73%

control Glucose Maintain euglycemia Treat glucose > 300 mg/dl with insulin 24 Source: Rnning, Stroke 1999 True Time of Onset How normal were they? What are they like at baseline? Who saw them last? Clearly no symptoms? Times of reference

Television The time the basketball game started 25 Stroke Risk Factors Modifiable risk factors Non-modifiable risk factors

High blood pressure Cigarette smoking Transient ischemic attacks Heart disease Diabetes mellitus Hypercoagulopathy Carotid stenosis

Age Gender Race Prior stroke Heredity Bruits Other 26

Differential Diagnosis Intracerebral hemorrhage Hypoglycemia / Hyperglycemia Seizure Migraine headache Hypertensive crisis Epidural / Subdural Meningitis / Encephalitis / Brain abscess Tumor

27 What are the Options? No thrombolytics Nothing Aspirin Heparin Intravenous rt-PA

Other Intra-arterial thrombolytics Investigative procedure 28 Exclusions to Thrombolytics Bleeding concerns Stroke/head trauma in 3 mos Major surgery<14 days Hx of intracranial hemorrhage

Seizures at the onset of stroke SBP > 185 mm Hg DBP > 110 mm Hg

Symptoms suggestive of hemorrhage GI hemorrhage within 21 days Urinary tract hemorrhage within 21 days Arterial puncture at noncompressible site < 7 days Rx anticoagulants Possibly not indicated or wrong diagnosis

Rapidly improving or minor symptoms Glucose < 50 or > 400 mg/dl Possible Setup for DIC/other metabolic disorders

Heparin within 48 hours PTT High PT High INR High Platelet count low 29 Lets talk about blood pressure MAP Mean Arterial Pressure (70-90 Normal) Systolic (2 Diastolic ) 3

ICP Intracranial Pressure Normally about 0-15mmHg >20 = Bad CPP Cerebral Perfusion Pressure CPP=MAP-ICP CPP must be above 70mmHg for cerebral perfusion You do the math 30 IF CPP=MAP-ICP And we know that the body autoregulates

pressures to preserve itself 80-90% of ischemic strokes present with elevated BP ICP may have risen because of Edema 31 Studied: Multicenter Study 372 patients Compared Neuro outcome vs BP changes in first 24 hours If Diastolic BP decreased by >25% (even once) Poorer outcomes regardless of baseline diastolic BP

levels, Stroke location or use of HTN agents NO EVIDENCE THAT LOWERING BP HELPS Remember were still talking about ischemic strokes FAIR Evidence that it harms 32 BP Treated in extreme cases Gentle management if thrombolytic candidate: SBP > 180 mm Hg DBP > 110 mm Hg

Choices: Labetalol Enalapril Nitropaste 33 Treatment Considerations: Who will benefit from rt-PA? Patient age Co-morbid factors Medical history Risks of treatment Odds of Presenting

Benefits of Treatment Odds of surviving 34 Treatment considerations (contd) Time from onset (Remember 3 hours) Stroke severity Stroke subtype Data driven here too CT findings

Assymetry = Bad Density image Tissue/fluid ratio Charcoal=Normal Dark = Higher density (more tissue than fluid) Ischemia Light = Lower density (More fluid than tissue) Hemorrhage Tumor 35 Which one is which?

36 Factors Associated with Increased Risk of ICH Treatment initiated > 3 hours Increased thrombolytic dose Elevated blood pressure

NIHSS > 20 * Acute hypodensity or mass effect * * Even though increased r/o ICH, still with benefit vs. placebo 37 Stroke Treatment Aspirin Two important trials: > International Stroke Trial > Chinese Acute Stroke Trial Combined analysis (n=40,090) Death / nonfatal strokes reduced 11% Dont forget to check swallowing

Local protocol driven 38 Stroke Treatment Heparinoids Decreased recurrent ischemic strokes Increased hemorrhagic events No net stroke benefit 39 The "Golden Hour" of Acute Ischemic Stroke

> Case Study History: A 61 year old male, with acute aphasia, right facial droop, and right sided weakness. 40 12:30 Sudden onset while working in yard. 12:45 Family calls 911. 13:05 Advanced squad evaluates neurologic deficits and glucose. 13:15 Squad notifies receiving hospital of

possible stroke patient 13:30 ED arrival. Initial evaluation by E.D. physician. 13:45 Stroke Team arrives. NIHSS 18. 14:00 CT scan performed. 14:15 Discuss with family and PMD. 14:20 Labs back: gluc 97. BP remains 150/70s. 14:20 CT reading back. No hemorrhage or early signs of ischemia 41 42

14:25 Checklist done. No exclusion criteria met. 14:30 Decision time. 14:35 IV rt-PA given. 0.9 mg/kg total > 10% bolus - 9 mg > 90% over 1 hr - 81 mg 15:45 Patient goes to ICU. Report personally given to ICU staff. 15:50 Pathway actions begin (HOB, BP parameters, aspiration precautions). 43

24 Hour Follow-up A 61 year old male, with acute stroke, treated with rt-PA. Repeat NIHSS = 3: VF intact No gaze palsy Mild facial palsy Mild right arm drift Mild dysarthria 44

Hemorrhagic Stroke Treatment Goals (Different) 1. Reduce the risk of re-bleed 2. Reduce risk of continued bleeding 45 Hemorrhagic Stroke (16%) Bleeding into or surrounding the brain Intracerebral Hemorrhage (ICH) HTN Tumor/Lesions Venous sinus thrombosis

Drains from the dura mater Amyloid angiopathy Starch-like deposits on vessel walls- precursor 46 Hemorrhagic Stroke (16%) Bleeding into or surrounding the brain Sub-arachnoid hemorrhage (SAH) Blood in arachnoid space, basal cisterns &

often intraventricular Aneurysm rupture Trauma Arteriovenous malformation (AVM) 47 Some Skull Ground Rules

Monroe-Kellie Hypothesis Intracranial space/volume constant Three components = ICP CSF 100mL Production/absorption is pressure driven Blood 150mL Here lies the problem K VCSF VBlood VBrain Brain 1250mL (or grams) Relatively constant (IS H2O minimally displaceable)

48 Head Bleeds Still assuming a closed system (non-trauma) ICP will rise BP will rise Remember autoregulation (compensatory)

If SBP>230 & DBP > 120 Sodium Nitroprusside 0.5mcg/kg/min If SBP>180 & DBP >105 Labetolol 10mg/1-2min Double q10 to 300mg If Hypertensive, but not extremely high LEAVE IT ALONE 49

Benefits of playing with BP Decrease Edema Limit size of damaged area Limit further vascular damage Might actually need a fluid bolus 1 Hypotensive episode-mortality 30+ % 50

Risks of playing with BP TOO MUCH TOO FAST Can extend stroke by eliminating tamponade Expose patients to medication reactions Goal SBP < 160 DBP < 100 Sometimes use a 20% of original rule 51

Respiratory Management Intubate patients with GCS < 8 Paralyze & Heavily Sedate 11th commandment Causes of Increased ICP Gagging Puking

Stress Respiratory distress Cause increased intra-thoracic pressure Decreases cerebral drainage 52 Respiratory Management Post-intubation Use LA paralytic Watch BP Carefully for hypotension 53

Respiratory Management Hyper-oxygenate DO NOT hyperventilate CO2 is POTENT vasodilator Hypocarbia causes cerebral vasoconstriction Vasoconstriction causes edema ICPs may rise CPP will drop Loss of autoregulation Brain death 54 Adjuncts

SpO2 Monitoring (Volume) Bag to keep sats at 95-100% (This might be VERY slow) 5-7mL/kg CO2 Monitoring (Rate) Bag slow enough to keep EtCO2 28-32 (40ish is normal) 55 Other treatments considered Osmotic Diuretics

Mannitol (comes in and out of favor) Anticonvulsants Prevent seizures Anti-emetics May operate on bleeders Often too late by the time it is diagnosed 56 Questions

57 Some pictures, Just for fun 58 59 60 61 62

63 64 65 66 67 68


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