STROKE CARE IN THE EMERGENCY

SETTING

Ann M. Hoff, MD

ETC Physician

Trinity Health

American Stroke Association

Guidelines for the Early Management of Adults with Ischemic Stroke (2007)

“Time is Brain”

Stroke Facts

In the US, someone has a stroke every 40 secondsEvery 3-4 minutes, someone dies of stroke

> 700,000 strokes and > 150,000 stroke deaths each year

Stroke is the 3rd leading cause of death

Stroke is the leading cause of long-term disability

Ischemic strokes account for 85% of all strokes

In 2009, stroke cost the US $68.9 billion

Stroke Signs/Symptoms

5 most common signs/symptomsSudden numbness/weakness of the face, arm,

or legSudden confusion or trouble speaking or

understandingSudden trouble seeing in one or both eyesSudden dizziness, trouble walking, or loss of

balance/coordinationSudden severe headache with unknown cause

Stroke Risk – Race/Ethnicity

African Americans have the double the risk of stroke in comparison to Caucasians

Hispanic Americans fall between Caucasians and African Americans

African and Hispanic Americans are more likely to die following a stroke than are Caucasians

Stroke Risk - Age

Nearly one quarter of strokes occur in people under the age of 65

Stroke Risk Factors

In 2003, approximately 37% of adults reported having two or more of the risk factors listed above.

US Stroke Map

Hospitalizations

Mortality

ND Hospitalizations

ND Mortality

Prehospital Management

EMS Utilization29-65%

62-95% of EMS activations occurred by an individual other than the patient

Dispatcher identified 52% of patients ultimately proven to have had a stroke on the initial telephone conversation

19-60% present within 3 hrs

14-32% present within 2 hrs

Decreased time to physician exam, CT, and neuro evaluation

EMS Care

Rapid identification of stroke

Identification of possible stroke mimics19-31%

ABCs Transport Notify ER

Community Ambulance

Cincinnati Stroke Scale

ACT F.A.S.T.Facial DroopArm WeaknessSpeechTime

Golden Hour of Stroke

Emergency Room Care

The First 15 MinutesAcute Stroke Protocol

○ Focused H&P○ NIHSS○ Labs○ IVs○ EKG○ Weight○ Alert pharmacy to possible need for tPA○ Order CT scan

Stroke Alert Team Response

ER MD Neuro MDRecorder

EKG CT TECH LAB

Radiologist

Clinical Assessment

http://www.youtube.com/watch?v=gUkQmY33Hhc&feature=player_embedded#!

Treatment

Emergency TreatmentBased on results of head CT and time of

symptom onset

No blood on CT, < 3hrs from onsetReview inclusion/exclusion criteriaObtain consentIf tPA given, admit to ICU for 24 hrs

No blood on CT, > 3hrs & < 8 hrsOff-label IV tPA up to 4.5 hrsFurther imaging may expand treatment options:

○ CT angiogramIA tPAMechanical thrombectomy

- MERCI clot retrieval system (8/2004)- Penumbra system (12/2007)

No blood on CT, > 8 hrs325 mg of aspirin

○ Reduces early death○ Reduces long-term disability

Prevention1 in 8 stroke survivors will have another stroke

within 5 yearsTreatment of underlying cause is important

Education

RehabilitationPT/OT to relearn skills

Resources

Management of Ischemic Stroke: Part 1. Emergency Room Management. Journal of Hospital Medicine. Vol 5; No1; January 2010.

Guidelines for the Early Management of Adults with Ischemic Stroke. Stroke 2007, 38:1655-1711; April 12, 2007.

CDC American Heart Association American Stroke Association National Stroke Association Mayo Clinic Genentech