Transcript Developing Acute Stroke Services Diagnosing Screening

Developing Acute Stroke Services
Diagnosing
Screening
Acute Care pathways
Thrombolysis
Dr C. Roffe
Clinical Lead Shropshire and Staffordshire
Heart and Stroke Network
Patient or bystander recognizes stroke
Dial 999
Ambulance response
Blue-light FAST positive potential strokes to A&E
Fits thrombolysis criteria
pre alert A&E
Does not fit thrombolysis
criteria
Immediate assessment
Thrombolysis pathway
and CT within 15 min
Stroke pathway and CT
within 1 hour
Thrombolysis
Admit to ASU within 4 h of presentation
Diagnosing Stroke and TIA
F A S T
Face–Arm–Speech Test
F Facial weakness: Can the person smile? Has their mouth
or an eye drooped?
A Arm weakness: Can the person raise both arms?
S Speech problems: Can the person speak clearly and
understand what you say?
T Time to call 999.
ROSIER
Recognizing Stroke in the Emergency Room
Only count new symptoms
Exclude hypo by BM stix
Unilateral facial weakness?
y (1) n (0)
Unilateral arm weakness?
y (1) n (0)
Unilateral leg weakness?
y (1) n (0)
Speech disturbance ?
y (1) n (0)
Visual field defect?
y (1) n (0)
Any loss of consciousness or syncope y (-1) n (0)
Any seizures?
y (-1) n (0)
Rosier >0 suggests ischaemic stroke and potential thrombolysis case
Stroke or TIA?
• Symptoms still present => Stroke
• Symptoms gone =>TIA
WHO DEFINITION OF
STROKE
A NEUROLOGICAL DEFICIT OF
• Sudden onset
• With focal rather than global dysfunction
• In which, after adequate investigations,
symptoms are presumed to be of nontraumatic vascular origin
• and last for >24 hours
Stroke onset
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Witness?
Woke with hemiparesis?
Found collapsed?
Sudden/gradual/ stuttering
ABCD2 Scoring for all new TIAs
Symptom
Score
Age > 60 years
1 point
Blood pressure > 140/80
1 point
Clinical (neurological
deficit)
2 points for hemiparesis
1 point for speech problem without
weakness
Duration
2 points for >60 minutes
1 point for 10-60 min
Diabetes
1 point
Stroke risk within 1 week 6% for scores 4-5, 12% for scores >5
Admit all with score 5 or above.
TIA management
• Do not allow any TIA patient to leave the department
without having administered the first dose of antiplatelet
• ABCD 4 or above admit or ensure TIA clinic appointment
(and Doppler) within 24 hours.
• Endarterectomy within 48 h for patients with
symptomatic stenosis
• ABCD <4 see in TIA clinic within 1 week.
Endarterectomy within 14 days for patients with
symptomatic stenosis
This will reduce strokes within 1 week by 80%!!!
Role of Paramedics
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Establish working diagnosis of stroke/TIA
Identify potential thrombolysis candidates
Prealert A&E if thrombolysis an option
Establish onset time
Bring a witness
Airway Breathing Circulation
Exclude Hypo BM
Prevent aspiration
Get patient to nearest hyper acute stroke centre
Investigations and tests in the early
stages
CT Head scan
Intracerebral haemorrhage
Cerebral Infarct
• Thrombolysis or
• immediate antiplatelet
treatment
• Correct abnormal INR or low
platelets immediately
• Neurosurgical referral
Early signs of infarction
Loss of insular ribbon
14.jpg
SW, day 1
Early signs of infarction
Effacement of sulci
SW, day 1
CT angiogram
Diffusion Perfusion CT
Other tests
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FBC
U&E
INR
Glucose
ECG
Carotid Doppler
Thrombolysis
Why?
DH A New Ambition for Stroke
A consultation document for a
National Stroke strategy Dec 2008
If 10% of stroke patients in the UK were
given thrombolysis, 1000 people less would
be dead or dependent in one year.
http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/Publicati
onsPolicyAndGuidance/DH_081062
NINDS trial of rt-PA for acute
ischaemic stroke
• 633 patients recruited
• Rt-PA 0.9 mg/kg (10% bolus the rest over 1 h) given within 3 hrs of
symptom onset
• BP<185/110
• Not on warfarin or heparin, platelets and coagulation normal
• Blood glucose 2.7-22 mmol/L
• No seizure at onset
Quasi intensive care environment
Aggressive BP control
16,000 screened to recruit 633
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N Engl J Med 1995;333:1581-1587
NINDS rt-PA trial 1995
Improvements in dependency (modified Rankin Scale: mRS)
Normal
Needs
No
help
INDEPENDENT
Wheelchair
Dead
DEPENDENT
Mean Score 2.8 for rt-PA and 3.3 for control : difference 0.5 mRS points*
Number needed to treat to improve by 1 point is 2*
Number needed to treat to improve by 1 or more points is 3**
Number needed to treat to make one patient more independent =5*
* My own calculation bases on the original paper
** Saver. Arch Neurol, Jul 2004; 61: 1066 - 1070.
Eligibility
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Age 80 or below
Previously fit and independent
Onset time known and less than 3 hours
CT excludes haemorrhage
Exclusions
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Recent surgery, biopsies arterial cannulation
Increased bleeding risk
Past history of intracranial haemorrhage
Any CNS pathology other than current stroke
Any past stroke plus diabetes
Stroke within 3 months
Systolic blood pressure >185
Alteplase (rt-Pa)
• 0.9 mg/kg body weight
• 10% as bolus over 2 min
• 90% as infusion over 1 hour
No heparin for 24 hours
Post thrombolysis Care
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Needs trained team / ASU
Neurological observations (NIHSS)
Blood pressure
Observation for complications
Scan at 24 h
Prevent recurrence
Early Doppler/ CTangio in recovered cases
The acute stroke pathway
How can I make sure my patient
will do well?
Most complications of stroke
develop in the first 24 hours
Management in the first few hours
has a major effect on outcome
and LOS
Important factors for successful
early stroke rehabilitation
• Mobilise ASAP
The probability of returning home decreases by 20% for each
day the patient is not mobilized
• Maintain normal haemodynamic and
biochemical environment
• Prevent complications
• Keep patient and family informed
1. Transfer to ASU within 4 h or
less of admission
2. Prevent Aspiration
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Swallow screen on arrival on ASU
Sit up
Drowsy patients in recovery position
Antiememtics for haemorrhages and
patients who feel sick
• All members of staff have at least basic
knowledge of the diagnosis and
management of swallowing problems
3. Prevent hypotension and
dehydration
• IV saline
• Sufficient fluids by mouth or ngt
4. Prevent pneumonia
Mobilization
Mouthcare
Dysphagic patients have impaired oral movements resulting in debris, pooled secretions and
tongue coating.
5. Prevent hospital acquired
infections
MRSA/ ESBL/ C.Difficile
Avoid catheters at all costs
Hand hygiene
Bed spacing
Appropriate antibiotics
6. Prevent starvation
7. Prevent stagnation and
deterioration
• Time does not cure strokes
• Give at least 45 min of each therapy needed every day 7/7
7. Detect and treat problems
early
• 72 hour monitoring
• Neurological scores (NIHSS/SSS)
• Daily consultant ward rounds 7/7