Acute Stroke and Seizure in the Prehospital Setting

1. Evie Marcolini Assistant Professor Emergency Medicine, Neurocritical Care, Surgical Critical Care Yale University School of Medicine New Haven, Connecticut Acute Stroke and Seizure in the Prehospital Setting

2. Objectives • Epidemiology of Stroke • Current treatment guidelines for acute stroke care • Prehospital care for acute stroke • Epidemiology of seizure • Current treatment guidelines for seizure • Current prehospital care for seizure

3. Stroke • 3rd leading cause of death • Highest cause of disability • Average time from symptom onset to ED is 17-22 hours • Only 25% arrive within 3 hours

4. Stroke • 42% of people over 50 years do not recognize signs and symptoms of stroke • After a stroke or TIA, the risk of a second event increases to 14 %

5. Stroke Two types of stroke: • Ischemic: 75% of strokes • Hemorrhagic: can be intraparenchymal, or caused by subdural, epidural or subarachnoid hemorrhage

6. Stroke • For ischemic stroke, just as in myocardial infarction, we know that the key to improving outcome is the time to opening up the blocked vessel • The most common method of this is to use tissue plasminogen activator (tPA)

7. Stroke • There is some controversy around using tPA, so I would like to take you through the data first • NINDS • ECASS III • IST-3

8. Stroke NINDS • 624 patientswithin 3 hours of symptom onset • Randomized to tPA versus placebo • 32% relative increase in patients with minimal or no disability at 3 months on modified Rankin Scale (mRS)

9. Stroke NINDS • Symptomatic intracranial hemorrhage 7% (vs 1% for placebo) • No significant mortality difference • When studied 1 year out, outcomes and mortality were similar

10. Stroke

11. Stroke • The fact still remains that only 25% of patients show up within the time frame of 3 hours • The next question was: • Can we give tPA to patients who are greater than 3 hours from symptom onset?

12. Stroke • 821 patients randomized to tPA vs placebo within 3-4.5 hours • Age < 80 • Excluded patients with prior stroke or diabetes

13. Stroke • Favorable outcome: 52.4% vs 45.2% for 0/1 on mRS • Symptomatic intracranial hemorrhage 2.4% vs0.2% • No significant mortality difference

14. Stroke What can we take from ECASS III? • We can extend the time window for giving tPA to stroke patients, but must consider the characteristics of the study patients. (no prior stroke, elderly or very sick)

15. Stroke What can we take from ECASS III? • Even though these patients can be treated, the fact still remains that patients do better the earlier they get tPA (this we know from NINDS, which showed that very old patients with severe stroke did better with treatment)

16. Stroke • -3,035 patients, international multicenter study • tPA given within 6 hours of symptom onset • Unblinded, no placebo • Pragmatic design means that the patient gets tPA if both the physician as well as the patient believe that it would be beneficial

17. Stroke • -3,035 patients, international multicenter study • Pragmatic designed studies are well-known to give a distinct advantage to the treatment group • Nonblinded trials tend to enhance the effect of any intervention in comparison to control groups

18. Stroke: IST-3 • Very controversial • tPA failed to reduce death or dependence at 6 months • There was no discernible relationship between timing of administration and drug effect

19. Stroke: IST-3 • Effect was good in the first 3 hours, harmful for the next 90 minutes, and then good in the following 90 minutes • These results are biologically nonsensical and suggest that time differences do not mediate the drug effect

20. Stroke: IST-3 • In spite of the results, the investigators concluded that the study was positive. • Describe “secondary exploration” of data, using ordinal analysis, which shifted some patients toward better categories of outcome, despite not shifting them toward being alive or independent, which was the primary outcome.

21. Stroke: IST-3 • “For the types of patient recruited in IST-3, despite the early hazards, thrombolysis within 6 hours improved functional outcome. Benefit did not seem to be diminished in elderly patients”

22. Stroke So at the end of the day, where do we stand with tPA? • Given within 3 hours, the data shows improvement, and there is no strong data beyond 3 hours.

23. Stroke • But patients that have larger, more proximal clot did not do well with thrombolysis. In NINDS, patients with NIHSS >20, 48% were dead at 3 months, 21% had moderate to severe impairment (mRS 4/5) • We then ask: is there a better therapy?

24. Stroke Endovascular therapy • Includes intra-arterial thrombolytic, and mechanical thrombectomy • The treatment window expands up to 8-48 hours

25. Stroke Endovascular therapy • We consider interventional therapy for major deficits and large vessel occlusion, such as internal carotid, middle cerebral, vertebral and basilar arteries

26. Stroke Endovascular therapy • The window typically expands to 8 hours, but if there is a large basilar artery occlusion, the prognosis is so poor that it can only get better.

27. Stroke PROACT II • 1999, 180 patients with acute ischemic stroke, presenting within 6 hours of symptoms and MCA occlusion • Randomized to 9 mg of intra-arterial pro urokinase plus heparin, or heparin alone

28. Stroke PROACT II • Improved mRS <2 or 40% vs 25% • Improved recanalization rate of 66% vs 18% • Similar intracranial hemorrhage rate of 10% vs 2% • No change in mortality

29. Stroke • In 2004, we started studying mechanical thrombectomy devices

30. Three studies looked at mechanical thrombectomypublished in March of 2013: they did not show improved outcome

31. One of the major limitations of all 3 studies was the use of the older devices, which are less effective than the newer stent retrievers

32. Nonetheless, mechanical thrombectomy is continuing to increase in practice, with the numbers of these procedures doubling from 2008 to 2010 alone.

33. This study was a registry named “Get with the Guidelines” • It enrolled 58,000 patients from 2003-2012 in 25% of all US hospitals

34. For every 1,000 treated patients, there were 18 more with improved ambulation, 8 more fully independent, 13 more to an independent environment, 7 more to home and 4 fewer dying

35. The message is that we need to support efforts to get patients to treatment more quickly and to streamline regional and hospital systems of acute stroke care • This is where prehospital personnel become very important

36. Stroke • Prehospital providers play a critical role in the emergency care of stroke patients • In the US, half of all stroke patients use emergency medical services (EMS), but this comprises the majority of the patients who present within the 3 hour window

37. Stroke • EMS use decreases time to hospital arrival and the ability to implement acute stroke intervention

38. Stroke Goals for prehospital stroke care • Reduce stroke mortality • Improve quality of life for stroke survivors and their families • Increase public awareness • Timely initiation of dispatch system

39. Stroke Goals for prehospital stroke care • Streamline EMS identification of stroke • Rapid delivery to a stroke center, which is a hospital that has the available resources to swiftly treat stroke

40. Public Education Emergency Dispatch EMS Response Transport to Stroke Center Code Stroke Team Response • Public Service Announcements – FAST, “Give Me Five”, Radio and Television • Emergency Dispatch Education and Priority Dispatch for Stroke – same priority level as for Myocardial Infarct – using FAST or “Give Me Five” criteria

41. Public Education Emergency Dispatch EMS Response Transport to Stroke Center Code Stroke Team Response • Specific Protocols for Stroke – priority transport to stroke center, activation of “Code Stroke” team prior to arrival at stroke center • “Code Stroke” notification in hospital and team response • Quality improvement review of each case with EMS and hospital involvement

42. Stroke National Stroke Association • “FAST”: face (smile), arms (weakness), speech (slurred), time (onset)

43. Stroke ACEP, AAN, ASA Stroke Collaborative • “Give Me Five for Stroke”: • Walk (balance) • Talk (speech) • Reach (weakness) • See (vision) • Feel (headache)

44. Stroke: Prehospital Protocol • Suspect stroke if FAST criteria met • Early hospital notification, transport to stroke center • Basic EMT: manage airway, request advanced life support (ALS), perform point of care glucose test

45. Stroke: Prehospital Protocol • Paramedic (ALS): cardiac monitor, intravenous access, administer glucose if blood glucose < 80 and check again in 5 minutes

46. Stroke: Prehospital Protocol • If IV unavailable, do not place intraosseous device (IO), but give glucagon by intramuscular method • Contact medical control for option of repeating glucose, repeating glucagon or placing an IO

47. Stroke: Prehospital Protocol Cincinnati Prehospital Stroke Scale • Speech: have patient say “you can’t teach an old dog new tricks” • Abnormal = wrong word, slurred or absent speech • Facial droop: when asked to smile • Abnormal = one side doesn’t move as well

48. Stroke: Prehospital Protocol Cincinnati Prehospital Stroke Scale • Motor: have patient close eyes and hold out both arms • Abnormal = arm cannot move, or drifts down

49. Stroke: Prehospital Protocol • If stroke scale is positive, determine time of “last seen normal,” and record contact information of person who is able to confirm “last seen normal” • As early as possible, notify the receiving hospital of “Code Stroke”

50. Stroke: Prehospital Protocol “Code Stroke” information • Patient age and gender • Potential stroke patient • Neurologic deficits and Cincinnati Stroke Scale findings