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Stroke Systems and Stroke Scales in the Management of Acute Stroke Patients

Stroke Systems and Stroke Scales in the Management of Acute Stroke Patients. Kama Guluma, MD. Kama Guluma, MD Assistant Professor Department of Emergency Medicine University of California San Diego Medical Center San Diego, CA. Objectives.

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Stroke Systems and Stroke Scales in the Management of Acute Stroke Patients

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  1. Stroke Systems and Stroke Scales in the Management of Acute Stroke Patients Kama Guluma, MD

  2. Kama Guluma, MDAssistant ProfessorDepartment of Emergency MedicineUniversity of California San Diego Medical CenterSan Diego, CA

  3. Objectives • Understand the concept of Stroke Systems and Stroke Centers, and the benefits these provide to ED physicians and the patients we care for • Understand the concept of EMS triage of stroke patients • Understand what the NIHSS stroke scale means for the clinical exam and clinical decision making • Understand what the mRS, GOS and BI mean for a interpretation of stroke outcome Kama Guluma, MD

  4. Stroke Team Response Stroke Unit Patient Awareness 911 Call EMS ED The Stroke Chain-of-Survival Kama Guluma, MD

  5. The Problem Blind Men and the Elephant, by Antonello Silverini Kama Guluma, MD

  6. The Problem • Fragmentation of health care delivery results in suboptimal treatment, errors, and safety concerns • There may be a lack of expertise or resources at one or another site • Exacerbated in rural or underserved areas Blind Men and the Elephant, by Antonello Silverini Kama Guluma, MD

  7. The Brain Attack Coalitiona multidisplinary group • American Academy of Neurology • American Association of Neurological Surgeons • American Association of Neurosciences Nurses • American College of Emergency Physicians • American Heart Association • American Society of Neuroradiology • National Institute of Neurologic Disorders and Stroke • National Stroke Association • Stroke Belt Consortium Kama Guluma, MD

  8. The Trauma System Kama Guluma, MD

  9. 2000: Brain Attack Coalition Primary Stroke Centers Kama Guluma, MD JAMA 2000; 283:3102-3109

  10. Patient Care Areas Emergency medical services Emergency Department Acute stroke teams Written protocols Stroke unit Neurosurgical services Support Services Commitment & support of medical organization; stroke center director Neuroimaging services Laboratory services Outcome & quality improvement activities Continuing medical education PRIMARY STROKE CENTERSKey recommendations by the BAC Kama Guluma, MD

  11. PRIMARY STROKE CENTERSKey recommendations by the BAC • EMS: • High-priority stroke transports • Written agreements and transport protocols • Fluid administrative line of communication between Stroke Center and EMS • Cooperative educational activities at least semi-annually Kama Guluma, MD

  12. PRIMARY STROKE CENTERSKey recommendations by the BAC • Emergency Department: • ED personnel trained in stroke care • Established lines of communication with EMS to prepare for stroke patient arrival • ED representation on Stroke Team • Triage protocol • Treatment protocol (e.g., diagnostics, meds, imaging, BP mgm’t) • Stroke treatment education semiannually Kama Guluma, MD

  13. PRIMARY STROKE CENTERSKey recommendations by the BAC • Acute stroke team: • A physician with cardiovascular expertise + another person (nurse, PA, NP) • Available 24/7 to respond to acute stroke • Specific and organized paging mechanism • 15-minute response time • Log and CQI process Kama Guluma, MD

  14. PRIMARY STROKE CENTERSKey recommendations by the BAC • Stroke Unit • nurses and physicians with stroke training • BP monitoring • can be part of an ICU (e.g. dedicated beds) • Neurosurgical service • 24/7 access (in house or via transfer) within 2 hrs • call schedule, written transfer agreements • Neuroimaging • 24-hour availability • brain CT or MRI within 25 minutes • radiologist or neurologist read within 20 minutes (in house or via teleradiography) • Laboratories with 45 minutes Kama Guluma, MD

  15. PRIMARY STROKE CENTERSExpected benefits • Improved efficiency of patient care • Increased use of acute stroke therapies • Fewer complications • Reduced mortality and morbidity • Improved long term outcomes • Reduced costs to healthcare system • Increased patient satisfaction Kama Guluma, MD

  16. PRIMARY STROKE CENTERS Implications/benefits for the Emergency Physician • Acute care supported by a Stroke Team (of which EM would/should be an integral part) and the institution • Streamlined protocols for patient disposition (ICU, transfer, admission) • Institutionalized neurology, neuroradiology and neurosurgical backup • Collateral improvements (ICH, SDH, SAH, imaging, labs) • Education/CME Kama Guluma, MD

  17. JCAHO Certification Joint Commission on Accreditation of Health Care Organizations Kama Guluma, MD

  18. Kama Guluma, MD

  19. 2005: Brain Attack Coalition Comprehensive Stroke Centers Kama Guluma, MD Stroke. 2005;36:1597-1618.

  20. COMPREHENSIVE STROKE CENTER • Specialized tertiary care referral center (None “certified” yet) • In house, 24/7, specialty teams: e.g., interventional neuroradiology, neurosurgery, neurology • Might get the “after 3 hour” crowd, large strokes, complex cases, after stabilization at PSCs • A place to refer post t-PA patients if needed • Research protocols • Telemedicine? Kama Guluma, MD

  21. Beyond Individual Stroke CentersSTROKE SYSTEMS Kama Guluma, MD Stroke. 2005;36:690-703

  22. Beyond Individual Stroke CentersCity-wide systems of stroke care • Birmingham, AL (with direct EMS Triage) • Cincinnati, OH • Dallas, TX • Houston, TX • New York, NY (with direct EMS Triage) • Ann Arbor, MI Kama Guluma, MD

  23. Beyond Individual Stroke CentersState-wide systems of stroke care From Lily Chaput, MD, California Dept of Health Services Kama Guluma, MD

  24. EMS Triage of Stroke Kama Guluma, MD

  25. Cincinnati Prehospital Stroke Scale One positive = possible stroke From the National Institute of Neurological Disorders and Stroke Kama Guluma, MD

  26. LA Prehospital Stroke Scale “Stroke Code” from the field From the National Institute of Neurological Disorders and Stroke Kama Guluma, MD

  27. Stroke alert from the field Dallas Area Stroke Council Stroke Evaluation Sheet From the National Institute of Neurological Disorders and Stroke Kama Guluma, MD

  28. Birmingham Regional Emergency Medical Services System Used to enter patients into Stroke System From the National Institute of Neurological Disorders and Stroke Kama Guluma, MD

  29. Paramedic accuracy at diagnosing stroke Kama Guluma, MD

  30. Stroke Scales Kama Guluma, MD

  31. The utility of clinical scales • Allow gross quantification of injury/pathology • Aid in communication to consultants • Can be used to track improvement or deterioration in the acute treatment phase • Can be used to track outcome • Can be useful research tools Kama Guluma, MD

  32. The NIH Stroke Scale Kama Guluma, MD

  33. The Stroke-focused Neuro ExamThe NIHSS • Level of consciousness • Gaze • Visual fields • Facial strength • Arm strength • Leg strength • Limb ataxia (FNF, heel-down-shin) • Sensation (pinch/pinprick) • Language (re: aphasia) • Dysarthria • Extinction/inattention (bilat sensory) Maximum Score = 42 Maximum score from ischemic stroke = 31 Kama Guluma, MD

  34. The NIH Stroke Scale LEVEL OF CONSCIOUSNESS Kama Guluma, MD

  35. The NIH Stroke Scale GAZE VISUAL FIELDS Kama Guluma, MD

  36. The NIH Stroke Scale FACIAL MOTOR Kama Guluma, MD

  37. The NIH Stroke Scale MOTOR OF THE ARM MOTOR OF THE LEG ATAXIA Kama Guluma, MD

  38. The NIH Stroke Scale SENSORY Kama Guluma, MD

  39. The NIH Stroke Scale LANGUAGE Kama Guluma, MD

  40. The NIH Stroke Scale DYSARTHRIA Kama Guluma, MD

  41. The NIH Stroke Scale EXTINCTION/NEGLECT Kama Guluma, MD

  42. What the NIHSS score means to the EP • NIHSS 1 - 4: mild stroke • NIHSS 5 -15: moderate stroke • NIHSS 15 – 20: moderate to severe stroke • NIHSS > 20: severe stroke • Prognosis: likelihood of favorable outcome • NIHSS < 10: 60 – 70% • NIHSS > 20: 4 -16% Stroke. 2003;34:1056 –1083. Kama Guluma, MD

  43. What the NIHSS score means to the EP NIHSS vs Outcome at 3 months Kama Guluma, MD Adams HP, Neurology 1999; 53:126-131

  44. Ann Emerg Med. 2001;37:202-216 What the NIHSS score means to the EP • Chance of ICH with tPA • NIHSS < 10: 3% • NIHSS > 20: 17% • Max benefit:risk ratio: NIHSS 10 – 20? Stroke. 2003;34:1056 –1083. Kama Guluma, MD

  45. “He’s got a GCS of 10” “GCS of 10…what’s the patient’s exam?” A limitation of certain scales…The call from the Trauma Bay to a Neurosurgeon Kama Guluma, MD

  46. Consideration: the “low NIHSS score” stroke with a devastating effect on livelihood Kama Guluma, MD

  47. NIHSS Clinical data TREATMENT DECISION Pre-stroke function Age Co-morbidities Discussion with patient and family The lytic treatment decision Kama Guluma, MD

  48. Consideration: The “high NIHSS score” stroke dilemma: 1) “A terminal intracranial bleed” VS 2) “Bedridden for rest of life in a nursing home” Kama Guluma, MD

  49. The Stroke-focused Neuro ExamBased on the NIHSS • Level of consciousness • Visual fields • Gaze • Facial strength • Arm strength • Leg strength • Limb ataxia (FNF, heel-down-shin) • Dysarthria • Sensation (pinch/pinprick) • Extinction/inattention (bilat sensory) • Language (re: aphasia) LOC Vision Motor strength Coordination Sensation Language Kama Guluma, MD

  50. MOTOR SPEECH / LANGUAGE CN / VISUAL LOC Grade as: Mild = 2 Moderate = 4 Severe = 8 2 / 4 / 8 2 / 4 / 8 2 / 4 / 8 2 / 4 / 8 TOTAL Estimated NIHSS Estimating an NIHSS score Do full neuro exam, but focus on four areas of deficit: • Unilateral motor deficit • Speech and language deficit • CN, neglect and visual field deficit • Depressed level of consciousness Kama Guluma, MD From the Foundation for Education and Research in Neurological Emergencies

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