Patient or bystander recognizes stroke

1. Developing Acute Stroke ServicesDiagnosingScreeningAcute Care pathwaysThrombolysisDr C. RoffeClinical Lead Shropshire and Staffordshire Heart and Stroke Network

2. 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

3. Diagnosing Stroke and TIA

4. 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.

5. ROSIERRecognizing 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

6. Stroke or TIA? • Symptoms still present => Stroke • Symptoms gone =>TIA

7. 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 non-traumatic vascular origin • and last for >24 hours

8. Stroke onset • Witness? • Woke with hemiparesis? • Found collapsed? • Sudden/gradual/ stuttering

9. ABCD2 Scoring for all new TIAs Stroke risk within 1 week 6% for scores 4-5, 12% for scores >5 Admit all with score 5 or above.

10. 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%!!!

11. Role of Paramedics • 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

12. Investigations and tests in the early stages

13. CT Head scan • Intracerebral haemorrhage • Correct abnormal INR or low platelets immediately • Neurosurgical referral • Cerebral Infarct • Thrombolysis or • immediate antiplatelet treatment

14. Early signs of infarctionLoss of insular ribbon 14.jpg SW, day 1

15. Early signs of infarctionEffacement of sulci SW, day 1

16. CT angiogram

17. Diffusion Perfusion CT

18. Other tests • FBC • U&E • INR • Glucose • ECG • Carotid Doppler

19. Thrombolysis

20. Why?

21. DH A New Ambition for StrokeA 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/PublicationsPolicyAndGuidance/DH_081062

22. 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 N Engl J Med 1995;333:1581-1587.

23. NINDS rt-PA trial 1995Improvements in dependency (modified Rankin Scale: mRS) 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* Needs No help Wheelchair Dead Normal INDEPENDENT DEPENDENT * My own calculation bases on the original paper ** Saver. Arch Neurol, Jul 2004; 61: 1066 - 1070.

24. Eligibility • Age 80 or below • Previously fit and independent • Onset time known and less than 3 hours • CT excludes haemorrhage

25. Exclusions • 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

26. 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

27. Post thrombolysis Care • Needs trained team / ASU • Neurological observations (NIHSS) • Blood pressure • Observation for complications • Scan at 24 h • Prevent recurrence • Early Doppler/ CTangio in recovered cases

28. The acute stroke pathwayHow can I make sure my patient will do well?

29. Most complications of stroke develop in the first 24 hours Management in the first few hours has a major effect on outcome and LOS

30. 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

31. 1. Transfer to ASU within 4 h or less of admission

32. 2. Prevent Aspiration • 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

33. 3. Prevent hypotension and dehydration • IV saline • Sufficient fluids by mouth or ngt

34. 4. Prevent pneumonia Mobilization

35. Mouthcare Dysphagic patients have impaired oral movements resulting in debris, pooled secretions and tongue coating.

36. 5. Prevent hospital acquired infectionsMRSA/ ESBL/ C.Difficile Avoid catheters at all costs Hand hygiene Bed spacing Appropriate antibiotics

37. 6. Prevent starvation

38. 7. Prevent stagnation and deterioration • Time does not cure strokes • Give at least 45 min of each therapy needed every day 7/7

39. 7. Detect and treat problems early • 72 hour monitoring • Neurological scores (NIHSS/SSS) • Daily consultant ward rounds 7/7