Stroke Care in the Emergency Setting

1. Ann M. Hoff, MD ETC Physician Trinity Health Stroke Care in the Emergency Setting

3. American Stroke Association • Guidelines for the Early Management of Adults with Ischemic Stroke (2007) • “Time is Brain”

4. Stroke Facts • In the US, someone has a stroke every 40 seconds • Every 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

5. 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

6. Stroke Signs/Symptoms • 5 most common signs/symptoms • Sudden numbness/weakness of the face, arm, or leg • Sudden confusion or trouble speaking or understanding • Sudden trouble seeing in one or both eyes • Sudden dizziness, trouble walking, or loss of balance/coordination • Sudden severe headache with unknown cause

7. 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

8. Stroke Risk - Age • Nearly one quarter of strokes occur in people under the age of 65

9. Stroke Risk Factors • In 2003, approximately 37% of adults reported having two or more of the risk factors listed above.

10. US Stroke Map

11. Hospitalizations

12. Mortality

13. ND Hospitalizations

14. ND Mortality

15. Prehospital Management • EMS Utilization • 29-65% • 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

16. 19-60% present within 3 hrs • 14-32% present within 2 hrs • Decreased time to physician exam, CT, and neuro evaluation

17. EMS Care • Rapid identification of stroke • Identification of possible stroke mimics • 19-31% • ABCs • Transport • Notify ER

18. Community Ambulance

19. Cincinnati Stroke Scale

21. ACT F.A.S.T. • Facial Droop • Arm Weakness • Speech • Time

22. Golden Hour of Stroke

23. Emergency Room Care • The First 15 Minutes • Acute Stroke Protocol • Focused H&P • NIHSS • Labs • IVs • EKG • Weight • Alert pharmacy to possible need for tPA • Order CT scan

24. Stroke Alert Team Response ER MD NeuroMD Recorder Radiologist EKG CT TECH LAB

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

26. Treatment • Emergency Treatment • Based on results of head CT and time of symptom onset

27. No blood on CT, < 3hrs from onset • Review inclusion/exclusion criteria • Obtain consent • If tPA given, admit to ICU for 24 hrs

28. No blood on CT, > 3hrs & < 8 hrs • Off-label IV tPA up to 4.5 hrs • Further imaging may expand treatment options: • CT angiogram • IA tPA • Mechanical thrombectomy • MERCI clot retrieval system (8/2004) • Penumbra system (12/2007)

29. No blood on CT, > 8 hrs • 325 mg of aspirin • Reduces early death • Reduces long-term disability

30. Prevention • 1 in 8 stroke survivors will have another stroke within 5 years • Treatment of underlying cause is important • Education • Rehabilitation • PT/OT to relearn skills

31. 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