Developing Acute Stroke Services Diagnosing Screening Acute Care pathways Thrombolysis Dr C. Roffe...

40
Developing Acute Stroke Services Diagnosing Screening Acute Care pathways Thrombolysis Dr C. Roffe Clinical Lead Shropshire and Staffordshire Heart and Stroke Network

Transcript of Developing Acute Stroke Services Diagnosing Screening Acute Care pathways Thrombolysis Dr C. Roffe...

Developing Acute Stroke Services

DiagnosingScreening

Acute Care pathwaysThrombolysis

Dr C. RoffeClinical 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

Admit to ASU within 4 h of presentation

Thrombolysis

Stroke pathway and CT within 1 hour

Diagnosing Stroke and TIA

F A S TFace–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.

ROSIERRecognizing Stroke in the Emergency Room

Only count new symptomsExclude 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 non-traumatic vascular origin

• and last for >24 hours

Stroke onset

• 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 >5Admit 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

• 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

• Correct abnormal INR or low platelets immediately

• Neurosurgical referral

Cerebral Infarct• Thrombolysis or • immediate antiplatelet

treatment

Early signs of infarctionLoss of insular ribbon

14.jpgSW, day 1

Early signs of infarctionEffacement of sulci

SW, day 1

CT angiogram

Diffusion Perfusion CT

Other tests

• FBC

• U&E

• INR

• Glucose

• ECG

• Carotid Doppler

Thrombolysis

Why?

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

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 environmentAggressive BP control16,000 screened to recruit 633

N Engl J Med 1995;333:1581-

1587.

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*

DeadNormal

WheelchairNeeds No help

INDEPENDENT DEPENDENT

* My own calculation bases on the original paper ** Saver. Arch Neurol, Jul 2004; 61: 1066 - 1070.

Eligibility

• Age 80 or below

• Previously fit and independent

• Onset time known and less than 3 hours

• CT excludes haemorrhage

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

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

• 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

• 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