Rural Stroke Care for Prehospital Providers
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Rural Stroke Care for Prehospital Providers
Chris Hogness, MD
Telehealth Training
March 17th, 2010
Northwest Regional Stroke Network
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Welcome Thank you for joining us!
Format
Introductions
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What we will talk about today
Evidence behind current stroke therapiesFocus on intravenous thrombolysis
Role of EMS in stroke systems of care:Activation of 911 Identification of stroke pt in the fieldAppropriate pre-hospital careTransport
System planning for improved care
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CASE Previously healthy 48 yo man
History of migraine HA, last episode 1 yr ago Possible episodic hypertension remotely,
normal blood pressure in recent visit to PCP Low grade hemoglobin A1C elevation: 6.2 Normal LDL cholesterol: 100 No family history of vascular disease
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CASE, continued Experienced episode of weakness, fell at
homeWent back to bed
Awoke 1 hour later with speech difficulty and left hemiparesis
EMS activated:Delay in reaching rural location, paramedics
chain up to get to his home
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CASE, continued Taken to local t-PA capable, critical
access hospital Head CT done: no acute change Phone consultation with neurologist 2 hrs away Time since last normal 4 ½ hrs Recommendation for no TPA, not given Transferred to larger hospital
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CASE, continued Further evaluation:
MRA brain: Acute stroke involving posterior division of R MCA
MRA neck: Complete occlusion proximal R internal carotid
F/U CT brain 4 days after event: Interval extension of large R MCA infarct with surrounding edema
Specials: TEE with bubble: no PFO Hypercoagulable w/u negative
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Stroke kills and disables many
Most common cause of disability in the world1 person disabled every 45 seconds in US
Third leading cause of death in US700,000 strokes/year in US
Washington state:26,612 hosp and 3,167 (6.9%) deaths (2005)
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Pathophysiology of strokeAngiographic and autopsy studies reveal
approximately 80% of strokes caused by occlusive arterial thrombus
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Brain cells die quickly in stroke 1.9 million neurons lost per minute
Initial ischemic penumbra, area of decreased perfusion with neurologic dysfunction which may not be permanent if flow restored
Time window for clinical benefit of opening artery challengingly brief
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Intravenous thrombolytic Intra-arterial thrombolytic Mechanical
Opening the occluded artery
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Recanalization (restoring flow) rates by intervention Spontaneous: 24.1% Intravenous thrombolysis: 46.2% Intra-arterial thrombolysis: 63.2% Combined IV and IA thrombolysis: 67.5% Mechanical: 83.6%
Rha et al: The impact of recanalization in ischemic stroke outcome: a meta-analysis. Stroke 2007: 38:967
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Recanalization (restoring flow) rates by intervention, update
1,122 severe stroke patients at 13 academic centers between 2005 and 2009
Treated with one or more of: intra-arterial tPA intracranial stenting IV delivery of tPA in the arm Merci Retriever for clot removal Prenumbra aspiration catheter for clot removal glycoprotein IIb/IIIa antagonists angioplasty without stenting
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Recanalization update, continued
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Most patient outcome data from intravenous thrombolysis
Intra-arterial, mechanical not randomized with iv thrombolysis:
No RCT data comparing disability, death Improved flow may not correlate with improved outcome
depending on technique used (eg distal embolization)
Exact niche for each modality not determined Intra-arterial lower tPA volume, role in pts at increased risk of
bleeding Intra-arterial may be more effective for more proximal
occlusions
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Intravenous thrombolysis
Multiple randomized controlled trials demonstrate reduced stroke disability
Consensus guidelines recommend: American Heart Association American College of Chest Physicians
Regulatory agencies approve: FDA 1996 Canada 1999 European Union 2002
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National Institute of Neurologic Disorders and Stroke (NINDS): NEJM 1995
• 624 pts with acute ischemic stroke, treated within 3 hrs of symptoms onset
• Randomized to TPA vs placebo
• Complete/near complete recovery at 90 days:
•31-50% TPA vs 20-35% placebo
•Mortality not significantly different
•17% TPA vs 21% placebo
•10 fold increase in brain hemorrhage
•6.4% TPA vs 0.5% placebo
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Stroke disability scores used in NINDS trial and others Modified Rankin scale: functional score
0 = no symptoms; 5 = severe disability Barthel index: activities of daily living
0-100; 100 = complete independence Glasgow outcome scale: function
1 = good recovery; 5 = death NIH Stroke Scale (NIHSS)
42 point scale measure of neurologic deficit
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NINDS favorable disability outcomes
Modified Rankin scale of 0-1:39% tPA vs 26 % placebo
Barthel index of 95-100: 50% tPA vs 38% placebo
Glasgow Outcome Scale of 1:44% tPA vs 32% placebo
NIHSS 0-1:31% tPA vs 20% placebo
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Pooled analysis of 6 tPA trials 2775 patients
NINDS parts 1&2 (3 hr window) ECASS I and II (6 hr window) ATLANTIS A (6 hr window) and B (5 hr)
Findings: Benefit dependent on time from onset of symptoms to
treatment Hemorrhage 5.9% tPA vs 1.1% placebo
Lancet 2004: 363:768-774
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Favorable outcome at 3 months by time of treatment: pooled data IV rtPA vs Placebo
Time (min) Odds Ratio 95% CI
090 2.8 1.84.5
91180 1.5 1.12.1 181270 1.4 1.11.9 271360 1.2 0.91.5
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Pooled tPA data: benefit vs time
3 hours
Pooled analysis of ATLANTIS, ECASS, and NINDS rt-PA stroke trials. Lancet. 2004;363:768
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3 TO 4 ½ HOURS:ECASS III: NEJM 2008
821 pts 18 to 80 yrs old with acute ischemic stroke for whom treatment could be administered 3 to 4 ½ hrs from stroke onset, randomized to tPA vs placebo 52% no disability with tPA vs 45% placebo No mortality difference (7.7% tPA vs 8.4%) Symptomatic hemorrhage 7.9% tPA vs 3.5%
NEJM 2008;359:1317-29
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IV thrombolysis is underutilized
Currently, estimated 4% of patients with ischemic stroke receive thrombolysis with rt-PA
Very short time window Patients arrive late Hospitals may be slow to respond
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How long does it take pts to get to the hospital?
106,924 pts treated over 4 year period at 905 “Get-With-the-Guidelines” hospitals for whom time of onset of stroke available28.3% arrived within 60 minutes31.7% 1-3 hours40.1% > 3 hours
Jeff Saver, Feb 18, 2009, ASA International Stroke Conference
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How long does it take to begin rtPA after pt arrives at hospital?•
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Goal treatment timeline for door-to-needle
Evaluation by physician: 10 min Stroke expertise contacted:15 min Head CT or MRI performed: 25 min Interpretation of CT/MRI: 45 min Start of treatment: 60 min
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Why do patients delay seeking care for acute ischemic stroke?
PainlessUnlike myocardial infarction
Cognition may be impaired by the event Not calling 911
1st call to physician associated with delay 911 dispatch may fail to recognize sx or
not understand pt due to stroke
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True/False: EMS response times to suspected stroke should be equal to response times for suspected MI
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AHA recommended goals for EMS response time in stroke Dispatch time < 1 minute Turnout time < 1 minute Travel time equivalent to trauma or MI
calls
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What is the maximum on scene time recommended for EMS personnel prior to transport of the patient with stroke?
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Minimize on-scene time Least is best No more than 10 minutes in assessment
Some parts may be done in transit Goal <15 minutes total on-scene time
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True / False: EMS personnel should use a validated screening tool in assessing pts for stroke
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EMS stroke assessment tools
Cincinnati Prehospital Stroke Scale Los Angeles Prehospital Stroke Screen F.A.S.T.
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F.A.S.T.
Face Arm Speech Time last normal
If one component abnormal, 72% probability CVA
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Name several conditions that can mimic stroke
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Conditions mimicking stroke: Hypoglycemia Seizure with post-ictal period Complex migraine Conversion disorder Drug ingestion
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Over-triage Err on the side of over-identification rather
than under-identification AHA: “Initially, EMSS should establish a
goal of over-triage of 30% for the prehospital assessment of acute stroke”
Lessons from trauma: if over-triage is not present, under-triage will result
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What routine pieces of history should be obtained?
TIME LAST NORMAL Hx diabetes? Use of insulin? Hypertension? Medications used? Hx seizure disorder?
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What piece of history is often not included in prehospital assessments?
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Time last normal EMS personnel often only medical
providers with access to all witnesses Transporting family/witnesses with patient
may help with treatment decisions at the hospital
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Prehospital treatment of stroke True/False:
__First address ABCs__Run glucose containing solutions IV__Correct hypovolemia with IV saline__Correct hypoglylcemia when present__Administer aspirin__Administer oxygen in the non-hypoxic patient__Keep pt NPO
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Prehospital treatment of stroke True/False:
T__First address ABCs F__Run glucose containing solutions IV T__Correct hypovolemia with IV saline T__Correct hypoglylcemia when present F__Administer aspirin F__Administer oxygen in the non-hypoxic patient T__Keep pt NPO
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Transport Determine appropriate facility
Closest TPA capable if < 2 hrs from time last normal
Assumes door-to-needle will be <60 min
Primary stroke center / Comprehensive stroke center
State guidelines pending regarding appropriate level of stroke center based on time last normal
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Transport, cont. Early hospital notification
Confirm availability of CTSpecify F.A.S.T findings
Consider air transport in remote areasEMS responders simultaneously call for air
transport and prenotify ED at receiving stroke center in some systems
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Management en route
Lay patient flat unless airway compromiseDon’t elevate head greater than 20 degrees
IV access16 or 18 gage if possibleAvoid glucose containing solutions
2nd exam/neuro reassess Perform TPA check list
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What labs need to be sent on stroke TPA treatment candidates?
CBC including platelets Cardiac enzymes Electrolytes, BUN, creatinine, glucose PT/INR PTT
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Name as many contraindications to tPA as you can
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Contraindications to TPA: clinical Symptoms/signs only minor or rapidly improving Seizure at onset of stroke (not absolute) Symptoms suggestive of subarachnoid hemorrhage Persistent blood pressure elevation >185/110
Active bleeding or acute trauma (fx)
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Contraindications to tPA: historical Stroke or head trauma in prior 3 months Any hx intracranial hemorrhage Major surgery in previous 14 days GI or GU tract bleeding in previous 21 d MI in prior 3 months Arterial puncture at noncompressible site
previous 7 days
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Contraindications to TPA: lab Platelets less than 100K Glucose less than 50 On oral anticoagulant with INR > 1.7 On heparin with PTT higher than normal
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Contraindications to TPA: CT Evidence of hemorrhage Major early infarct signs (diffuse swelling
of affected hemisphere, parenchymal hypodensity, and/or effacement of >33% of middle cerebral artery territory)
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Telemedicine and telephone consultation
Several successful demonstrations publishedTechnical issues with portable
videoconferencing, transmittle of CT scansFinancial issues: reimbursementLegal issues: liability
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Drip and Ship Starting IV t-PA infusions for acute
ischemic stroke at community hospitals prior to transfer to a regional stroke center is feasible and safeSeveral demonstrations published
Silva et al, ASA International Stroke Conference, February 2009, others
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How often do vital signs need to be checked after the administration of rt-PA?
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Monitoring after rt-PA in stroke
Vital signs and neurologic status should be checked:Every 15 minutes for two hours, thenEvery 30 minutes for six hours, thenEvery 60 minutes until 24 hrs from start of rx
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Treatment of hypertension in stroke
If no rt-PA given, best to leave any acute treatment to hospitalGenerally we do not treat acutely unless >220/120
If rt-PA has been given:Systolic >180, diastolic >105:
Labetalol 10 mg iv over 1-2 minutes, repeat every 10-20 minutes to max 300 mg
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System improvement Public education on signs/sx/rx stroke Fundamental role of EMS in getting pt to
appropriate center on time Integrate EMS in planningContinuous case-based feedback to EMS
personnel Hospital systems to shorten door-to-needle
time
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Questions? Q & A
Follow-up questions:Dr. Hogness: [email protected]
Network questions & future trainings:Coordinator: [email protected]