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