the continuum of stroke care
TRANSCRIPT
The Continuum of Stroke Care
Justin A. Sattin, M.D.Assistant Professor
UW Department of NeurologyMedical Director
UW Health Comprehensive Stroke Program
The Chain of Survival
• Healthful Choices• Public Recognition• EMS Access• ED Recognition• Radiology / Lab• Neurologist• Pharmacy
• ICU Nursing Care• General RN Care• More Radiology / Lab• Inter-D Care• Rehabilitation• Re-Integration
Stroke Symptoms
Cincinnati Prehospital Stroke Scale
Facial Droop
Instruction: Ask patient to smile
Normal: Both sides of face move equally
Abnormal: One side of face does not move as well
Arm Drift
Instruction: Ask patient to close eyes and extend both arms straight out for 10 seconds
Normal: Both arms move the same or not at all
Abnormal: One arm does not move or drifts down
Speech
Instruction: Ask patient to say “You can’t teach an old dog new tricks.”
Normal: Patient says correct words without slurring
Abnormal: Patient slurs words, says wrong words, or is unable to speak
Kothari RU, et al. Cincinnati Prehospital Stroke Scale: reproducibility and validity. Ann Emerg Med. 1999;33:373-8.
Ischemic or Hemorrhagic?
Ischemic or Hemorrhagic?
NINDS tPA Trial
0
5
10
15
20
25
30
35
t-PA Placebo
DeathHemorrhage
The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. N Eng J Med. 1995;333:1588–1593.
39 – 26 = 13
13---- = 50% relative benefit26
39 – 26 = 13% absolute difference
100----- = 8 needed to treat 13
Hacke W, et al. Association of outcome with early stroke treatment: pooled analysis of ATLANTIS, ECASS, and NINDS rt-PA stroke trials. Lancet 2004;363:768-74.
Time is of the Essence
Furlan A, Higashida R, Wechsler L, et al. Intra-arterial prourokinase for acute ischemic stroke. The PROACT II Study: A randomized controlled trial. JAMA. 1999;282:2003-2011.
Mechanical Embolectomy
Leary MC, et al. Beyond tissue plasminogen activator: mechanical intervention in acute stroke. Ann Emerg Med. 2003;41:838-46.
Courtesy of Concentric Medical, Inc.
Mechanical Embolectomy
Annual Stroke Mortality 2001-2004
<10 (64)
10-50 (1,033)
50-100 (1,067)
>100 (1,186)
Avg# of deaths per county per year (total for all counties in group)
Yuan, H. and Brue, C. Wisconsin Heart Disease and Stroke Surveillance Summary Update – 2007 – PPH 43040 (01/07). Wisconsin Department of Health and Family Services, Division of Public Health.
The Joint Commission. Available at: http://www.jointcommission.org/CertificationPrograms/Disease-SpecificCare/DSCOrgs/ Accessed 10/14/07
General Management Principles
• Hypoxic pts. should receive O2
– SpO2 > 92%
• Cardiac monitoring for at least 24 hrs.
• Treat HTN conservatively for 24 hrs.– Ischemic: SBP < 220 mmHg– Hemorrhagic: SBP < 160 mmHg
General Management Principles
• Minimize urinary catheterization
• Fevers should be evaluated and treated
• Hyperglycemia should be treated– Optimal threshold is not established– < 140 mg/dL? < 185 mg/dL?
General Management Principles
• Dysphagia screening
• Early mobilization
• DVT prophylaxis– LMWH
Stroke
Hemorrhagic
ICH SAH
IschemicCardioembolic
Large artery athero.
Small vessel dz.
Other
Unknown
Adams HP Jr, Bendixen BH, Kappelle LJ, Biller J, Love BB, Gordon DL, Marsh EE 3rd. Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical trial. TOAST. Trial of Org 10172 in Acute Stroke Treatment. Stroke. 1993;24(1):35-41.
Stroke
IschemicCardioembolic
Large artery athero.
Small vessel dz.
Other
Unknown
http://www.florida-oxygen.com/treatment.htm
Stroke
IschemicCardioembolic
Large artery athero.
Small vessel dz.
Other
Unknown
http://www.cardioliving.com/consumer/Stroke/AF_Causes.shtm
Cardioembolic Stroke
Stroke
IschemicCardioembolic
Large artery athero.
Small vessel dz.
Other
Unknown
http://biocomp.stanford.edu/3dreconstruction/movies/haveri/stenosis_ica_angio%26ssd.jpg
Stroke
IschemicCardioembolic
Large artery athero.
Small vessel dz.
Other
Unknown
Stroke
IschemicCardioembolic
Large artery athero.
Small vessel dz.
Other
Unknownhttp://bbh.hhdev.psu.edu/courses/368/slide.21.(164).htm
Stroke
IschemicCardioembolic
Large artery athero.
Small vessel dz.
Other
Unknown
Risk Factor Modification
• Hypertension• Diabetes• Dyslipidemia• Metabolic Syndrome• Tobacco Dependence
Antithrombotic Therapies
• Aspirin• Aspirin/Dipyridamole (Aggrenox)• Clopidogrel (Plavix)• Warfarin (Coumadin)
Important Collaborators
• PT• OT• Speech• Swallow• Rehab• Neuro Ψ
• Health Ψ• Case Managers!• Social Work• Pastoral Care• Palliative Care• ACE Team
Discharge Dispositions
• Home– often with outpt. or home health therapies)
• Acute Rehab• Subacute Rehab• Skilled Nursing Facility• Hospice• (Celestial Discharge)
Vascular Cognitive
Impairment
How to Reach Us
Emergent ReferralsUW Access Center
Phone: 800-472-0111
Office ReferralsUW Stroke Clinic
Phone: 608-265-8899Fax: 608-265-1753