Assessment in the Emergency Department

Dr Jeff KeepConsultant in Emergency Medicine & Major Trauma

King’s College Hospital

Time Critical

Thrombolysis has elevated acute stroke to a time-critical condition

Comparable to acute MI, Major Trauma, Severe Sepsis / Septic Shock, Acute Severe Asthma etc.

Definition?• crit·i·cal  (krt-kl) adj. 1. Inclined to judge severely and find fault.• 2. Characterized by careful, exact evaluation and judgment: a critical

reading.• 3. Of, relating to, or characteristic of critics or criticism: critical acclaim; a

critical analysis of Melville's writings.• 4. Forming or having the nature of a turning point; crucial or decisive: a

critical point in the campaign.• 5. a. Of or relating to a medical crisis: an illness at the critical stage.• b. Being or relating to a grave physical condition especially of a patient.• 6. Indispensable; essential: a critical element of the plan; a second income

that is critical to the family's well-being.• 7. Being in or verging on a state of crisis or emergency: a critical shortage of

food.• 8. Fraught with danger or risk; perilous.

Definition?• crit·i·cal  (krt-kl) adj. 1. Inclined to judge severely and find fault.• 2. Characterized by careful, exact evaluation and judgment: a critical

reading.• 3. Of, relating to, or characteristic of critics or criticism: critical acclaim; a

critical analysis of Melville's writings.• 4. Forming or having the nature of a turning point; crucial or decisive: a

critical point in the campaign.• 5. a. Of or relating to a medical crisis: an illness at the critical stage.• b. Being or relating to a grave physical condition especially of a patient.• 6. Indispensable; essential: a critical element of the plan; a second income

that is critical to the family's well-being.• 7. Being in or verging on a state of crisis or emergency: a critical shortage of

food.• 8. Fraught with danger or risk; perilous.

Time-Critical

Essentially, a serious condition in which there is rapid deterioration with time unless it is stopped.

Emergency Systems

Emergency systems are designed and developed to manage Emergent and Time-Critical situations or events

NNT (Lansberg, Stanford University)

• 0-90 minutes NNTB = 3.6• 91-180 minutes NNTB = 4.3• 181-270 minutes NNTB = 5.9• 271 – 360 minutes NNTB = 19.3

NNT (Lansberg, Stanford University)

• 0-90 minutes NNTB/H = 3.6/65• 91-180 minutes NNTB/H = 4.3/38• 181-270 minutes NNTB/H = 5.9/30• 271 – 360 minutes NNTB/H = 19.3/14

Therefore gives the cut-off of 4.5 hours

4.5 hours

• But we do not have this much time• We must act as soon as we can• In London we have a target of 30 minutes

‘Door-to-Needle’• Which means that if a patient has a

thrombolysable stroke, they must be receiving thrombolysis within 30 minutes of arriving at the ED

The Chain of Survival

• Recognition of symptoms• Contact EMS (999)• Priority dispatch• EMS transport patient to the

right hospital• EMS pre-alert• Early recognition of

symptoms/signs• Early imaging• Early treatment

Easy-Peasy?

• The more links in the chain, the more potential places that it can break

• Chinese Whispers...

Easy-Peasy?

• Airway compromise• Aspiration• Hypertension• Arrhythmia• Altered conscious level• Coagulopathy – on Warfarin?

Easy-Peasy?

• Neurological Stroke Mimic• Variable Symptoms / Signs• Head Injury• Metabolic Injury• Psychiatric Illness

The Solution?

Almost...

The solution

Stroke Team

• What is a team?• Who should be in a stroke team?• What is the role of a team leader?

• What is the role of a team member?

Stroke Doctor

• Confirm FAST positive & time of onset• Look for inclusions / exclusions• More in-depth history & examination

ED doctor

• ABC assessment• Interpret ECG• Contact CT and organise scan

ED Technician / FY2

• IV access• Routine bloods• Rapid INR test if on warfarin

ED / Stroke Nurse

• ABC assessment• Attach directly to transport monitor• Perform ECG• Accompany patient to CT

Stroke Unit Sister

• Aware of potential admission• Able to organise bed• Able to come and assist

Radiographer

• Empty the scanner• Prepare for investigations

Receptionist

• Book in patient immediately onto system

Porter

• Check oxygen cylinder• Transport patient

What’s next?

• Multiple patients• Haemorrhagic stroke• Airway problem• Not a stroke

Focus on the Team

Possible members

• Anaesthetist• Physician• Stroke Nurse• Radiologist• Neurosurgeon

Multiple Strokes

Summary

• Time-critical illness needs a structured, safe approach

• Does not mean we run around quickly• Develop a Team approach – many people

with few, achievable tasks within their comfort zone

• Regular meetings – build bonds, review practise, learn

Thank you for listening...