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Get it to me FAST: Stroke Update
Laura Heitsch, MD
Assistant Professor, Emergency Medicine
Stroke Team Physician
Washington University
St. Louis, Missouri
Code3 Conference October 23rd, 2014
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Disclosures • Funding
– NIH/NINDS: POINT (local-PI) – EMF Career Development Grant – AHA/ASA Career Development Grant
• Industry Relationship – Genentech Advisory Board – VINDICO Medical Education Speakers Bureau
• Off-Label Discussion – None
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Objectives • Understand role and function of EMS within
the Stroke System of Care • Recognize current EMS guidelines for stroke • Discuss limitations and ways to improve care
of the stroke patient in the pre-hospital setting • Be aware of the potential role of EMS in
research
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International top Door-To-Needle times
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TIME IS BRAIN
www.genengnews.com
www.darkseniorjournal.blogspot.com
1.9 millions neurons/minute
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Stroke and the Golden Hour • Narrow therapeutic time window
– Time for thrombolytic is 0-3 (4.5) hours – 15-60% arrive within 3 hrs
• Early intervention critical • Pre-hospital personnel
– 35-70% of patients arrive by ambulance – Unique position: FIRST medical
professional to come in contact – Can be an hour before stroke team!
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Prehospital & ED Times
Kothari RU et al. Stroke. 1995;26:2238-2241.
Min
utes
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• Detection: Early recognition
• Dispatch: Early EMS activation (911)
• Delivery: Transport & management
• Door: Appropriate triage to stroke center
• Data: ED evaluation & management
• Decision: Neurology input, Rx selection
• Drug: Thrombolytic & future agents • Disposition: Rapid admission to stroke unit
ACLS 2012
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Dispatch EMS team Community
Recognize signs and symptoms of
stroke
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Patient Stroke Detection – Room for Improvement
• There is poor recognition of stroke by the public – < 50% of community know potential stroke symptoms – About 70% of respondents correctly named at least 1 stroke
(same for naming at least 1 stroke risk factor)
• Especially by high risk individuals* – Groups of individuals with the highest risk and
incidence of stroke (> 75 years old, blacks, and men) were the least knowledgeable about warning signs and risk factors
*Schneider AT et al. JAMA. 2003 Jan 15;289(3):343-6.
Hsia AW, et al. Stroke. 2011;42:1697-1701
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Patient Stroke Detection – Room for Improvement
One or more of face weakness, arm weakness, and speech difficulty symptoms are present in 88% of all strokes and TIAs.
Kleindorfer et al. Stroke 2007
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Dispatch EMS team Community
Recognize signs and symptoms of
stroke
Call 911 & Describe
ASAP
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GWTG Regional Numbers for 911/EMS
Get With the Guidelines Numbers for Greater St Louis Area 33% of patients arriving via private transport! Increase from 2013
which was 24%
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Dispatch EMS team Community
Recognize signs and symptoms of
stroke
Recognize signs and symptoms of
stroke
Call 911 & Describe
ASAP
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Making the Right Call • Extract information quickly and
accurately to make clinical decisions • Provide high priority dispatch for stroke • 30 - 83% of calls recognized as stroke
– Effects priority response – Impacts the level of care sent – To what extent is time effected?
Buck DH, et al. Stroke. 2009;40(6):2027-2030 Rosamond WD et al. Prehosp Emerg Care. 2005;9(1):19-23
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Directions for Dispatchers
• Improve dispatcher education of stroke
• Develop dispatch algorithms for stroke
• Evaluate its impact on prehospital times
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Dispatch EMS team Community
Recognize signs and symptoms of
stroke
Recognize signs and symptoms of
stroke
Call 911 & Describe Dispatch EMS team
ASAP < 90 seconds
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Primary Goals of EMS team in Acute Stroke Care
• Rapid evaluation • Early Stabilization • Neurological Evaluation • Rapid transport and triage to a
stroke-ready hospital
Jauch EC et al. Circulation 2010
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Prehospital Management
• Routine standard care – Guideline and consensus based – Best if protocols developed for EMS – Determine time of onset (Level IA) – Pre-arrival notification (Level IIA)
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Last Known Normal (LKN)
• Critical piece of information • Can be collected on scene • What is reliability of LKN
collected by EMS providers?
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Last Known Normal – BJH study
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Rel
ativ
e Fr
eque
ncy
Time (minutes)
Differences in EMS-Reported and Neurologist-Determined LKN Times: ED Stroke Diagnosis vs. Non-Stroke Diagnosis
Stroke
Non Stroke
Curfman D et al. Stroke 2014;45:1275-1279.
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Last Known Normal – BJH study
0%
10%
20%
30%
40%
50%
60%
70%
80%
Rel
ativ
e Fr
eque
ncy
Time (minutes)
Differences in EMS-Reported and Neurologist-Determined LKN Times: Wake-Up vs. Non Wake-Up
Non Wake-Up
Wake-Up
Curfman D et al. Stroke 2014;45:1275-1279.
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Last Known Normal
Ways to ask: • Where the symptoms there when you
woke up this morning? If yes: • What time did you go to bed? • Did you get up at any time in the night?
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Prehospital Management
• Oxygen (Level IC) – Combination of poor perfusion & hypoxemia will exacerbate
& extend ischemic brain injury, and has been associated with worse outcome from stroke1
– Both out-of-hospital and in-hospital medical personnel should administer supplementary oxygen to hypoxemic (ie, oxygen saturation <93%) stroke patients or those with unknown oxygen saturation 2
1 Langhorne P. Stroke. 2000;31(10):2518-2519 2 AHA ACLS 2012 Update
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Prehospital Management • IV Access (Level IIIB)
– Rapid transport is important, delays should be avoided – IV used for lab tests, meds, IV contrast during imaging – Current recommendations1,2
• If not requiring immediate resuscitation, minimize scene time, attempt en route • If placing line meets therapeutic and diagnostic needs, it may save critical time
• IV Fluids (Level IIIA) – Used cautiously in patients with heart/renal disease – Dehydrated or poorly perfused patients should receive boluses – Avoid hypertonic saline or glucose containing fluids – Recommend: TKO
1 Crocco T. Stroke. 2003;34(8):1918-22 2 Saver JL. Stroke;35(5);e106-108
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Prehospital Management • Transport Position (
– Traditional position HOB 30o to decrease ICP – ICP does not peak until 48 hrs post-infarction – Schwartz et al. (Stroke. 2002;33(2):497–501)
• Improvement of CPP from 64.7 +/- 1.7 mmHg with 30o elevation to 77 +/- 1.7 mmHg with flat position (p<0.001)
• ICP changes clinically insignificant
– Wojner-Alexandrov et al. (Neurology. 2005;64(8):1354–7) • Demonstrated 20% improvement MCA blood flow (TCD) in flat
position c/w 30o head elevation with no detrimental effects
– No out-of-hospital studies examining head position – Risk/benefits unknown for flat vs. elevated head
position.
Level IV)
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Prehospital Management • Hypertension
– ED BP management is a component of care of stroke patients, no data to support that hypertension intervention should begin in the prehospital environment
– Unless the patient is hypotensive, prehospital intervention on blood pressure is not recommended
Adams HP. Stroke 2007;38:1955-1711 Level IIIB
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Prehospital Management • Glucose
– Hypoglycemia: stroke mimic and can lead to brain injury – Hyperglycemia: worsens edema, enhances HT of infarct,
exacerbates postischemic injury – Assess blood glucose prehospital, correct hypoglycemia
• Pre-hospital treatment-feasible? – Single Finnish Study – Randomized Insulin SQ (n=11), IV insulin (n=12), historical
controls (n=38) – Results:
• IV insulin significantly lowers blood sugar without any adverse events • No outcome data
• No current evidence support pre-hospital regulation Level IIIA
Nurmi J, et al. Acad Emerg Med. 2011 Apr (18)4:463-9
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Neurologic Evaluation
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Stroke Assessment Tools • Cincinnati Prehospital Stroke Scale • Los Angeles Prehospital Stroke Scale • Miami Emergency Neurologic Deficit
(MEND) Prehospital Checklist • Houston • Dallas
Level IB
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CPSS-Cincinnati Prehospital Stroke Scale
• 10 minutes to train • < 1 minute to perform • Diagnosis of stroke1,2
– Sensitivity 90% – Specificity 66%
• Carotid strokes • Sensitivity = 95%
Facial Droop
Arm Drift
Speech
Tirschwell DL et al. Stroke 2003;34:267 (Abstract) Kothari et al. Ann Emerg Med 1999;33:373-78
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• History – Age >45 – History of seizures absent – Duration < 24 hours – Not bedridden
• Evaluation – Blood glucose <60 to >400
mg/dL – Facial smile/grimace – Grip – Arm strength
• Short training video • Sensitivity = 93% • Specificity = 97%
Kidwell CS et al. Stroke. 2000;31:71-76.
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EMS Education • Standard Paramedic Training1-3
– Sensitivity: 61-66% identifying stroke • Stroke Assessment Tool Training
– Sensitivity: 86-97% identifying stroke • All paramedics and EMT-basic should
be trained in recognition of stroke
1 Smith WS. Prehosp Emerg Care. 1998;2(3):170-175 2 Ellison SR. Mo Med. 2004;101(1):64-66 3 Wojner AW. Am J Crit Care. 2003;12(5):411-417 4Kidwell CS. Stroke. 2000;31(1):71-76 5Smith WS. Prehosp Emerg Care. 1999;3(3):207-210 6 Zweifler RM. Journal of Stroke and Cerebrovascular Diseases. 1998;7(6):446-448
Level IB
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Dispatch EMS team Community
Recognize signs and symptoms of
stroke
Recognize signs and symptoms of
stroke
Assessment and management
Call 911 & Describe Dispatch EMS team Rapid transport to stroke ready hospital with
pre-notification (Level IIa)
ASAP < 90 seconds
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EMS and Pre-Hospital Notification: NC Stroke Care Collaborative
• Study: 52 hospitals, covering 39/100 NC counties = 61% of all stroke discharges in NC
– All suspected strokes enrolled by NCSCC 2008-2009 • 16,179 enrolled, 13,894 study patients (exclusions) • 45% by private transportation • 55% by EMS (58% with pre-notification)
Patel MD, et al. Prehospital Notification by EMS. Stroke. 2011;42:1-6
Conclusion: Stroke patients arriving by EMS more likely to receive brain imaging and interpretation by an MD in a more timely manner than those arriving by private transport. Also, prenotification additionally expedited the most rapid evaluation.
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EMS and Pre-Hospital Notification: GWTG-Stroke Experience
• 371,988 AIS, EMS transport, GWTG (2003-2011) • Pre-notification: 67% overall • Of those notified:
– Treated with tPA within 3 hours: 83% vs. 79% (p<0.0001) – NIHSS performed: 73% vs. 64% (p<0.0001) – Door-to-imaging times: 26 vs. 31 min (p<0.0001) – Door-to-Needle times: 78 vs. 80 min (p<0.001)
• Conclusions: – EMS pre-notification = improved evaluation, timelier
treatment and more eligible patients treated with tPA
Lin CB et al. Circulation: CV Quality and Outcomes. 2012;5:514-522 Level IIA
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Get With the Guidelines Numbers for Greater St Louis Area
EMS and Pre-Hospital Notification: GWTG-Greater St Louis Experience
Advanced notification down from 75% to 70% in 2014
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Dispatch EMS team Community
Recognize signs and symptoms of
stroke
Recognize signs and symptoms of
stroke
Assessment and management
Call 911 & Describe Dispatch EMS team Rapid transport to stroke ready hospital with
prenotification
ASAP < 90 seconds < 15 min on scene
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Future Directions
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Models of EMS Care
Audebert HJ, Saver JL, Starkman S, Lees KR, Endres M. Neurology 2013;81:501-508
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Mobile Stroke Units
Bringing Treatment to the Patient
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Mobile Stroke Unit (STEMO) • Stroke Emergency
Mobile project-Berlin • CT and POC testing • Pilot underway
(PHANTOM-S)
– 23 treats in 52 days
PHANTOM-S. The pre-hospital acute neurological Therapy and optimization of medical care in stroke Patients study. 2012. Available at: http://clinicaltrials.gov/ct2/show/NCT01382862
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Mobile Stroke Unit (STEMO)
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Audebert HJ, Saver JL, Starkman S, Lees KR, Endres M. Neurology 2013;81:501-508
Level IV
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EMS-based Clinical Trials
Bringing Research to the Patient
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Research in Prehospital Management
• Neuroprotection (Level IIB) – Protocol: LD of 4 g MgSO4 IV over 15 min or matched placebo, followed after
hospital arrival by a maintenance infusion of 16 g MgSO4 IV over 24 hrs or matched placebo
– CLOSED with 1700 patients enrolled – NO DIFFERENCE IN 90day ENDPOINT (mRS) – VERY SUCCESSFUL SECOND AIM – Facts:
• 32 min avg time EMS arrival to ED (pre-trial was 35 minutes) • 48 min avg time onset to drug • 72% receive drug < 1 hour (1253 patients) • 25% enrolled 61-120 minutes after sx onset • 160 received drug < 30 minutes after sx onset
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Summary
• EMS often ‘owns’ patient 1-hour before MD
• EMS is critical link in Stroke Systems of Care
• Future of EMS is exciting
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Thank You
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Dispatch EMS team Community
Recognize signs and symptoms of
stroke
Recognize signs and symptoms of
stroke
Assessment and management
Call 911 & Describe Dispatch EMS team Rapid transport to stroke ready hospital with
prenotification
ASAP < 90 seconds < 15 min on scene