get it to me fast: stroke update - code 3...

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

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

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

International top Door-To-Needle times

TIME IS BRAIN

www.genengnews.com

www.darkseniorjournal.blogspot.com

1.9 millions neurons/minute

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!

Prehospital & ED Times

Kothari RU et al. Stroke. 1995;26:2238-2241.

Min

utes

•  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

Dispatch EMS team Community

Recognize signs and symptoms of

stroke

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

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



stroke

Call 911 & Describe

ASAP

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%



stroke


stroke

Call 911 & Describe

ASAP

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

Directions for Dispatchers

•  Improve dispatcher education of stroke

•  Develop dispatch algorithms for stroke

•  Evaluate its impact on prehospital times



stroke


stroke

Call 911 & Describe Dispatch EMS team

ASAP < 90 seconds

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

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)

Last Known Normal (LKN)

•  Critical piece of information •  Can be collected on scene •  What is reliability of LKN

collected by EMS providers?

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.

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.

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?

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

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

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)

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

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

Neurologic Evaluation

Stroke Assessment Tools •  Cincinnati Prehospital Stroke Scale •  Los Angeles Prehospital Stroke Scale •  Miami Emergency Neurologic Deficit

(MEND) Prehospital Checklist •  Houston •  Dallas

Level IB

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

•  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.

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



stroke


stroke

Assessment and management

Call 911 & Describe Dispatch EMS team Rapid transport to stroke ready hospital with

pre-notification (Level IIa)

ASAP < 90 seconds

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.

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

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



stroke


stroke



prenotification

ASAP < 90 seconds < 15 min on scene

Future Directions

Models of EMS Care

Audebert HJ, Saver JL, Starkman S, Lees KR, Endres M. Neurology 2013;81:501-508

Mobile Stroke Units

Bringing Treatment to the Patient

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

Mobile Stroke Unit (STEMO)

Audebert HJ, Saver JL, Starkman S, Lees KR, Endres M. Neurology 2013;81:501-508

Level IV

EMS-based Clinical Trials

Bringing Research to the Patient

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

Summary

•  EMS often ‘owns’ patient 1-hour before MD

•  EMS is critical link in Stroke Systems of Care

•  Future of EMS is exciting

Thank You



stroke


stroke



prenotification

ASAP < 90 seconds < 15 min on scene

get it to me fast: stroke update - code 3...

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