Stroke and the Emergency Department
Ali Haedar
Clinical lecturer & Emergency Medicine Specialist | American Heart Association’s
instructors for BLS-ACLS | Board member of Asian Emergency Medical Services
Council for Indonesia | Member of American College of Emergency Physician
Department of Emergency Medicine
Faculty of Medicine – University of Brawijaya
Saiful Anwar General Hospital
Indonesia
Disclosure
Presenter is American Heart
Association (AHA) instructor
The following presentation is
mostly taken from the AHA’s
Acute Stroke: Current
Treatments and Paradigms.
2
Improving Door-to-Needle Times in Acute
Ischemic Stroke: The Design and Rationale for the
American Heart Association/American Stroke
Association’s Target: Stroke Initiative
Gregg C. Fonarow, MD; Eric E. Smith, MD, MPH; Jeffrey L. Saver, MD;
Mathew J. Reeves, PhD; Adrian F. Hernandez, MD, MHS; Eric D.
Peterson, MD, MPH; Ralph L. Sacco, MD; Lee H. Schwamm, MD
Stroke. 2011;42:00-00
4
7 Step Stroke Chain of
Survival and Recovery
Pre-arrival: Post-arrival:
1. Detection 4. Door
2. Dispatch 5. Data
3. Delivery 6. Decision
7. Drug
8. Disposition
5
Door: Emergency
Department Triage
Even if a potential stroke victim arrives in the
emergency department in a timely fashion,
too often hours may elapse before
appropriate neurological consultation and
diagnostic studies are performed.
6
Data: Emergency Evaluation
and Management
ABCs should be
reassessed and
rechecked
frequently.
7
An emergency neurological stroke assessment
should be done quickly focusing on four key
issues:
1. Level of consciousness
2. Type of stroke (hemorrhagic versus
nonhemorrhagic)
3. Location of stroke (carotid versus vertebrobasilar)
4. Severity of stroke
8
• Obtaining the exact time of stroke or onset
of symptoms from family or people at the
scene is critical.
9
Emergency Diagnostic Studies
• Currently, CT is the single most important
diagnostic test.
• Goal: CT scan obtained and read within 45 minutes
of the stroke victim's arrival at the emergency
department.
10
Emergency Diagnostic
Studies
• Anticoagulants
and fibrinolytic
agents should be
withheld until CT
has ruled out a
brain
hemorrhage.
11
Differential Diagnosis:
• Unrecognized seizures
• Confusional states
• Syncope
• Toxic or metabolic disorders
• Hypoglycemia
• Brain tumors
• Subdural hematoma
Adams et al. Stroke. 2003;34:1056
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Decision: Specific Stroke Therapies
General care includes, but is not limited
to:
• Prevention of aspiration
• Management of hypertension
• Management of hyper/hypo-glycemia
• Management of seizures
• Management of intra-cranial pressure
(ICP)
Acute Stroke, 2003 American Heart Association 13
Drugs: Fibrinolytic Therapy for Ischemic Stroke
• Intravenous tPA represents the first FDA-
approved therapy for acute ischemic stroke.
• In the NINDS trial, patients treated with tPA
within 3 hours of onset of symptoms were at
least 30% more likely to have minimal or no
disability at 3 months compared with those
treated with placebo.
*NINDS: National Institute of Neurological Disorders
and Stroke
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NINDS TPA Stroke Trial
Excellent outcome at 3 months on all scales
60%
52%
50% 45%
43%
38%
40% 34%
31%
30% 26%
21% TPA
20% Placebo
10%
0%
Barthel Rankin Glasgow NIHSS
Index Scale Outcome score
Global outcome statistic: OR=1.7, 50% v. 38%= 12% benefit
N Engl J Med 1995;333:1581-7
15
Drugs: Fibrinolytic Therapy for Ischemic Stroke
• However, there were 10-fold increases in the
risk of fatal intracranial hemorrhage in the
treated group (3% vs 0.3%) and the frequency
of all symptomatic hemorrhage (6.4% vs.
0.6%).
• This increase in symptomatic hemorrhage did
not lead to an overall increase in mortality in
the treated group.
16
Drugs: Fibrinolytic Therapy for Ischemic Stroke
Careful patient selection and strict
adherence to the treatment protocol are
essential!
17
Drugs: Fibrinolytic Therapy for Ischemic Stroke
Because of the time criteria and risk
associated with fibrinolytic therapy, it is
important for hospitals to develop specific
strategies and protocols that will achieve
rapid initiation of therapy.
18
NINDS-Recommended Stroke Evaluation Targets
for Potential Fibrinolytic Candidates*
Time Target
Door to doctor 10 minutes
Door to CT† completion 25 minutes
Door to CT read 45 minutes
Door to treatment 60 minutes
Access to neurological expertise‡ 15 minutes
Access to neurosurgical expertise‡ 2 hours
Admit to monitored bed 3 hours
*Target times will not be achieved in all cases, but they represent a
reasonable goal.
†CT indicates computed tomography.
‡By phone or in person.
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Management of Hemorrhagic Stroke
Optimal management:
• Prevention of continued bleeding.
• Appropriate management of ICP.
• Timely neurosurgical decompression when
warranted.
Large intracerebral or cerebellar hematomas
often require surgical intervention.
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Disposition: Neurology Vs Neurosurgery
Depends on local protocol
Ischemic Stroke: Neurology
Hemorrhagic Stroke: Neurosurgery (unless
inoperable, to Neurology)
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Conclusion:
Now, fibrinolytic and other emerging
therapies offer practitioners the opportunity
to limit neurological insult and improve
outcome in stroke patients.
22
Conclusion:
The challenge with these therapies is that
they require administration within hours of
stroke onset, making the following
measures imperative:
• Education of at-risk patients
• Early recognition of stroke signs
• Prompt transport to the hospital
• Rapid hospital triage and evaluation
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Thank You
haedaryahya@yahoo.com
