Stroke (2010 CPR & ECC Guideline)

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Adult Stroke 2010 AHA Guidelines for CPR and ECC Circulation. 2010;122:S818-S828 http://decode-medicine.blogspot.com/ summarized & animated by sun yaicheng

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The “D's of Stroke Care” Detection Dispatch Delivery Rapid recognition of stroke symptoms Early activation and dispatch of EMSS by calling 911 Rapid EMS identification, management & transport Door Appropriate triage to stroke center Data Decision Drug Rapid triage, evaluation & management within the ED Stroke expertise and therapy selection Fibrinolytic therapy, intra-arterial strategies Disposition Rapid admission to stroke unit, ICU

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Management Goals Time is Brain Minimize acute brain injury and maximize patient recovery Stroke Chain of Survival

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EMS Stroke Recognition Cincinnati Prehospital Stroke Scale (CPSS) Sensitivity: 59% Specificity: 89% Los Angeles Prehospital Stroke Screen (LAPSS) Sensitivity: 93% Specificity: 97%

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In-Hospital Care Protocols should be used in the ED to minimize delay to definitive diagnosis and therapy. ED personnel should assess the patient with suspected stroke within 10 minutes of arrival in the ED. The EP should perform a neurologic screening assessment, order emergent CT, and activate the stroke team.

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Approach To Arterial Hypertension In Acute Ischemic Stroke

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For Patients Potentially Eligible for Acute Reperfusion Therapy Patient eligible for acute reperfusion therapy except that BP >185/110 mmHg Labetalol 10 to 20 mg IV over 1 to 2 minutes, may repeat ×1; or Nicardipine infusion, 5 mg/h, titrate up by 2.5 mg/h every 5–15 minute, maximum 15 mg/h; when desired BP reached, lower to 3 mg/h If BP does not below 185/110 mmHg, do not administer rtPA

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Management of BP During and After rtPA or Other Acute Reperfusion Therapy Monitor BP every 15 minutes for 2 hours from the start of rtPA therapy; then every 30 minutes for 6 hours; and then every hour for 16 hours If SBP180–230 mmHg or DBP 105–120 mmHg Labetalol 10 mg IV followed by continuous IV infusion 2–8 mg/min, or Nicardipine IV 5 mg/h, titrate up to desired effect by 2.5 mg/hr every 5–15 minutes, maximum 15 mg/h If BP not controlled or diastolic BP >140 mmHg, consider sodium nitroprusside

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For Patients Not Potential Candidates for Acute Reperfusion Therapy Consider lowering BP in acute ischemic stroke if BP >220/120 mmHg Consider BP reduction as indicated for other concomitant organ system injury AMI CHF Acute aortic dissection A reasonable target is to lower BP by 15% to 25% within the first day

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Imaging CT should be completed within 25 minutes and should be interpreted within 45 minutes of the patient's arrival in the ED. Centers may perform more advanced neurologic imaging (MRI, CT perfusion, and CTA), but obtaining these studies should not delay initiation of IV rtPA in eligible patients.

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Inclusion and Exclusion Characteristics of Patients with Ischemic Stroke Who Could Be Treated with rtPA within 3 Hours from Symptom Onset

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Inclusion Criteria Diagnosis of ischemic stroke causing measurable neurologic deficit Onset of symptoms <3 hours before beginning treatment Age >18 years

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Exclusion Criteria Head trauma or prior stroke in previous 3 months Symptoms suggest SAH Arterial puncture at non-compressible site in previous 7 days History of previous ICH Elevated BP (systolic >185 mmHg or diastolic >110 mmHg) Evidence of active bleeding on examination Acute bleeding diathesis, including but not limited to Platelet count <100,000/mm3 Heparin received within 48 hours, resulting in aPTT >upper limit of normal Current use of anticoagulant with INR >1.7 or PT >15 seconds Blood glucose <50 mg/dL CT demonstrates multilobar infarction (hypodensity >1/3 cerebral hemisphere)

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Relative Exclusion Criteria Only minor or rapidly improving stroke symptoms (clearing spontaneously) Seizure at onset with postictal residual neurologic impairments Major surgery or serious trauma within previous 14 days Recent GI or urinary tract hemorrhage (within previous 21 days) Recent AMI (within previous 3 months)

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Additional Inclusion and Exclusion Characteristics of Patients with Ischemic Stroke Who Could Be Treated with rtPA from 3 to 4.5 Hours from Symptom Onset

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Inclusion Criteria Diagnosis of ischemic stroke causing measurable neurologic deficit Onset of symptoms 3 to 4.5 hours before beginning treatment

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Exclusion Criteria Age >80 years Severe stroke (NIHSS >25) Taking an oral anticoagulant regardless of INR History of both DM and prior ischemic stroke At present, use of IV rtPA within 3 to 4.5 hour has not yet been FDA approved, although it is recommended by current AHA/ASA science advisory

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General Stroke Care Blood Pressure Management Glycemic Control hyperglycemia should be treated with insulin when glucose >185 mg/dL Temperature Control treat fever >37.5°C Dysphagia Screening Observe for signs of IICP severe stroke posterior circulation stroke younger patient

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Treatment of Acute Ischemic Stroke: IV rtPA Infuse 0.9 mg/kg (maximum dose 90 mg) over 60 minutes with 10% of the dose given as a bolus over 1 minute. Admit the patient to an ICU or stroke unit for monitoring. Perform neurological assessments every 15 minutes during the infusion and every 30 minutes for the next 6 hours, then hourly until 24 hours after treatment. If the patient develops severe headache, acute hypertension, nausea, or vomiting, discontinue the infusion and obtain emergency CT. Measure BP every 15 minutes for the first 2 hours and subsequently every 30 minutes for the next 6 hours, then hourly until 24 hours after treatment. Increase the frequency of BP measurements if a SBP >180 mm Hg or if a DBP >105 mm Hg. Administer antihypertensive medications to maintain BP at or below these level.

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Identify signs of possible stroke Activate EMS Critical EMS assessment and actions Support ABCs; give O2 if needed Perform prehospital stroke assessment Establish time of symptoms onset (last normal) Triage to stroke center Alert hospital Check glucose if possible Immediate general assessment and stabilization Assess ABCs, vital signs Provide O2 if hypoxemic (SpO2 < 94%) Obtain IV access and perform lab assessments Check glucose; treat if indicated Perform neurologic screening assessment Activate stroke team Oder emergent CT scan of brain Obtain 12-lead ECG Immediate neurologic neurologic assessment by stroke team or designee Review patient history Establish symptom onset Perform neurologic examination (NIHSS) MINS TIME GOLES ED Arrival ED Arrival 10 min 25 min

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Does CT scan show any hemorrhage Probable acute ischemic stroke; consider fibrinolytic therapy Check for fibrinolytic exclusions Repeat neurologic exam: are deficits rapidly improving to normal? Consult neurologist or neurosurgon; consider transfer if not available Patient remains candidate for fibrinolytic therapy? Administer aspirin Review risks/benefits with patient and family if accptable: Give tPA No anticoagulants or antiplatelet tx for 24 hrs Begin stroke pathway Admit to stroke unit or ICU Hemorrhage No hemorrhage Candidate Not a Candidate ED Arrival 45 min ED Arrival 60 min Stroke Admission 3 hrs Begin post-rtPA stroke pathway Aggressively monitor: BP per protocol For neurologic deterioration Emergent admission to stroke unit or ICU

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What Has Change ?

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Time is Brain ! Administrate rtPA to treat acute ischemic stroke within 4.5 hrs 4.5 hrs

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Oral anticoagulants NIHSS > 25 Both stroke & DM hx Older than 80 years Exclusions

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Symptomatic ICH Neurologic Outcome Benefit vs. Risk

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Thanks for Your Attention

Summary: Adult Stroke 2010 AHA Guidelines for CPR and ECC Circulation. 2010;122:S818-S828

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