EMS Management of Stroke. Deaver Shattuck, M.D. Brian Wiseman, M.D. Keith Woodward, M.D.

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1 EMS Management of Stroke Deaver Shattuck, M.D. Brian Wiseman, M.D. Keith Woodward, M.D.

2 Financial Disclosure: No relevant financial relationship exists

3 Working Together to End Stroke

4 Formed in 2013 Identified opportunity to improve stroke care throughout Region II Consensus among team members that collaboration is critical component of success Plan to serve as resource for regional EMS and facilities

5 Promote evidence-based acute stroke care in East Tennessee through advocacy and education of its citizens and the healthcare community

6 Promote state of the art evidence-based acute stroke care in East Tennessee through education of EMS, hospitals, providers, administrators, and the public Expedite immediate management of acute ischemic and hemorrhagic stroke (i.e. intravenous tissue plasminogen activator [t-pa]) Expedite identification of acute ischemic and hemorrhagic stroke patients that would benefit from a higher level of care (i.e. neurointerventional radiology; neurosurgery) Assist and educate any healthcare organizations and providers interested in becoming acute stroke ready or certified primary stroke center

7 EMS Management Deaver Shattuck, M.D. Medical Director Blount Memorial Hospital Primary Stroke Center

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14 Primary Stroke Centers in Tennessee=18 Comprehensive Stroke Centers in Tennessee=5

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17 ED Management Brian Wiseman, M.D. Medical Director The University of Tennessee Medical Center Comprehensive Stroke Center

18 Approximately 2 million neurons are lost per minute in typical stroke!

19 Time is Brain Pre-hospital notification Improves Door-to-Needle Time (DNT) Pre-hospital preparation EMS Cincinnati Prehospital Stroke Scale (CPSS) Determination of last known well Contact Number(s) of critical historian(s) Lab draw IV access

20 Time is Brain Prehospital preparation ED Stretcher available Pre-registration Nurse, Physician and Pharmacist ready CT technologist clears scanner Stroke Team Toolkit Collect information Critical historian interview by telephone if possible

21 Stroke Team Time is Brain ED Nurse ED Physician Stroke Team Nurse Practitioner Neurologist Pharmacist Lab Technician CT Technician Radiologist Interventional neuroradiologist

22 ED Evaluation & Management Time is Brain Acute Stroke order pathway initiated History Time last known well Inclusion/exclusion criteria BP <185/110 NIHSS (NIH Stroke Scale) 0-42 point scale IV Access Higher score generally correlates with more severe stroke deficits Does not always correlate with degree of disability 2 18-gauge IV s Laboratory Blood glucose only lab result necessary prior to IV t-pa Other labs (PT/INR, PTT, CBC, CMP, Troponin) should be sent and processing

23 Time is Brain ED Evaluation & Management Neuroimaging Non-contrast Head CT Bleed or No Bleed Only imaging necessary to administer IV t-pa for acute stroke CT Angiogram CT Perfusion MRI Angiogram» Clot retrieval

24 Time is Brain ED Evaluation & Management IV t-pa Inclusion/Exclusion criteria 0.9mg/Kg 1 st 10% is given as a bolus over 1 minute Remainder is infused over the next 1 hour Monitor Every 15 minutes x2 hours Every 30 minutes x6 hours Every 1 hour x16 hours» Neurologic examination (e.g. NIHSS, MEND)» Vitals (BP, HR) Anti-hypertensive medications

25 Time is Brain ED Evaluation & Management Suspected IV t-pa related intracranial hemorrhage Stop IV t-pa and immediate non-contrast Head CT Acute neurological worsening Sudden severe headache Abrupt and unexpected BP spike Intracranial hemorrhage related to IV t-pa BP management Cryoprecipitate, Platelets, Aminocaproic Acid Neurosurgical consultation

26 Time is Brain Target Stroke DNT 60 minutes 75% of eligible Acute Ischemic Stroke patients receive IV t-pa DNT 45 minutes 50% of eligible Acute Ischemic Stroke patients receive IV t-pa American Stroke Association initiative

27 Time is Brain Hemorrhagic Stroke The Basics BP management Target SBP Titratable anti-hypertensive medication Reverse coagulopathy Neurointensive Care Unit Neurosurgical Consultation

28 Interfacility Transport Keith Woodward, M.D. Medical Director Fort Sanders Regional Medical Center Comprehensive Stroke Center

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30 First Line Stroke Treatment Stabilize Patient Obtain History Rapid Diagnosis IV tpa

31 Is there more?

32 Acute Stroke CT Findings

33 Acute Stroke CT Findings X

34 CTA tells only part of the story

35 Collaterals

36 Collaterals Predict Outcome

37 Penumbra

38 Perfusion Imaging Can Measure Collaterals

39 Perfusion Imaging Can Measure Collaterals

40 Perfusion Imaging Can Measure Collaterals MTT CBV

41 1.5 hours Post Treatment MTT CBV

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43 Comprehensive Stroke Center Diagnosis Estimate Penumbra and Collaterals CT Perfusion MR Perfusion Procedures Embolectomy Not a candidate for tpa No improvement after tpa

44 2004

45 2012

46 2014

47 Penumbra Aspiration Catheter

48 Mechanical Clinical Trials IMS III (tpa) IMS III (Endovascular ) TREVO STAR N Age Baseline NIHSS, median Successful recanalization - 44% 78.3% 84.2% mrs 2 at 3 months Mortality at 3 months Symptomatic ICH at 24 hrs 38.7% 40.8% 55.0% 57.9% 21.6% 19.1% 20% 6.9% 5.9% 6.2% 5% 1.5%

49 tpa Success

50 Mechanical Clinical Trials Improved Patient Selection MRCLEAN + tpa MRCLEAN + tpa & + Embolectomy N Age Baseline NIHSS, median Successful recanalization - 80% mrs 2 at 3 months 19% 33% Mortality at 3 months 20% 7% Symptomatic ICH at 24 hrs 5% 6%

51 Ischemic Stroke Transfers No different than field stroke protocols Strict BP management < 160 SBP Especially after tpa! Frequent VS/neuro assessments en route Every 15 minutes at minimum

52 Angioedema after IV tpa < 5% of Cases

53 Ischemic 80-85% Hemorrhagic 15-20%

54 Comprehensive Stroke Center Diagnosis CTA and Angiography 24/7 Aneurysms Embolization Aneurysm Clipping Hypertensive Bleed / ICH Craniotomy Minimally Invasive Clot Aspiration

55 Hemorrhagic Stroke Transfers No different than ischemic stroke protocols Strict BP management < 160 SBP Monitor VS/neuro assessments frequently Monitor for airway compromise HOB

56 Every second counts Summary Each team member must be on top of their game to ensure optimal outcome Utilizing for EMS activation is best practice EMS is critical first contact for most patients Your assessment, history, and rapid transport makes the difference!!

57 Questions???

58 Working Together to End Stroke For More Information:

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