Get documents about "The Continuum of Stroke Care
Shared by: 5J3LR8
-
Stats
- views:
- 1
- posted:
- 11/24/2011
- language:
- English
- pages:
- 31
Document Sample
The Continuum of Stroke Care
Justin A. Sattin, M.D.
Assistant Professor
UW Department of Neurology
Medical Director
UW Health Comprehensive Stroke Program
The Chain of Survival
• Healthful Choices • ICU Nursing Care
• Public Recognition • General RN Care
• EMS Access • More Radiology / Lab
• ED Recognition • Inter-D Care
• Radiology / Lab • Rehabilitation
• Neurologist • Re-Integration
• Pharmacy
Stroke Symptoms
Cincinnati Prehospital Stroke Scale
Facial Droop
Instruction: Ask patient to smile
o Normal: Both sides of face move equally
o Abnormal: One side of face does not move as well
Arm Drift
Instruction: Ask patient to close eyes and extend both arms straight
out for 10 seconds
o Normal: Both arms move the same or not at all
o Abnormal: One arm does not move or drifts down
Speech
Instruction: Ask patient to say “You can’t teach an old dog new tricks.”
o Normal: Patient says correct words without slurring
o Abnormal: Patient slurs words, says wrong words, or is unable to
speak
Kothari RU, et al. Cincinnati Prehospital Stroke Scale: reproducibility and validity. Ann
Emerg Med. 1999;33:373-8.
Ischemic or Hemorrhagic?
Ischemic or Hemorrhagic?
NINDS tPA Trial
35
30
25
20 Death
15 Hemorrhage
10
5
0
t-PA Placebo
The National Institute of Neurological Disorders and Stroke rt-PA
Stroke Study Group. Tissue plasminogen activator for acute
ischemic stroke. N Eng J Med. 1995;333:1588–1593.
39 – 26 = 13
39 – 26 = 13% absolute difference
10013
= needed to treat
---------8= 50% relative benefit
13 26
Time is of the Essence
Hacke W, et al. Association of outcome with early stroke
treatment: pooled analysis of ATLANTIS, ECASS, and NINDS
rt-PA stroke trials. Lancet 2004;363:768-74.
Furlan A, Higashida R, Wechsler L, et al. Intra-arterial prourokinase for acute ischemic
stroke. The PROACT II Study: A randomized controlled trial. JAMA. 1999;282:2003-2011.
Mechanical Embolectomy
Leary MC, et al.
Beyond tissue
plasminogen
activator:
mechanical
intervention in
acute stroke.
Ann Emerg
Med.
2003;41:838-
46.
Courtesy of Concentric Medical, Inc.
Mechanical Embolectomy
Annual Stroke Mortality
2001-2004
Avg# of deaths per county per year
(total for all counties in group)
<10 (64) 50-100 (1,067)
10-50 (1,033) >100 (1,186)
Yuan, H. and Brue, C. Wisconsin Heart Disease and
Stroke Surveillance Summary Update – 2007 – PPH
43040 (01/07). Wisconsin Department of Health and
Family Services, Division of Public Health.
The Joint Commission. Available at:
http://www.jointcommission.org/CertificationPrograms/Disease-
SpecificCare/DSCOrgs/ Accessed 10/14/07
General Management Principles
• Hypoxic pts. should receive O2
– SpO2 > 92%
• Cardiac monitoring for at least 24 hrs.
• Treat HTN conservatively for 24 hrs.
– Ischemic: SBP < 220 mmHg
– Hemorrhagic: SBP < 160 mmHg
General Management Principles
• Minimize urinary catheterization
• Fevers should be evaluated and treated
• Hyperglycemia should be treated
– Optimal threshold is not established
– < 140 mg/dL? < 185 mg/dL?
General Management Principles
• Dysphagia screening
• Early mobilization
• DVT prophylaxis
– LMWH
Stroke
Hemorrhagic Ischemic
Cardioembolic
Large artery athero.
ICH SAH
Small vessel dz.
Other
Unknown
Adams HP Jr, Bendixen BH, Kappelle LJ, Biller J, Love BB, Gordon DL, Marsh EE 3rd.
Classification of subtype of acute ischemic stroke. Definitions for use in a multicenter clinical
trial. TOAST. Trial of Org 10172 in Acute Stroke Treatment. Stroke. 1993;24(1):35-41.
Stroke
Ischemic
Cardioembolic
Large artery athero.
Small vessel dz.
Other
Unknown
http://www.florida-oxygen.com/treatment.htm
Stroke
Ischemic
Cardioembolic
Large artery athero.
Small vessel dz.
Other
Unknown
http://www.cardioliving.com/consumer/Stroke/AF_Causes.shtm
Cardioembolic Stroke
Stroke
Ischemic
Cardioembolic
Large artery athero.
Small vessel dz.
Other
Unknown
http://biocomp.stanford.edu/3dreconstruction/movies/haveri/stenosis_ica_angio%26ssd.jpg
Stroke
Ischemic
Cardioembolic
Large artery athero.
Small vessel dz.
Other
Unknown
Stroke
Ischemic
Cardioembolic
Large artery athero.
Small vessel dz.
Other
Unknown
http://bbh.hhdev.psu.edu/courses/368/slide.21.(164).htm
Stroke
Ischemic
Cardioembolic
Large artery athero.
Small vessel dz.
Other
Unknown
Risk Factor Modification
• Hypertension
• Diabetes
• Dyslipidemia
• Metabolic Syndrome
• Tobacco Dependence
Antithrombotic Therapies
• Aspirin
• Aspirin/Dipyridamole (Aggrenox)
• Clopidogrel (Plavix)
• Warfarin (Coumadin)
Important Collaborators
• PT • Health Ψ
• OT • Case Managers!
• Speech • Social Work
• Swallow • Pastoral Care
• Rehab • Palliative Care
• Neuro Ψ • ACE Team
Discharge Dispositions
• Home
– often with outpt. or home health therapies)
• Acute Rehab
• Subacute Rehab
• Skilled Nursing Facility
• Hospice
• (Celestial Discharge)
Vascular
Cognitive
Impairment
How to Reach Us
Emergent Referrals Office Referrals
UW Access Center UW Stroke Clinic
Phone: 800-472-0111 Phone: 608-265-8899
Fax: 608-265-1753
