Microsoft PowerPoint - M Dr Scharf ER Stroke ppt june 2009

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					    Telestroke Update
     Dr. Lorne Scharf
             June 12, 2009
              EDP meeting
Cornwall Community Hospital
             My Concerns
ED staff are cynical about lysing strokes in
Lysing strokes is not really proven to be beneficial
Lysing strokes is meant to be done only within
research trials
the benefit is so small it is not worth the time and
The risk of bleed is a serious problem - especially
in a rural setting
CAEP (our professional association) is against the
       My Concerns (contd)
Who administers the tnk/tpa -
ED docs - neurologist - internist?
Where - in the ED? in the ICU?
If there is no ICU bed, do we not lyse the patient?

The internists and on-call docs are too busy to be
called in for this.
And - if the ED is busy - how much "at the
bedside time" will this really take?
We’re about 5-10 years behind
          the current thinking
    (and Jerry Hoffman probably is too)
Telestroke is not an experiment
Just completed its 1000th consultation
Similar program in Alberta
Similar programs all over the USA
Similar treatment program in Germany

 Thrombolysis is the current standard of care
 for acute ischemic stroke
 # Canadian Stroke Network; Heart and Stroke Foundation of Canada. Canadian best practice recommendations for
 stroke care 2006. Ottawa (ON): Canadian Stroke Strategy; 2006. Available: (accessed 2008 Oct 28).
 # Lindsay P, Bayley M, McDonald A, et al. Toward a more effective approach to stroke: Canadian Best Practice
 Recommendations for Stroke Care. CMAJ 2008;178:1418-25.[Abstract/Free Full Text]
 # Lindsay P, Bayley M, Hellings C, et al. Canadian best practice recommendations for stroke care (updated 2008).
 CMAJ Available:
   MYTH: It is not really proven to be beneficial, and
It is meant to be administered only within research trials

Multiple trials and meta-analyses confirm the
effectiveness of tPA within protocols.
The latest of these was the ECASS 3 published
last fall in the NEJM.
This trial and the accompanying editorial well lay
out the benefits.
The last trial was not to prove efficacy but rather
to expand the time window to 4.5 hours.
The efficacy has not been in question within the
stroke community for many years.
MYTH: The benefit is so small it
  is not worth the time and
 Absolutely false
 the RR for death and disability is 55%
 NNT of 9 within 3 hours which drops to 34% and
 NNT 14 in the 3 to 4.5 hour time frame.
 The problem with this treatment in not lack of
 efficacy but rather the fact that it is so potent that
 any other comparators will have difficulty
 showing additional efficacy.
A number of cost effectiveness analyses
inculding one in Canada demonstrate that
the use of TPA is cost saving.
The use of this agent results in more money
for the system by preventing disability
which results in a huge economic burden.
 MYTH: The risk of bleed is a
serious problem - especially in a
          rural setting
Bleeding has not been an issue at all within
the system.
There is no indication for neurosurgical care
The protocols cover the medical
management steps.
CAEP (our professional association) is against the

The CAEP statement is considerably out of date
and is in the process of being revised.
Even as it is it is not against the treatment
CAEP requests that data be collected for quality
control -
10 years ago there was a question as to whether
the trial results could be replicated in clinical
This has been done in multiple jurisdictions
including Canada and currently the largest
database contains > 10,000 cases.
The results of rural and low
volume centers are actually
slightly better than those from
high volume centers.
Who administers the tnk/tpa? -
       and Where?
The practice uses both internists and ED
physicians in various centers based on availability.
The best determinant of outcome is time to
Therefore the ED physician is ideally placed at the
majority of centers in the system.
The post treatment requires monitoring for 24 hrs
but the absence of an ICU bed does not preclude
      We’re alone and busy!
The solo Doc is common to most centers in the
Experience has been overwhelmingly positive.
The typical telestroke consultation takes 25
minutes on camera.
The protocol is usually activated quickly after
brief asessment by the physician (about another 5
 Afterwards nurses monitor throughout the
Protocols involve the physician for specific
This is the standard of care
Our colleagues in other centers have had a positive
experience with this - and so should we
Yes - there will be more study in the field - and
protocols will evolve - but the properly selected
patients will benefit
Our challenge will be to work as a team, provide
the appropriate care for the patients, and
collaborate as effectively with Telestroke as we
have with CODE STEMI
Feel good about this - we now have something we
can do about a horrible disease