Rural Stroke Care for Prehospital Providers Chris Hogness

Rural Stroke Care for Prehospital Providers Chris Hogness, MD Telehealth Training March 17 th, 2010 Northwest Regional Stroke Network

Welcome n Thank you for joining us! n Format n Introductions

What we will talk about today n n n Evidence behind current stroke therapies ¨ Focus on intravenous thrombolysis Role of EMS in stroke systems of care: ¨ Activation of 911 ¨ Identification of stroke pt in the field ¨ Appropriate pre-hospital care ¨ Transport System planning for improved care

CASE n Previously healthy 48 yo man n History of migraine HA, last episode 1 yr ago n Possible episodic hypertension remotely, normal blood pressure in recent visit to PCP n Low grade hemoglobin A 1 C elevation: 6. 2 n Normal LDL cholesterol: 100 n No family history of vascular disease

CASE, continued n Experienced episode of weakness, fell at home ¨ Went back to bed Awoke 1 hour later with speech difficulty and left hemiparesis n EMS activated: n ¨ Delay in reaching rural location, paramedics chain up to get to his home

CASE, continued n Taken to local t-PA capable, critical access hospital Head CT done: no acute change n Phone consultation with neurologist 2 hrs away n Time since last normal 4 ½ hrs n Recommendation for no TPA, not given n Transferred to larger hospital n

CASE, continued n Further evaluation: MRA brain: Acute stroke involving posterior division of R MCA n MRA neck: Complete occlusion proximal R internal carotid n F/U CT brain 4 days after event: Interval extension of large R MCA infarct with surrounding edema n Specials: n TEE with bubble: no PFO ¨ Hypercoagulable w/u negative ¨

Stroke kills and disables many n Most common cause of disability in the world ¨ 1 n person disabled every 45 seconds in US Third leading cause of death in US ¨ 700, 000 n strokes/year in US Washington state: ¨ 26, 612 hosp and 3, 167 (6. 9%) deaths (2005)

Pathophysiology of stroke Angiographic and autopsy studies reveal approximately 80% of strokes caused by occlusive arterial thrombus

Brain cells die quickly in stroke n 1. 9 million neurons lost per minute ¨ Initial ischemic penumbra, area of decreased perfusion with neurologic dysfunction which may not be permanent if flow restored n Time window for clinical benefit of opening artery challengingly brief

Opening the occluded artery Intravenous thrombolytic n Intra-arterial thrombolytic n Mechanical n

Recanalization (restoring flow) rates by intervention Spontaneous: 24. 1% n Intravenous thrombolysis: 46. 2% n Intra-arterial thrombolysis: 63. 2% n Combined IV and IA thrombolysis: 67. 5% n Mechanical: 83. 6% n ¨ Rha et al: The impact of recanalization in ischemic stroke outcome: a meta-analysis. Stroke 2007: 38: 967

Recanalization (restoring flow) rates by intervention, update ¨ 1, 122 severe stroke patients at 13 academic centers between 2005 and 2009 ¨ Treated with one or more of: intra-arterial t. PA n intracranial stenting n IV delivery of t. PA in the arm n Merci Retriever for clot removal n Prenumbra aspiration catheter for clot removal n glycoprotein IIb/IIIa antagonists n angioplasty without stenting n

Recanalization update, continued n n n Patients treated with mechanical agents and drugs (n=584) compared to those treated only with mechanical therapy (n=274) or only drug therapy (n=264). Successful recanalization in 68% of all patients Recanalization rate for multimodal therapy patients 74%, no higher incidence of hemorrhage. ¨ Stenting and IA TPA only independent predictors of vessel recanalization during endovascular treatment. ASA International Stroke Conference Feb 2010

Most patient outcome data from intravenous thrombolysis n Intra-arterial, mechanical not randomized with iv thrombolysis: No RCT data comparing disability, death ¨ Improved flow may not correlate with improved outcome depending on technique used (eg distal embolization) ¨ n Exact niche for each modality not determined Intra-arterial lower t. PA volume, role in pts at increased risk of bleeding ¨ Intra-arterial may be more effective for more proximal occlusions ¨

Intravenous thrombolysis Multiple randomized controlled trials demonstrate reduced stroke disability n Consensus guidelines recommend: n American Heart Association n American College of Chest Physicians n n Regulatory agencies approve: FDA 1996 n Canada 1999 n European Union 2002 n

National Institute of Neurologic Disorders and Stroke (NINDS): NEJM 1995 • 624 pts with acute ischemic stroke, treated within 3 hrs of symptoms onset • Randomized to TPA vs placebo • Complete/near complete recovery at 90 days: • 31 -50% TPA vs 20 -35% placebo • Mortality not significantly different • 17% TPA vs 21% placebo • 10 fold increase in brain hemorrhage • 6. 4% TPA vs 0. 5% placebo

Stroke disability scores used in NINDS trial and others n n Modified Rankin scale: functional score ¨ 0 = no symptoms; 5 = severe disability Barthel index: activities of daily living ¨ 0 -100; 100 = complete independence Glasgow outcome scale: function ¨ 1 = good recovery; 5 = death NIH Stroke Scale (NIHSS) ¨ 42 point scale measure of neurologic deficit

NINDS favorable disability outcomes n n Modified Rankin scale of 0 -1: ¨ 39% t. PA vs 26 % placebo Barthel index of 95 -100: ¨ 50% t. PA vs 38% placebo Glasgow Outcome Scale of 1: ¨ 44% t. PA vs 32% placebo NIHSS 0 -1: ¨ 31% t. PA vs 20% placebo

Pooled analysis of 6 t. PA trials n n 2775 patients ¨ NINDS parts 1&2 (3 hr window) ¨ ECASS I and II (6 hr window) ¨ ATLANTIS A (6 hr window) and B (5 hr) Findings: ¨ Benefit dependent on time from onset of symptoms to treatment ¨ Hemorrhage 5. 9% t. PA vs 1. 1% placebo § Lancet 2004: 363: 768 -774

Favorable outcome at 3 months by time of treatment: pooled data IV rt. PA vs Placebo Time (min) 0 90 91 180 181 270 271 360 Odds Ratio 2. 8 1. 5 1. 4 1. 2 95% CI 1. 8 4. 5 1. 1 2. 1 1. 9 0. 9 1. 5

Pooled t. PA data: benefit vs time 3 hours Pooled analysis of ATLANTIS, ECASS, and NINDS rt-PA stroke trials. Lancet. 2004; 363: 768

3 TO 4 ½ HOURS: ECASS III: NEJM 2008 n 821 pts 18 to 80 yrs old with acute ischemic stroke for whom treatment could be administered 3 to 4 ½ hrs from stroke onset, randomized to t. PA vs placebo ¨ 52% no disability with t. PA vs 45% placebo ¨ No mortality difference (7. 7% t. PA vs 8. 4%) ¨ Symptomatic hemorrhage 7. 9% t. PA vs 3. 5% § NEJM 2008; 359: 1317 -29

IV thrombolysis is underutilized Currently, estimated 4% of patients with ischemic stroke receive thrombolysis with rt-PA n Very short time window n Patients arrive late n Hospitals may be slow to respond n

How long does it take pts to get to the hospital? n 106, 924 pts treated over 4 year period at 905 “Get-With-the-Guidelines” hospitals for whom time of onset of stroke available ¨ 28. 3% arrived within 60 minutes ¨ 31. 7% 1 -3 hours ¨ 40. 1% > 3 hours § Jeff Saver, Feb 18, 2009, ASA International Stroke Conference

How long does it take to begin rt. PA after pt arrives at hospital? •

Goal treatment timeline for doorto-needle Evaluation by physician: 10 min n Stroke expertise contacted: 15 min n Head CT or MRI performed: 25 min n Interpretation of CT/MRI: 45 min n Start of treatment: 60 min n

Why do patients delay seeking care for acute ischemic stroke? n Painless ¨ Unlike myocardial infarction Cognition may be impaired by the event n Not calling 911 n ¨ 1 st n call to physician associated with delay 911 dispatch may fail to recognize sx or not understand pt due to stroke

True/False: EMS response times to suspected stroke should be equal to response times for suspected MI

AHA recommended goals for EMS response time in stroke Dispatch time < 1 minute n Turnout time < 1 minute n Travel time equivalent to trauma or MI calls n

What is the maximum on scene time recommended for EMS personnel prior to transport of the patient with stroke?

Minimize on-scene time Least is best n No more than 10 minutes in assessment n ¨ Some n parts may be done in transit Goal <15 minutes total on-scene time

True / False: EMS personnel should use a validated screening tool in assessing pts for stroke

EMS stroke assessment tools Cincinnati Prehospital Stroke Scale n Los Angeles Prehospital Stroke Screen n F. A. S. T. n

F. A. S. T. Face n Arm n Speech n Time last normal n n If one component abnormal, 72% probability CVA

Name several conditions that can mimic stroke

Conditions mimicking stroke: Hypoglycemia n Seizure with post-ictal period n Complex migraine n Conversion disorder n Drug ingestion n

Over-triage Err on the side of over-identification rather than under-identification n AHA: “Initially, EMSS should establish a goal of over-triage of 30% for the prehospital assessment of acute stroke” n Lessons from trauma: if over-triage is not present, under-triage will result n

What routine pieces of history should be obtained? TIME LAST NORMAL n Hx diabetes? Use of insulin? n Hypertension? Medications used? n Hx seizure disorder? n

What piece of history is often not included in prehospital assessments?

Time last normal EMS personnel often only medical providers with access to all witnesses n Transporting family/witnesses with patient may help with treatment decisions at the hospital n

Prehospital treatment of stroke n True/False: ¨ __First address ABCs ¨ __Run glucose containing solutions IV ¨ __Correct hypovolemia with IV saline ¨ __Correct hypoglylcemia when present ¨ __Administer aspirin ¨ __Administer oxygen in the non-hypoxic patient ¨ __Keep pt NPO

Prehospital treatment of stroke n True/False: ¨ T__First address ABCs ¨ F__Run glucose containing solutions IV ¨ T__Correct hypovolemia with IV saline ¨ T__Correct hypoglylcemia when present ¨ F__Administer aspirin ¨ F__Administer oxygen in the non-hypoxic patient ¨ T__Keep pt NPO

Transport n Determine appropriate facility ¨ Closest TPA capable if < 2 hrs from time last normal n Assumes door-to-needle will be <60 min ¨ Primary stroke center / Comprehensive stroke center n State guidelines pending regarding appropriate level of stroke center based on time last normal

Transport, cont. n Early hospital notification ¨ Confirm availability of CT ¨ Specify F. A. S. T findings n Consider air transport in remote areas ¨ EMS responders simultaneously call for air transport and prenotify ED at receiving stroke center in some systems

Management en route n Lay patient flat unless airway compromise ¨ Don’t n elevate head greater than 20 degrees IV access ¨ 16 or 18 gage if possible ¨ Avoid glucose containing solutions 2 nd exam/neuro reassess n Perform TPA check list n

What labs need to be sent on stroke TPA treatment candidates? CBC including platelets n Cardiac enzymes n Electrolytes, BUN, creatinine, glucose n PT/INR n PTT n

Name as many contraindications to t. PA as you can

Contraindications to TPA: clinical n Symptoms/signs only minor or rapidly improving Seizure at onset of stroke (not absolute) Symptoms suggestive of subarachnoid hemorrhage Persistent blood pressure elevation >185/110 n Active bleeding or acute trauma n n n (fx)

Contraindications to t. PA: historical Stroke or head trauma in prior 3 months n Any hx intracranial hemorrhage n Major surgery in previous 14 days n GI or GU tract bleeding in previous 21 d n MI in prior 3 months n Arterial puncture at noncompressible site previous 7 days n

Contraindications to TPA: lab Platelets less than 100 K n Glucose less than 50 n On oral anticoagulant with INR > 1. 7 n On heparin with PTT higher than normal n

Contraindications to TPA: CT Evidence of hemorrhage n Major early infarct signs (diffuse swelling of affected hemisphere, parenchymal hypodensity, and/or effacement of >33% of middle cerebral artery territory) n

Telemedicine and telephone consultation n Several successful demonstrations published ¨ Technical issues with portable videoconferencing, transmittle of CT scans ¨ Financial issues: reimbursement ¨ Legal issues: liability

Drip and Ship n Starting IV t-PA infusions for acute ischemic stroke at community hospitals prior to transfer to a regional stroke center is feasible and safe ¨ Several n demonstrations published Silva et al, ASA International Stroke Conference, February 2009, others

How often do vital signs need to be checked after the administration of rt-PA?

Monitoring after rt-PA in stroke n Vital signs and neurologic status should be checked: ¨ Every 15 minutes for two hours, then ¨ Every 30 minutes for six hours, then ¨ Every 60 minutes until 24 hrs from start of rx

Treatment of hypertension in stroke n If no rt-PA given, best to leave any acute treatment to hospital ¨ Generally we do not treat acutely unless >220/120 n If rt-PA has been given: ¨ Systolic n >180, diastolic >105: Labetalol 10 mg iv over 1 -2 minutes, repeat every 10 -20 minutes to max 300 mg

System improvement Public education on signs/sx/rx stroke n Fundamental role of EMS in getting pt to appropriate center on time n ¨ Integrate EMS in planning ¨ Continuous case-based feedback to EMS personnel n Hospital systems to shorten door-to-needle time

Questions? n Q&A n Follow-up questions: ¨ Dr. n Hogness: cchogness@methownet. com Network questions & future trainings: ¨ Coordinator: chara. chamie@doh. wa. gov