Proceedings of a National Symposium on
Rapid Identification and Treatment of Acute Stroke
December 12-13, 1996
The Emergency Department Panel made specific recommendations in four areas: educational needs for physicians and nurses, response systems, medical management of blood pressure, and classification systems for stroke patients.
- Educational Needs
Pathophysiology of Stroke
Frequency of Stroke
Accentuating the Positive
- Response Systems
- Medical Management of Blood Pressure
- Classification System for Stroke Patients
A thorough understanding of the pathophysiology of stroke is critically important, not only for emergency physicians (EPs) but also for emergency department (ED) nurses. A subject not currently stressed in emergency medicine residency curricula is the natural history of ischemic stroke, and particularly those issues dealing with time-sensitive events in brain ischemia. These include time-critical pathophysiological changes and those events that necessitate an emergency response and early intervention.
Patient identification is a second area that requires more study and better guidelines. Just as emergency medical services personnel must be able to rapidly assess a stroke patient, so too must ED personnel be trained to rapidly appraise stroke-related events. Information that might seem simple to obtain may not be so. For example, establishing the pivotal time of stroke onset can be very difficult.
A third issue regards thrombolysis. Since this is the current treatment for acute ischemic stroke, ED nurses and EPs must clearly understand the inclusion and exclusion criteria for thrombolysis and the potential benefits. The EP may be responsible for explaining risks and benefits to patients and will require a full understanding of the potential complications and risks from such treatment.
One approach to creating effective educational programs on stroke thrombolysis is to teach medical personnel the similarities and differences between coronary and stroke thrombolysis. EPs and nurses have a good understanding of coronary thrombolysis and this knowledge base can help create a similar level of understanding of the unique aspects of stroke and particularly the response of stroke patients to thrombolytic treatment.
Another educational need is training of physicians in the interpretation of brain CT scans. Such training must cover not only recognition of intracranial hemorrhage but also recognition of brain infarction, a sign that may give further information about the time of stroke onset.
Another key subject is blood pressure management, particularly the expected outcome and complications of treating elevated blood pressure. It is important to know how to respond to elevations in blood pressure in all types of stroke. To do this effectively, we need to identify acceptable control measures and appropriate drugs for each stroke type.
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Accurate classification of stroke type and quantification of the extent of neurological deficit requires an efficient neurological exam. Unfortunately, neither neurology residents nor emergency residents or nurses are consistently educated in the use of scales like the NIH Stroke Scale. EPs must be able to evaluate stroke patients using the NIH Stroke Scale in order to give quantifiable information to other members of the stroke team. As we go about developing simplified stroke scales for use in the prehospital phase of patient screening, we may also be able to develop more efficient neurological exams for use in triage of stroke patients.
Nurses and physicians will need to be very familiar with communications protocols and will need to understand which protocol to follow when a stroke occurs. A ready method of initiating a stroke team response must be in place.
In a Level I trauma system, effective communications protocols require a great deal of education. Staff in a Level I trauma center know what responses are expected for each type of trauma patient. We need similar types of communications protocols for managing patients with ischemic stroke.
Defining the role of the stroke team is critically important. When does the stroke team need to be involved? Who is on the stroke team? What are the essential tests and standard orders in the ED? What other tests may be needed to make a decision to treat specific conditions that occur in some stroke patients? The answers to these questions may be different for various medical centers but all EPs will need to be educated and involved in the plan that is established.
In addition to a CT scan, what are the essential tests for a patient with stroke? In line with the American Heart Association guidelines, the Emergency Department Panel identified the following necessary tests: complete blood cell count with differential and platelet count; electrolytes, BUN, creatinine, coagulation profile; chest radiograph; and electrocardiogram. It is critical that certain of these tests be obtained in a timely manner. It will be important to teach the medical staff which tests are essential and which are needed prior to considering specific treatments.
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How frequently does a given hospital admit a stroke victim who is eligible for thrombolytic treatment? Of the 500,000 strokes that occur each year in the United States, about 400,000 will be ischemic. In contrast, each year about 1.5 million Americans have a myocardial infarction (MI). If one assumes that the percentage of stroke patients eligible for treatment is the same as the percentage of MI patients eligible for treatment, this would mean that there would be only one eligible stroke victim for every 3.75 eligible MI patients. Currently, we treat approximately 25% of MI patients but only 3-5% of stroke patients. This indicates that we have a great need to maintain staff awareness with frequent refresher courses. Many physicians lack extensive experience in the area of stroke management. Ensuring quality of care for a disease entity that does not occur frequently will require extensive efforts to maintain adequate levels of awareness and to make allowances for limited experience.
There needs to be a practiced management response to stroke. This can be accomplished through repetitive exercises. We may want to consider stroke team drills similar to mock codes currently used in many hospitals. These drills should review the criteria for proper patient identification, the required tests and procedures to be taken, and the preferred communications systems.
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A key to successful training of medical staff will be to accentuate the positive; this could include case conferences highlighting successful cases, reminders of team goals, and a continuing reminder and feedback system that uses posters. For practicing team doctors and nurses there should be continuing medical education conferences, practice guidelines, and case conferences on a regular basis. For physicians and nurses in training we need to have early involvement of teaching institutions, and we must develop appropriate curricula and reevaluate curriculum design on a continuing basis.
In summary, we must shift attitudes using persuasive evidence of need, establish interdisciplinary working teams, and educate staff about patient selection, effective communication, and coordination of services. We need to teach staff how to clearly differentiate the different types of stroke patients and how to choose the correct treatment for a particular patient. We need different approaches for practicing physicians, nurses, students, and residents in training. And we must accentuate the positive outcomes that can be obtained from early stroke treatment. The emergency management of all types of stroke will be improved by the establishment of timely and knowledgeable approaches to acute stroke management from prehospital through the ED and inhospital phases.
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An effective hospital stroke response system should be efficient, high-quality, and cost effective. Some key factors in establishing an effective system include stressing the need for early recognition of eligible patients, early consideration for stroke team activation, and establishing standing orders for patients with stroke.
Certain standing orders that should be utilized relate to serial vital sign monitoring, O2 saturation monitoring, and rapid glucose assessment. Highly recommended are neurological monitoring with a scale similar to the NIH Stroke Scale and constant cardiac monitoring for all stroke patients. Intravenous access should be established for all stroke patients.
The Emergency Department Panel reached consensus on time-frames that need to be established as goals for those responding to acute stroke:
- A physician should evaluate a stroke patient within 10 minutes of arrival at the ED doors.
- A physician with expertise in the management of stroke should be available or notified within 15 minutes of patient arrival. Depending on the protocol established this may be accomplished by activating a stroke team.
- A CT scan of the head should begin within 25 minutes of arrival. The CT interpretation should be obtained within 45 minutes of arrival. This gives adequate time to perform the scan, process the images, and interpret the results.
- For ischemic stroke, treatment should be initiated within 60 minutes. There was clear consensus on this door-to-treatment guideline among participants in both the Emergency Department Panel and the Acute Hospital Care Panel.
- The time from patient arrival at the ED to placement in a monitored bed should not exceed 3 hours.
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Medical staff should assess for and appropriately treat hyperglycemia, hypoxia, fever, and congestive heart failure or arrhythmias. But one of the most important components of medical management involves blood pressure control.
There is no evidence from randomized clinical trials to mandate the best method for blood pressure treatment or what levels of blood pressure should be treated for any type of stroke. However, reasonable recommendations issued by the American Heart Association and others can be applied. In general, physicians should avoid treatment if possible and any treatment given should be based on multiple measurements taken 10 to 20 minutes apart and never on a single blood pressure reading.
Patients who present with a sustained diastolic blood pressure greater than 140 mm Hg should receive intravenous infusions of antihypertensive agents. Patients with a systolic blood pressure greater than 220 mm Hg or a diastolic blood pressure between 120 and 140 mm Hg should receive labetolol or other agents that do not require constant intravenous infusion.
Ischemic stroke patients with a systolic blood pressure less than 185 mm Hg and a diastolic blood pressure less than 120 mm Hg usually do not require treatment unless thrombolytic therapy is being administered. A specific protocol is currently recommended for patients who have ischemic stroke and are candidates for or are receiving thrombolytic therapy. For t-PA , if aggressive treatment is required to lower a patient’s blood pressure to meet the requirements for thrombolytic treatment, the patient is not eligible for treatment with t-PA. For example, a patient who requires continuous intravenous infusion of antihypertensive agents to maintain blood pressure below the 185/110 mm Hg level should not be considered a candidate for t-PA treatment.
For intravenous treatment of high blood pressure in acute ischemic stroke patients, the suggested agents include nitroprusside, esmolol, and nitroglycerin. Other agents for intermittent treatment are enalapril or labetalol.
Patients with acute ischemia who present with hypotension, either relative hypotension in a chronically hypertensive patient or hypotension in a normotensive patient, should be treated aggressively to increase the blood pressure.
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Patients should be rapidly evaluated to identify those who require resuscitation for life-threatening situations, treatment for stroke or nonstroke emergencies, or administration of thrombolytic agents. Ideally, patients should be classified at the site where they are first identified. This may be in the ED if the patient arrives as an ambulatory patient, at a referring hospital if the patient is going to be transferred to a stroke center or another facility, or in the prehospital setting where the patient is initially identified.
As is the case for trauma victims, the initial classification of stroke victims should be very simple so that it can be accomplished by a variety of personnel, not necessarily a physician. These include prehospital providers, triage or bedside nurses, EPs, or other individuals competent to apply the categorization criteria. In this first phase of categorization the goal is to cull as many potential patients as possible. While the initial phase of classification is simple to make it applicable to more who are not physicians, the subsequent phases get increasingly complex and specific in order to pare down to those who should receive emergency treatment. Each phase is carried out by increasingly prepared individuals, particularly physicians with stroke treatment experience. For now, at this early point in the development of acute stroke care, providers should be oriented to provide appropriate ischemic stroke patients with thrombolytic therapy since this is the treatment available. Patients who are identified with subarachnoid hemorrhage or intracerebral hemorrhage should be put through the same rapid categorization for treatment. When it is determined that a patient has a subarachnoid hemorrhage or an intracerebral hemorrhage and therefore is not a candidate for thrombolytic therapy, he or she should then receive treatment appropriate for that type of stroke.
What steps are recommended for categorizing stroke patients?
Step 1 is to identify any life threat. The first part of patient evaluation is always the ABC’s–airway, breathing, and circulation.
Step 2 is to identify all potential stroke patients using an abbreviated stroke scale developed for the prehospital and triage phase.
Step 3 is to initiate a priority response by a designated physician to plan evaluation for the use of appropriate emergency stroke therapies.
Step 4 is to complete patient assessment by performing a CT scan and other requested laboratory tests.
Step 5 is to review the CT and laboratory studies, confirm initial estimates of the time from symptom onset, and, if appropriate, administer the treatment.