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Developing Acute Stroke Services Diagnosing Screening Acute Care pathways Thrombolysis Dr C. Roffe Clinical Lead Shropshire and Staffordshire Heart and Stroke Network . Patient or bystander recognizes stroke. Dial 999. Ambulance response Blue-light FAST positive potential strokes to A&E.

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Developing Acute Stroke ServicesDiagnosingScreeningAcute Care pathwaysThrombolysisDr C. RoffeClinical Lead Shropshire and Staffordshire Heart and Stroke Network

Patient or bystander recognizes stroke

Dial 999

Ambulance response

Blue-light FAST positive potential strokes to A&E

Fits thrombolysis criteria pre alert A&E

Does not fit thrombolysis criteria

Immediate assessment

Thrombolysis pathway and CT within 15 min

Stroke pathway and CT within 1 hour


Admit to ASU within 4 h of presentation

Diagnosing Stroke and TIA


Face–Arm–Speech Test

F Facial weakness: Can the person smile? Has their mouth or an eye drooped?

A Arm weakness: Can the person raise both arms?

S Speech problems: Can the person speak clearly and understand what you say?

T Time to call 999.

ROSIERRecognizing Stroke in the Emergency Room

Only count new symptoms

Exclude hypo by BM stix

Unilateral facial weakness? y (1) n (0)Unilateral arm weakness? y (1) n (0) Unilateral leg weakness? y (1) n (0) Speech disturbance ? y (1) n (0) Visual field defect? y (1) n (0) Any loss of consciousness or syncope y (-1) n (0) Any seizures? y (-1) n (0)

Rosier >0 suggests ischaemic stroke and potential thrombolysis case

Stroke or TIA?

  • Symptoms still present => Stroke

  • Symptoms gone =>TIA



  • Sudden onset

  • With focal rather than global dysfunction

  • In which, after adequate investigations, symptoms are presumed to be of non-traumatic vascular origin

  • and last for >24 hours

Stroke onset

  • Witness?

  • Woke with hemiparesis?

  • Found collapsed?

  • Sudden/gradual/ stuttering

ABCD2 Scoring for all new TIAs

Stroke risk within 1 week 6% for scores 4-5, 12% for scores >5

Admit all with score 5 or above.

TIA management

  • Do not allow any TIA patient to leave the department without having administered the first dose of antiplatelet

  • ABCD 4 or above admit or ensure TIA clinic appointment (and Doppler) within 24 hours.

  • Endarterectomy within 48 h for patients with symptomatic stenosis

  • ABCD <4 see in TIA clinic within 1 week. Endarterectomy within 14 days for patients with symptomatic stenosis

    This will reduce strokes within 1 week by 80%!!!

Role of Paramedics

  • Establish working diagnosis of stroke/TIA

  • Identify potential thrombolysis candidates

  • Prealert A&E if thrombolysis an option

  • Establish onset time

  • Bring a witness

  • Airway Breathing Circulation

  • Exclude Hypo BM

  • Prevent aspiration

  • Get patient to nearest hyper acute stroke centre

Investigations and tests in the early stages

CT Head scan

  • Intracerebral haemorrhage

  • Correct abnormal INR or low platelets immediately

  • Neurosurgical referral

  • Cerebral Infarct

  • Thrombolysis or

  • immediate antiplatelet treatment

Early signs of infarctionLoss of insular ribbon


SW, day 1

Early signs of infarctionEffacement of sulci

SW, day 1

CT angiogram

Diffusion Perfusion CT

Other tests

  • FBC

  • U&E

  • INR

  • Glucose

  • ECG

  • Carotid Doppler



DH A New Ambition for StrokeA consultation document for a National Stroke strategy Dec 2008

If 10% of stroke patients in the UK were given thrombolysis, 1000 people less would be dead or dependent in one year.

NINDS trial of rt-PA for acute ischaemic stroke

  • 633 patients recruited

  • Rt-PA 0.9 mg/kg (10% bolus the rest over 1 h) given within 3 hrs of symptom onset

  • BP<185/110

  • Not on warfarin or heparin, platelets and coagulation normal

  • Blood glucose 2.7-22 mmol/L

  • No seizure at onset

    Quasi intensive care environment

    Aggressive BP control

    16,000 screened to recruit 633

    N Engl J Med 1995;333:1581-1587.

NINDS rt-PA trial 1995Improvements in dependency (modified Rankin Scale: mRS)

Mean Score 2.8 for rt-PA and 3.3 for control : difference 0.5 mRS points*

Number needed to treat to improve by 1 point is 2*

Number needed to treat to improve by 1 or more points is 3**

Number needed to treat to make one patient more independent =5*









* My own calculation bases on the original paper ** Saver. Arch Neurol, Jul 2004; 61: 1066 - 1070.


  • Age 80 or below

  • Previously fit and independent

  • Onset time known and less than 3 hours

  • CT excludes haemorrhage


  • Recent surgery, biopsies arterial cannulation

  • Increased bleeding risk

  • Past history of intracranial haemorrhage

  • Any CNS pathology other than current stroke

  • Any past stroke plus diabetes

  • Stroke within 3 months

  • Systolic blood pressure >185

Alteplase (rt-Pa)

  • 0.9 mg/kg body weight

  • 10% as bolus over 2 min

  • 90% as infusion over 1 hour

    No heparin for 24 hours

Post thrombolysis Care

  • Needs trained team / ASU

  • Neurological observations (NIHSS)

  • Blood pressure

  • Observation for complications

  • Scan at 24 h

  • Prevent recurrence

  • Early Doppler/ CTangio in recovered cases

The acute stroke pathwayHow can I make sure my patient will do well?

Most complications of stroke develop in the first 24 hours

Management in the first few hours has a major effect on outcome and LOS

Important factors for successful early stroke rehabilitation

  • Mobilise ASAP

    The probability of returning home decreases by 20% for each

    day the patient is not mobilized

  • Maintain normal haemodynamic and biochemical environment

  • Prevent complications

  • Keep patient and family informed

1. Transfer to ASU within 4 h or less of admission

2. Prevent Aspiration

  • Swallow screen on arrival on ASU

  • Sit up

  • Drowsy patients in recovery position

  • Antiememtics for haemorrhages and patients who feel sick

  • All members of staff have at least basic knowledge of the diagnosis and management of swallowing problems

3. Prevent hypotension and dehydration

  • IV saline

  • Sufficient fluids by mouth or ngt

4. Prevent pneumonia



Dysphagic patients have impaired oral movements resulting in debris, pooled secretions and

tongue coating.

5. Prevent hospital acquired infectionsMRSA/ ESBL/ C.Difficile

Avoid catheters at all costs

Hand hygiene

Bed spacing

Appropriate antibiotics

6. Prevent starvation

7. Prevent stagnation and deterioration

  • Time does not cure strokes

  • Give at least 45 min of each therapy needed every day 7/7

7. Detect and treat problems early

  • 72 hour monitoring

  • Neurological scores (NIHSS/SSS)

  • Daily consultant ward rounds 7/7

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