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.
Developing Acute Stroke ServicesDiagnosingScreeningAcute Care pathwaysThrombolysisDr C. RoffeClinical Lead Shropshire and Staffordshire Heart and Stroke Network
Patient or bystander recognizes stroke
Blue-light FAST positive potential strokes to A&E
Fits thrombolysis criteria pre alert A&E
Does not fit thrombolysis criteria
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
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.
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
A NEUROLOGICAL DEFICIT OF
Stroke risk within 1 week 6% for scores 4-5, 12% for scores >5
Admit all with score 5 or above.
This will reduce strokes within 1 week by 80%!!!
SW, day 1
SW, day 1
If 10% of stroke patients in the UK were given thrombolysis, 1000 people less would be dead or dependent in one year.
Quasi intensive care environment
Aggressive BP control
16,000 screened to recruit 633
N Engl J Med 1995;333:1581-1587.
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.
No heparin for 24 hours
Most complications of stroke develop in the first 24 hours
Management in the first few hours has a major effect on outcome and LOS
The probability of returning home decreases by 20% for each
day the patient is not mobilized
Dysphagic patients have impaired oral movements resulting in debris, pooled secretions and
Avoid catheters at all costs