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1 Acute stroke Speaker:

2 年 % 31.3% 糖尿 殺

3 Step I What signs and symptoms is the patient have? How are they typical of stroke? What are the major types of stroke?? Is there any treatment that can reduce disability? If the patient is having a stroke,, what are some goal for stroke care?

4 (Stroke &TIA) 狀 力 異 暈 不 Sudden severe headache with no known cause Sudden confusion

5 (transient ischemic attack) 塞 類 狀 ( 數 ) 5% aspirin, ticlopidine.

6 (2/3) (85% in USA) (1/3) (15% in USA) (a) 裂, (5% ): 烈 (b) : 識不 * 狀

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11 Goal of stroke care Minimize brain injury and maximize the patient s recovery Links actions to be taken by patients, family members, and healthcare providers

12 Stroke chain of survival 1. 識 2. 療 (EMS) (EMS) 3. EMS 4. 療

13 Step 2-EMS2 EMS assessments and actions to provide the best outcome for patients with stroke? Identify signs of TIA and stroke Support ABCs Do rapid out-of of-hospital stroke assessment Transport to a center with stroke unit Alert hospital Check glucose

14 What type of hospital is appropriate for this patients? Why is advance notification so important? Multidisciplinary approach: rapidly triage and treat Favorable benefit from stroke centers Allow activation of the facility stroke plan and team, minimizing delay

15 Cincinnati Prehospital Stroke Scale (CPSS) Facial droop Arm drift Abnormal speech 異 異 59% 異 > 89% (specificity)

16 露 兩 不 不

17 兩 不 不

18 異 說 句 ): You can t t teach an old dog new tricks 老 不 不 不 不

19 洛 不 1. 年 狀 < 不 輪 列 不 1-6 不 / 力量 異 93%, 異 97%.

20 Step 3-3 ED What is the initial ED assessment and stabilization? Assess ABCDs Provider oxygen (if SpO2 <94%) IV route, obtain blood samples Check glucose Perform neurologic screening: NIHSS Activate stroke team Order CT brain scan Obtain 12-lead ECG Not delay getting brain CT scan

21 P.E. and Lab data Slow hear rate, : IICP, ischemia AF and potential life threatening arrhythmia : Cardiac embolism Fever: infectious endocarditis Carotid bruit: ischemic stroke Absence of periphreal pulse: systemic emboli Seizure: sequelae ECG: LVH, ST-T T changes, ischemia, like AMI(ICH) Blood sugar: hypoglycemia, HHS Medications: drugs, alcohol

22 What are the possible outcomes of the CT scan? Which test result makes the patient a candidate for fibrinolytic therapy? Hemorrhage is present or not? Yes: Not a candidate No: May be a candidate

23 What dose fibrinolytic therapy do for victims of ischemic stroke? If r-tpa is given within 3 hours of onset of symptoms Higher likelihood of good-to to-excellent functional outcome 30% 神

24 Thrombolysis with alteplase 3 to 4.5 hrs after acute ischemic stroke P=.04 P=0.001 alteplase therapy n=418 placebo n=403 P=0.008 P= d disability Any ICH Symptomatic ICH 90d mortality N Engl J Med 2008 Sep 25; 359:

25 NIHSS 數 0 ( ) 42 若 4 不 療 ( ( 3 3 ) (( ) 例 例 ( > 22 ) 率

26 年 臨 神 狀 離 療

27 療 臨 (SAH), 葉 塞 ( 度 ) (ICH) 量, :SBP>185mmHg,DBP>110mmHg 行 ( ) (platelet <100,000, heparin 兩, prolong aptt,, use of warfarin INR>1.7 PT>15 sec), 刺 糖 <50 mg/dl

28 狀 尿 ( ) 塞 (3 ) Seizure at onset with postictal residual neurologic impairments

29 Clinical benefit is smaller than that achieved with treatment within 3 hours, has not been FDA approved.

30 r- t PA 療 mg/kg (maximal 90mg) 10%-IV bolus, the rest IV drip for 60 minutes.( for ASTEMI) min 尿 24 不 不

31 r- tpa 療 療 神 狀悪 立 brain CT. If hemorrhage (+) stop r-tpa,, check PT, aptt, platelet count, Hct,, fibrinogen. Blood transfusion, FFP, platelet transfusion.

32 療 療 Glycemic control use of insulin when blood sugar >185 mg/dl. (class IIa,, LOE C) Temperature control ( treat fever >37.5C ) Dysphagia screening

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36 Other Stroke Management Support of the airway Oxygenation and ventilation Nutritional support Seizure prophylaxis is not recommended If seizure give anticonvulsants Severe stroke, posterior circulation stroke, and in younger patients observe for signs of increased intracranial pressure

37 Complication of r-tpa Symptomatic hemorrhage 5.2% Orolingual angioedema 1.5% Acute hypotension Systemic bleeding 0.4% (at the site of femoral puncture for acute angiography) Neither anticoagulant nor antiplatelet treatment 24 hrs after administration of r-tpa until repeat CT scan at 24 hrs shows no hemorrhagic transformation.

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39 CT 讀 (60 )

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41 8-D Detection : : symptoms of stroke Dispatch : (call 119) Delivery : transport transport Door : 類 神 理 Data : 度神 理 (ED) Decision : 療 療 Drugs : 療,, intra-arterial arterial strategies Disposition : 理.

42 Case 68 years old female Complaint with acute onset of left side weakness and slurred speech ( at 14:40) Came to ER at 14:57. CT time 15:04 CT data 15:05 Call neurology Dr 15:10

43 Neuro Doctor exam the patient 15:30 NIHSS score time 16:00 8 ICU time 16:00 No contraindication for received r-tpa Signs permit 16:10 r-tpa time 16:30 (dose 0.9 mg/kg) Complete r-tpa 17:30 (within 3 Hrs) Discharge NIHSS score 1

44 Pre r-tpa ( )

45 Pre r-tpa ( )

46 Post r-tpa ( )

47 Post r-tpa ( )

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53 AMI vs CVA Clot 90% vs 50% Fibrinolysis <12h <3h Outcome