WV Appalachian Stroke Network 2016 State Stroke Conference The Big Decision Packaging the Patient for Transfer

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1 WV Appalachian Stroke Network 2016 State Stroke Conference The Big Decision Packaging the Patient for Transfer Dr. Jim Kyle, FACSM, FAAFP Regional Medical Director WVOEMS Executive Director, The Kyle Group Team Physician Concord University Matthew S. Smith, MD, MS Director of Neurocritical Care, WVU Stroke Center Medical Director, WVU Assistant Professor of Neurology and Neurosurgery Presenter Disclosure Information Matthew Smith The Big Decision: Packaging the Patient for Transfer FINANCIAL DISCLOSURE: No relevant financial relationships exist UNLABELED/UNAPPROVED USES DISCLOSURE: No plan for discussion of unlabeled or unapproved usage of medication 2 1

2 Saving Brains in Small Town USA Endovascular Stroke Care 8 hr window VF SCA with ROSC Cool & Cath Quick Stroke Center Endovascular Stroke Care WV Hospital Stats 55 Hospital ED 38 Trauma Centers 10 STEMI Centers 5 TH Centers 3 Stroke Centers 5 2 3/4 1 2

3 Region 1 EMS Statewide protocols Population = 250,000 Hospitals = 6 Trauma Centers = 5 Stroke Centers = 0 TH Centers = 0 WV OEMS Region Stroke runs = 328 Call to ED > 1hr = 64 % 2011 *Cardiac Arrest = 316 VF (42) Asystole (186) ROSC = * /4 3

4 Stroke Care History Any bed in the ED NINDS Study Brain Attack Coalition ACLS guidelines Cleveland hospital report ACEP policy statement JCAHO Stoke Center certification MERCI Mechanical Embolus Removal Cerebral Ischemia Florida Stroke Act DRG 559 Reimbursement ASLS University of Miami WV OEMS Stroke Center Certification 2004 Endovascular Stroke Care Cath the Brain 4

5 2016 Endovascular Stroke Treatment IMS 3 IV vs IA t-pa WVU Dr Matt Smith CAMC Dr David Carrington MAYO Dr Barrett UK - Dr Fraser Early IV as good as delayed IA Endovascular Stroke 2013 = Look for Proximal Occlusion Efficacy of tpa by Stroke Subtype % with good outcome tpa Placebo Small vessel Large vessel Cardioembolic 5

6 Rural ED: Treatment Options 1. Drip and Ship 2. Drip and No Ship 3. No Drip and Ship 4. No Drip or Ship 6

7 Case Presentation October 2016 Early am collapse at home L sided weakness -healthy 50yo Normotensive, bradycardic, NIHSS = 16 Clear sky day 3 critical patients in ER Staffing for 10 patients, absent unit clerk Radiologist delay Proximal Vessel Stroke 7

8 THE BIG DECISION 1. Drip and Ship 2. Drip and No Ship 3. No Drip and Ship 4. No Drip or Ship 8

9 Rural ED Drip and Ship Options 1. Drip and Ship 2. Drip and No Ship 3. No Drip and Ship 4. No Drip or Ship < 3 hour (4 ½) since onset And Double Digit NIHSS Single Digit NIHSS with Left side symptoms Posterior Circulation CVA Vascular Localization in Stroke Middle Cerebral Artery Contralateral weakness face/arm >> leg Dominant hemisphere MCAaphasia, +/- visual field cut Non- dominant MCA- Visuospatial deficit, neglect of contralateral space or body, +/- visual field cut 9

10 Vascular Localization in Stroke Posterior Cerebral Artery Occipital lobe, medial temporal lobe, midbrain Headache common as presenting feature Visual agnosias, visual field loss, optic ataxia, confusional state, may have alexia Vertebro-basilar stroke Brainstem, cerebellum, occipital lobe Ataxia, vertigo, diplopia crossed deficits, bilateral deficits stupor/coma Rural ED Drip and Ship Options 1. Drip and Ship 2. Drip and No Ship 3. No Drip and Ship 4. No Drip or Ship small vessel stroke Advanced age Neurology consult readily available 10

11 Rural ED Drip and Ship Options 1. Drip and Ship 2. Drip and No Ship 3. No Drip and Ship 4. No Drip or Ship Wake up Stroke < 3 hours onset and Coumadin, Pradaxa, Eliquis, Xarelto, etc Outside 3 4 ½ window double digit NIHSS HIS of Proximal occlusion Posterior circulation CVA Proximal Vessel Stroke 11

12 Add CTA or CT perfusion when High Index Suspicion for High Volume Stroke Dr Kevin Barrett Mayo JAX Dr Justin Fraser UK Neurosurgery Consider Craniotomy for < Age 50 High Volume CVA Rural ED Drip and Ship Options 1. Drip and Ship 2. Drip and No Ship 3. No Drip and Ship 4. No Drip or Ship Rapid Improving with TIA presentation Vascular Surgical talent Advanced Age requesting comfort only 12

13 WV EMS Stroke Care Public education EMS actions Priority dispatch ABC s Time of onset Neurological evaluation Check glucose Early hospital notification Rapid Transport Cincinnati Prehospital Stroke Scale Facial droop Arm drift Language 13

14 2016 WV EMS Stroke Care Call Regional Command after initial assessment - Consider Load and Go Current Meds: Coumadin, Pradaxa, Xarelto, Eliquis, etc Identify if ASLS certified EMT, Paramedic Precise onset of symptoms for appropriate ground or Aero-medical transport to Endovascular center Frequent VS for BP management Blood Pressure in Ischemic Stroke Acute elevations of BP are common in stroke Seen in 85% of patients Often declines spontaneously in first hours Cerebral autoregulation is defective in most stroke patients Acutely lowering BP can expand area of ischemia Supported by PET studies Supported by clinical experience Supported by ASA guidelines 14

15 Saving Brains in Small Town USA Blood Pressure Management Traditionally Labetolol Nicardipine: 5mg/hr and titrate BP achieved then 3mg/hr Rapid adjustment advantage. Cerebral Autoregulation Pressure Passive Dilation Zone of Autoregulation Vasodilatory Cascade Zone Pressure Passive Dilation Autoregulatory Breakthrough Zone Cerebral Blood Flow (CBF; ml/100 g/min) Mean Arterial Pressure (MAP; mm Hg) Adapted from Rose, JC, Mayer, SA. Neurocritical Care. 2004;3:

16 Stroke Care History Any bed in the ED NINDS Study Brain Attack Coalition ACLS guidelines Cleveland hospital report ACEP policy statement JCAHO Stoke Center certification MERCI Mechanical Embolus Removal Cerebral Ischemia Florida Stroke Act DRG 559 Reimbursement ASLS University of Miami 2015 CMS Focus WV OEMS Stroke Center Certification 16

17 Florida Stroke Act Stroke patients diversion to Hospitals with Stroke center certification, instead of nearest ER 2004 Legislative Initiative with 125 centers by 2007 Why high response in Florida? JAX STROKE CENTER 17

18 Stroke Care History Any bed in the ED NINDS Study Brain Attack Coalition ACLS guidelines Cleveland hospital report ACEP policy statement JCAHO Stoke Center certification MERCI Mechanical Embolus Removal Cerebral Ischemia Florida Stroke Act DRG 559 Reimbursement ASLS University of Miami 2015 CMS Focus WV OEMS Stroke Center Certification ED with TH focus TH Hospitals Stroke Center Invasive Neuro-radiology WV Hospital Stats 55 Hospital ED 38 Trauma Centers 10 STEMI Centers 6 TH Centers 3 Stroke Centers 5 2 3/4 1 18

19 Saving Brains in Small Town USA Endovascular Stroke Care = 8 hr window VF SCA with ROSC Cool & Cath Quick Accepting Stroke Patients: How It Should Work Matthew S. Smith, MD, MS Director of Neurocritical Care, WVU Medical Director Stroke Center, WVU 19

20 Transfer Case Example 50 year old man NIHSS 15 at Beckley NIHSS 12 on Arrival at WVU 2 hours 45 minutes from IV tpa starting 20

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32 CT Angiogram 32

33 CT Angiogram CT Angiogram 33

34 CT Angiogram CT Angiogram 34

35 11/2/2016 Angiogram Stent Retriever Deployed 35

36 Final: TICI 2b MRI: DWI 36

37 MRI: DWI MRI: DWI 37

38 MRI: DWI MRI: DWI 38

39 MRI: DWI MRI: DWI 39

40 MRI: DWI MRI: DWI 40

41 MRI: DWI Discharge NIH Stroke Scale 0 4/5 Strength Left Arm Walking With Assistance Discharged to Rehabilitation Facility 41

42 Stroke Clinic Follow Up Left Arm 4+/5 Gait Normal What We Need Accurate Last Seen Normal IV tpa administration if eligible (Y/N) Anticoagulation BP Control Treatment 180/105 (consider drips) Information for person able to consent to procedure Load Images to Image Grid 42

43 Questions/ Comments 43