9/18/16. Setting: Community ED, 30k admissions per year Time: Friday night, 11pm. CC: Syncope

Transcription

1 William A. Knight IV MD, FACEP Associate Professor Emergency Medicine & Neurosurgery University of Cincinnati September 21, 2016 ED as the Front Door Spectrum of care with Endovascular therapy Downrange effects in the ICU Time is Brain Common themes that integrate: Emergency Medicine Vascular Neurology Neurosurgery Interventional Neurology Neurocritical Care Setting: Community ED, 30k admissions per year Time: Friday night, 11pm CC: Syncope 1

2 Setting: Community ED, 30k admissions per year Time: Friday night, 11pm CC: Syncope HPI: 56 y/o male was at dance class this evening (10:45pm) when he began to feel dizzy, laid down on the floor and then became unresponsive. Bystander CPR was initiated. Upon arrival of EMS, the patient was noted to have a pulse. The monitor demonstrated atrial fibrillation with rapid ventricular response. During transport, the patient was noted by the paramedics to have posturing and a right gaze preference. He would not talk or follow commands for the medics, and did not have any purposeful movement. PMHx None per family Allergies None per family Social History Runner, no tobacco, alcohol or drugs Vital Signs: BP 204/110 HR 105 RR 14 SpO 2 99% via 100% NRB Neurologic Exam: Pupils equal, round and reactive to light 3mm à 2mm bilaterally Forced right gaze preference Does not regard examiner Extensor posturing to deep pain stimulus Mute A non-contrast CT and CT-Angiogram of the head and neck was performed. 2

3 9/18/16 Door to Needle 60 minutes 0 minutes Patient arrives in ED 10 minutes ED evaluation History LKN Labs NIHSS 25 minutes Non-contrast CT scan 60 minutes 15 minutes Stroke Treatment Stroke specialist notification 45 minutes CT interpretation 3

4 Airway evaluation and control Blood pressure control Established last seen normal Stroke Specialist Accepting hospital Comprehensive Stroke Center? Angiographic capabilities IV thrombolytics Multiple agents to choose from Multiple different properties Significant neurologic ramifications Debate surrounding aggressive measures Helpful to have institutional standards Autoregulation of cerebral blood flow in a normal brain and in the ischemic penumbra (the tissues surrounding the ischemic core after a stroke). Semplicini A, and Calò L CMAJ 2005;172: by Canadian Medical Association 4

5 Labetolol 10mg IV BP 180/95 Patient discussed with local Stroke Team BP 195/110 *Labetolol 10mg IV BP 180/90 Blood glucose Serum electrolytes / renal function tests Cardiac biomarkers Complete blood count Platelet count Coagulation tests aptt, PT, INR ECG Blood glucose Serum electrolytes / renal function tests Cardiac biomarkers Complete blood count Platelet count Coagulation tests aptt, PT, INR ECG 5

6 Point of Care in the Emergency Department Reduce time significantly INR Point of Care in the Emergency Department Reduce time significantly INR Target labs to specific patient Platelets INR 6

7 BP remained 180/90 All labs pending Radiology read confirmed: head CT: Normal CTA head/neck: Acute basilar artery thrombosis rt-pa advised 0.9 mg/kg tpa mixed 10% administered over 1 minute 90% administered over 1 hour Door to needle: 48 minutes Symptom onset to needle: 98 minutes Non-contrast CT Head Remains standard of care Fast and easy to interpret CT Angiogram CT Perfusion MRI Dynamic scanning during the arterial phase (venous administration) Rapid IV contrast bolus (~100 cc) Advanced 2D and 3D reconstructions 2D multiplanar ( sagittal, coronal) 3D volume-rendered 7

8 9/18/16 Technician dependent for reliability Routine maps: Mean Transit Time (MTT) Cerebral Blood Flow (CBF) Cerebral Blood Volume (CBV) Increased MTT, decreased CBF, normal CBV: Reversible ischemia Increased MTT, decreased CBF & CBV: Irreversible ischemia/infarct Homogenous magnetic field Aligning protons to spin parallel & antiparallel to the field DWI Diffusion Weighted Imaging Hyperacute ischemia Ischemia produces immediate reduction in diffusion coefficient of water Bright artifacts at air-bone interfaces ADC Apparent Diffusion Coefficient Real source image for DWI Bright in DWI = Dark in ADC Correlation with DWI confirms restricted diffusion 8

9 The patient was intubated via rapid sequence induction for airway protection. BP post intubation 160/80 Propofol and fentanyl infusions for anxiolysis and analgesia Accepted for transfer to Comprehensive Stroke Center ED Angio team activated Air medical transport requested. Little evidence on the utility of mechanical ventilation for endovascular management of stroke Failure to oxygenate Failure to ventilate Inability to protect the airway Anticipated clinical course 9

10 Hemodynamic changes Even mild BP-lowering may result in: penumbra à infarct Need to be mindful of inadvertent hyperventilation Decreased PaCO2 Cerebral vasoconstriction penumbra à infarct Neck position Carotid and vertebral artery kink Sedation/analgesia selection ramifications Hypotension Cognitive effects Inherent delay with RSI and intubation Institutional preference Conversation with angiographer 10

11 Resource utilization Helicopter = speed Helicopter RN/NP/MD/EMT-P Titrate medications $$$ Ambulance RN/EMT-P/EMT-B Medication titration = variable 11

12 4/111 (3%) = DTB < 90 min Early registration Avoid the F-A-B-Cs Direct to CT POC Labs Intubation and mechanical ventilation rt-pa in the Pyxis RN mix and administration Empower the ED MD 12

13 9/18/16 Door to Needle 60 minutes 0 minutes Patient arrives in ED 10 minutes ED evaluation History LKN Labs NIHSS 25 minutes Non-contrast CT scan 60 minutes 15 minutes Stroke Treatment Stroke specialist notification 45 minutes CT interpretation Helicopter transport 30 mile (45 min) ground transport Air medical crew on site Endovascular team awaiting patient arrival On table: 158 minutes from symptom onset 13

14 Following commands on HD #1 Extubated on HD #2 Reintubated HD#3 residual bulbar dysfunction Tracheostomy & Percutaneous Enteral Gastrostomy Rehab facility HD #5 Walking (and running) independently at 90 days ED is the Front Door There is a spectrum of care with Endovascular therapy Advanced imaging takes time And expertise Small decisions have down range effects on ICU care Disposition modality is important Time is Brain 14