Professional Documents
Culture Documents
Ali Haedar
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Improving Door-to-Needle Times in Acute
Ischemic Stroke: The Design and Rationale for the
American Heart Association/American Stroke
Association’s Target: Stroke Initiative
Gregg C. Fonarow, MD; Eric E. Smith, MD, MPH; Jeffrey L. Saver, MD;
Mathew J. Reeves, PhD; Adrian F. Hernandez, MD, MHS; Eric D.
Peterson, MD, MPH; Ralph L. Sacco, MD; Lee H. Schwamm, MD
Stroke. 2011;42:00-00
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7 Step Stroke Chain of
Survival and Recovery
Pre-arrival: Post-arrival:
1. Detection 4. Door
2. Dispatch 5. Data
3. Delivery 6. Decision
7. Drug
8. Disposition
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Door: Emergency
Department Triage
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Data: Emergency Evaluation
and Management
ABCs should be
reassessed and
rechecked
frequently.
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An emergency neurological stroke assessment
should be done quickly focusing on four key
issues:
1. Level of consciousness
2. Type of stroke (hemorrhagic versus
nonhemorrhagic)
3. Location of stroke (carotid versus vertebrobasilar)
4. Severity of stroke
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• Obtaining the exact time of stroke or onset
of symptoms from family or people at the
scene is critical.
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Emergency Diagnostic Studies
• Currently, CT is the single most important
diagnostic test.
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Emergency Diagnostic
Studies
• Anticoagulants
and fibrinolytic
agents should be
withheld until CT
has ruled out a
brain
hemorrhage.
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Differential Diagnosis:
• Unrecognized seizures
• Confusional states
• Syncope
• Toxic or metabolic disorders
• Hypoglycemia
• Brain tumors
• Subdural hematoma
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Decision: Specific Stroke Therapies
General care includes, but is not limited
to:
• Prevention of aspiration
• Management of hypertension
• Management of hyper/hypo-glycemia
• Management of seizures
• Management of intra-cranial pressure
(ICP)
10%
0%
Barthel Rankin Glasgow NIHSS
Index Scale Outcome score
Global outcome statistic: OR=1.7, 50% v. 38%= 12% benefit
N Engl J Med 1995;333:1581-7
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Drugs: Fibrinolytic Therapy for Ischemic Stroke
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Drugs: Fibrinolytic Therapy for Ischemic Stroke
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Drugs: Fibrinolytic Therapy for Ischemic Stroke
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NINDS-Recommended Stroke Evaluation Targets
for Potential Fibrinolytic Candidates*
Time Target
Door to doctor 10 minutes
Door to CT† completion 25 minutes
Door to CT read 45 minutes
Door to treatment 60 minutes
Access to neurological expertise‡ 15 minutes
*Target times will not be achieved in all cases, but they represent a
reasonable goal.
†CT indicates computed tomography.
‡By phone or in person.
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Management of Hemorrhagic Stroke
Optimal management:
• Prevention of continued bleeding.
• Appropriate management of ICP.
• Timely neurosurgical decompression when
warranted.
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Disposition: Neurology Vs Neurosurgery
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Conclusion:
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Conclusion:
The challenge with these therapies is that
they require administration within hours of
stroke onset, making the following
measures imperative: