Rapid CT Protocol

In a typical acute ischemic stroke: With every minute of delay 1.9 million neurons 14 billion synapses 7.5 miles myelinated fibers are DEAD -- Saver, Stroke 2006

TPA Treatment Time and Benefit Magnitude 58,353 Patients from 1395 GWTG-Stroke Hospitals --Saver et al ISC 2013 Among 1000 patients, for every 15 min acceleration of tPA treatment 18 more will have improved ambulation at discharge Including 8 more who will ambulate fully independently 13 more will be discharged to a more independent environment Including 7 more discharged to home 4 fewer patients will die prior to discharge

Running a Stroke Code Obtain brief/relevant history Determine last known normal Identify tPA contraindications (all are relative now) FSG, BP, draw POC INR and Cr Hypoglycemia can cause seizures and focal deficits; hyperglycemia can increase risk of ICH post-tPA

Running a Stroke Code 3. Examine and determine if there is a disabling deficit present and if could be caused by a stroke 4. CTH to r/o hemorrhage 5. If disabling deficit present, BP <185/110 and normoglycemic, benefits outweigh risks, symptoms due to stroke, LKW <4.5 hrs, staff with NICU fellow and likely give tPA (10% bolus, 90% infusion over 1 hr) A. For elevated BP, use Labetalol or Cardene gtt B. For hypoglycemia, use amp of D50, for hyperglycemia, give regular insulin

Running a Stroke Code 6. If concern for large vessel syndrome, obtain CTA head/neck to look for thrombus 7. If large vessel occlusion present, NIHSS>6, activate INR for thrombectomy 8. After tPA, keep BP <180/105, no a/c, heparin, antiplatelets, etc.

Running a Stroke Code 9. VS checks q15 mins. Initially, for any exam change, stat head CT for exam change to r/o hemorrhagic transformation

Prehospital Notification Patient directly to ED CT scanner Rapid CT Scan Protocol EMS   Get a FAST exam Connect to resident via stroke phone 18 gauge IV and draw labs Stroke Page ED STAFF Triage and pre-registration Establish IV access, order CT and labs CT TECH Empty out the scanner ON-CALL RESIDENT Take history (while pt. in ambulence) NIHSS STROKE/ICU FELLOW Call back in 15 minutes Decision on TPA/CTA INR FELLOW Review CT/CTA PHARMACY Pre-mix TPA Prehospital Notification Patient directly to ED CT scanner

Intracranial Hemorrhage Management SBP <140, Cardene gtt Reverse anticoagulants (FFP, vit K cryo, PCC, Amicar dif refractory, depending on agent) Reverse antiplatelets (ddAVP, platelets?) NSGY for EVD if ICP elevation, clot evac Prophylactic AEDs if cortical or c/f seizure

Intracranial Pressure Crisis

Intracranial Pressure Intracranial components Total volume approx 1500 cc 75-80% Parenchyma 10 % CSF 10 % Blood

Monroe - Kellie Doctrine Disturbance of volume equilibrium disrupts the pressure equilibrium Pressure = force/ area Pathologically elevated ICP represents the force required to displace blood and CSF from the intracranial space in order to accommodate new volume

Intracranial Compliance Demonstrates that for the same increment in intracranial volume (dVe), a larger intracranial pulse pressure results when Ve is further up the volume-pressure relationship

ICP and CPP Clinical management of ICP is also dependent on the relationship between blood pressure and cerebral blood flow (autoregulation)

Indications for ICP Monitoring Coma (Glasgow Coma Scale score ≤8) CT evidence of intracranial mass effect Extra-axial mass lesion Midline shift Effacement of basal cisterns Exception: severe TBI with motor posturing Prognosis is such that aggressive ICU care is warranted

Clinical Signs Depressed level of consciousness Pressor response Increased ICP Depressed level of consciousness Pressor response Projectile vomiting CN 6 palsies Brainstem herniation CN 3 palsy Motor posturing Lower extremity rigidity Loss of lateral EOMs Hyperventilation

Ventricular catheter Epidural Monitor Parenchymal Micosensor Richmond Bolt

Universal Measures Identify cause(s) of raised ICP or reduced CPP Head positioning r/o seizures or start prophylaxis Maintain Etco2 30-35 Hyperventilate transient Fever (1°C rise in core temp can inc metabolic rate by 10%) Raised intrathoracic or intraabdominal pressures

Revised Columbia Stepwise ICP Protocol PENTOBARBITAL 7 HYPOTHERMIA 6 HYPERVENTILATION 5 OSMOTHERAPY 4 CPP OPTIMIZATION 3 SEDATION 2 SURGICAL DECOMPRESSION 1

Bedside Shivering Assessment Scale (BSAS) Palpate masster, pectoralis, deltoids and quadriceps muscles 0 No shivering 1 Palpable shivering localized to the neck and/or chest 2 Visible shivering involving the arms 3 Visible shivering involving all 4 extremities Badjatia, et al: Stroke 2008;39:3242-3247

Therapeutic Temperature Modulation Repayment Here is the Columbia anti-shivering protocol. Choi et al. 2011

Shivering is the Enemy! Hinders the cooling process Painful and uncomfortable Exacerbates Cardiovascular and sympathetic stress Systemic metabolic stress Cerebral metabolic stress

Algorithm for GCSE