Acute Stroke Management Using HANDi Stroke Rx: A Palm-based Education and Treatment Aid Kevin Baumlin, MD, FACEP Jason Shapiro, MD, and Michael Bessette, MD Mount Sinai School of Medicine Department of Emergency Medicine

Introduction 1%-2% of all ED charts from acute stroke patients have a documented NIHSS Using NIHSS as a measure allows Neurologists and EP’s to follow stroke severity Handi Stroke Rx is a palm-based handheld computer program designed to assist clinicians in their management of acute ischemic stroke patients. The public release version is available for free from the FERNE website at www.ferne.org

Why the NIHSS? NINDS NIHSS Severity: median score = 14 NIHSS: 42 point scale, 11 categories Mild facial paralysis: NIHSS = 1 Complete r hemiplegia with aphasia, gaze deviation, visual field deficit, dysarthria, sensory loss: NIHSS = 25 NIHSS severity is critical to pt selection

Objective Primary Objective: To create an easy to use clinical assessment and educational tool for emergency department evaluation of acute ischemic stroke patients. The tool includes: 1) A National Institutes of Health Stroke Scale Calculator (NIHSS) 2) An interactive checklist of inclusion and exclusion criteria 3) A r-TPA dose calculator 4) Reference materials such as sets of sample orders, a list of sequence of events in management of these patients, and suggestions for documentation of consent and management of hypertension and intracerebral hemorrhage.

Objective Secondary Objective: To develop this tool on a forms/database platform for use as a data collection tool in future clinical studies. The goal of this objective is to have data literally streaming from the point of care through data base software and statistical analysis software, leaving little or no room for human error.

Methods Satellite Forms version 4.1 from Puma Technology was chosen as the design platform for this project.. Advantages of this platform included: A WYSIWIG (What You See Is What You Get) PC environment for handheld forms creation. Ability to add large amounts of content and powerful functionality using visual basic scripting and embedded third-party extensions. Pumatech's Enterprise Intellisync® Server software which allows data to be synced over the internet from each user to a server-based database program.

Description The program is set up in a linear fashion allowing users to go sequentially through an NIHSS calculator followed by inclusion criteria, absolute contraindications and relative warnings for rt-PA therapy, followed by an rt-PA dose calculator based on patient weight.

Description Alternatively the user can chose the “Jump” buttons located throughout the program to use individual components of the program from a table of contents or “Jump” menu.

Description The NIHSS portion of the program includes the standard 11 questions with full explanations available by tapping the “i” in the upper right hand corner of each screen. Standard NIHSS images are included in-line and a final score reporting screen with a scale relating risk of symptomatic intracranial hemorrhage to NIHSS score is included at the end.

NIHSS

NIHSS

NIHSS

NIHSS

NIHSS

NIHSS

Inclusion Criteria and Contraindications The inclusion criteria, absolute contraindications and relative warnings are set up as interactive check boxes.

tPa Dose Calculator The rt-PA dose calculator includes a simple input of the patients weight in kg, and a second screen that gives both bolus and infusion doses.

Sequence of Events This section allows users to be reminded of the appropriate protocol for treatment

Sample Orders

Management of ICH

Blood Pressure Control

Current Progress The primary objectives have all been reached and we are currently in the process of developing the program for use in data collection in order to satisfy our secondary objective. Specifically we are retooling the program to gather important patient information such as laboratory and CT findings, as well as working on the back-end database and conduit to allow direct syncing of data from end users. Additionally we are planning a validation study comparing the use of this new handheld NIHSS with traditional paper and pencil.

Conclusion HandiStroke is a palm based stroke education and treatment aid. This free application will be an effective tool for clinicians in their management of acute ischemic stroke in the emergency department and in stroke units. It should facilitate further understanding of the current guidelines for management of the acute stroke patient.

Case One 44 yo Male h/o HTN, BIBEMS at 2:00pm post notification, for acute change in his ability to speak. EMS reports CSS = 3 According to his co-workers he was talking on the phone at 1:15 when a colleague noticed slurred speech. Pt. Arrived. Code Stroke was called and the patient was immediately evaluated, labs were sent and CT was performed at 2:35.

Case One (cont.) BP 195/120, HR67, RR14, Temp 37 Medications: aspirin qd, HCTZ (? Taking) On examination the patient was alert but had difficulty with speech. He was able to say “okay” “yes” and appeared frustrated with being unable to communicate. He had a partial right facial droop. Exam also revealed a pronator drift on the right with normal strength. . NIHSS was performed using HandiStroke demo

Results NIHSS = 9 (1b:2, 4:2,5a:1,9:2,10:2) Lab and EKG were within normal limits CT: ....

CT Scan Image….

Treatment Labatelol 10 mg IV was given t-PA-- (see HTN guidelines) Demo bolus and drip

tPa Dose Calculator The rt-PA dose calculator includes a simple input of the patients weight in kg, and a second screen that gives both bolus and infusion doses.

Outcome Follow up Three months later he was back to work… His aphasia and right hemi improved by day 3. Carotid duplex showed no stenosis. The patient was discharged on Clopidogrel. (Plavix) Three months later he was back to work… As a paramedic

Discussion Giving tPA to a patient on Aspirin is okay. The protocol prohibits the use of aspirin AFTER thrombolytics for 24hours.. The original NINDS trial 1/3 of the patients had taken aspirin prior to stroke; no harmful interaction was noted. If stroke scale was 5-6 would you still have thrombolysed? Yes. It depends on what the deficit is. If the deficit was speech alone tPa would still be considered.