1. Assessment in the Emergency Department Dr Jeff Keep Consultant in Emergency Medicine & Major Trauma King’s College Hospital

2. Time Critical Thrombolysis has elevated acute stroke to a time-critical condition Comparable to acute MI, Major Trauma, Severe Sepsis / Septic Shock, Acute Severe Asthma etc.

3. Definition? crit·i·cal (krt-kl) adj. 1. Inclined to judge severely and find fault. 2. Characterized by careful, exact evaluation and judgment: a critical reading. 3. Of, relating to, or characteristic of critics or criticism: critical acclaim; a critical analysis of Melville's writings. 4. Forming or having the nature of a turning point; crucial or decisive: a critical point in the campaign. 5. a. Of or relating to a medical crisis: an illness at the critical stage. b. Being or relating to a grave physical condition especially of a patient. 6. Indispensable; essential: a critical element of the plan; a second income that is critical to the family's well-being. 7. Being in or verging on a state of crisis or emergency: a critical shortage of food. 8. Fraught with danger or risk; perilous.

4. Definition? crit·i·cal (krt-kl) adj. 1. Inclined to judge severely and find fault. 2. Characterized by careful, exact evaluation and judgment: a critical reading. 3. Of, relating to, or characteristic of critics or criticism: critical acclaim; a critical analysis of Melville's writings. 4. Forming or having the nature of a turning point; crucial or decisive: a critical point in the campaign. 5. a. Of or relating to a medical crisis: an illness at the critical stage. b. Being or relating to a grave physical condition especially of a patient. 6. Indispensable; essential: a critical element of the plan; a second income that is critical to the family's well-being. 7. Being in or verging on a state of crisis or emergency: a critical shortage of food. 8. Fraught with danger or risk; perilous.

5. Time-Critical Essentially, a serious condition in which there is rapid deterioration with time unless it is stopped.

6. Emergency Systems Emergency systems are designed and developed to manage Emergent and Time-Critical situations or events

7. NNT (Lansberg, Stanford University) 0-90 minutes NNTB = 3.6 91-180 minutes NNTB = 4.3 181-270 minutes NNTB= 5.9 271 – 360 minutes NNTB= 19.3

8. NNT (Lansberg, Stanford University) 0-90 minutes NNTB/H = 3.6/65 91-180 minutes NNTB/H = 4.3/38 181-270 minutes NNTB/H = 5.9/30 271 – 360 minutes NNTB/H= 19.3/14 Therefore gives the cut-off of 4.5 hours

9. 4.5 hours But we do not have this much time We must act as soon as we can In London we have a target of 30 minutes ‘Door-to-Needle’ Which means that if a patient has a thrombolysable stroke, they must be receiving thrombolysis within 30 minutes of arriving at the ED

10. The Chain of Survival Recognition of symptoms Contact EMS (999) Priority dispatch EMS transport patient to the right hospital EMS pre-alert Early recognition of symptoms/signs Early imaging Early treatment

11. Easy-Peasy? The more links in the chain, the more potential places that it can break Chinese Whispers...

12. Easy-Peasy? Airway compromise Aspiration Hypertension Arrhythmia Altered conscious level Coagulopathy – on Warfarin?

13. Easy-Peasy? Neurological Stroke Mimic Variable Symptoms / Signs Head Injury Metabolic Injury Psychiatric Illness

14. The Solution?

16. Almost...

17. The solution

18. Stroke Team What is a team? Who should be in a stroke team? What is the role of a team leader? What is the role of a team member?

19. Stroke Doctor Confirm FAST positive & time of onset Look for inclusions / exclusions More in-depth history & examination

20. ED doctor ABC assessment Interpret ECG Contact CT and organise scan

21. ED Technician / FY2 IV access Routine bloods Rapid INR test if on warfarin

22. ED / Stroke Nurse ABC assessment Attach directly to transport monitor Perform ECG Accompany patient to CT

23. Stroke Unit Sister Aware of potential admission Able to organise bed Able to come and assist

24. Radiographer Empty the scanner Prepare for investigations

25. Receptionist Book in patient immediately onto system

26. Porter Check oxygen cylinder Transport patient

28. What’s next? Multiple patients Haemorrhagic stroke Airway problem Not a stroke

29. Focus on the Team

30. Possible members Anaesthetist Physician Stroke Nurse Radiologist Neurosurgeon

31. Multiple Strokes

33. Summary Time-critical illness needs a structured, safe approach Does not mean we run around quickly Develop a Team approach – many people with few, achievable tasks within their comfort zone Regular meetings – build bonds, review practise, learn

34. Thank you for listening...