part 11

ISSN: 1524-4539 Copyright © 2010 American Heart Association. All rights reserved. Print ISSN: 0009-7322. Online 72514 Circulation is published by the American Heart Association. 7272 Greenville Avenue, Dallas, TX DOI: 10.1161/CIRCULATIONAHA.110.971044 2010;122;S818-S828 Circulation Yvonne (Yu-Feng) Chan, Nina Gentile and Mary Fran Hazinski Edward C. Jauch, Brett Cucchiara, Opeolu Adeoye, William Meurer, Jane Brice, Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Part 11: Adult Stroke: 2010 American Heart Association Guidelines for http://circ.ahajournals.org/cgi/content/full/122/18_suppl_3/S818 located on the World Wide Web at: The online version of this article, along with updated information and services, is http://www.lww.com/reprints Reprints: Information about reprints can be found online at journalpermissions@lww.com 410-528-8550. E-mail: Fax:Kluwer Health, 351 West Camden Street, Baltimore, MD 21202-2436. Phone: 410-528-4050. Permissions: Permissions & Rights Desk, Lippincott Williams & Wilkins, a division of Wolters http://circ.ahajournals.org/subscriptions/ Subscriptions: Information about subscribing to Circulation is online at by on October 22, 2010 circ.ahajournals.orgDownloaded from Part 11: Adult Stroke 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Edward C. Jauch, Co-Chair*; Brett Cucchiara, Co-Chair*; Opeolu Adeoye; William Meurer; Jane Brice; Yvonne (Yu-Feng) Chan; Nina Gentile; Mary Fran Hazinski Nearly 15 years of increased stroke education and orga-nization has produced significant strides in public awareness and development of stroke systems of care. De- spite these successes, though, each year 795 000 people suffer a new or repeat stroke, and stroke remains the third leading cause of death in the United States.1 Many advances have been made in stroke prevention, treatment, and rehabilitation, but arguably the greatest gains have been in the area of stroke systems of care. Integrating public education, 911 dispatch, prehospital detection and triage, hospital stroke system de- velopment, and stroke unit management have led to signifi- cant improvements in stroke care. Not only have the rates of appropriate fibrinolytic therapy increased over the past 5 years, but also overall stroke care has improved, in part through the creation of stroke centers.2 To achieve further improvement in reducing the burden of stroke, healthcare providers, hospitals, and communities must continue to de- velop systems to increase the efficiency and effectiveness of stroke care.3 The “D’s of Stroke Care” remain the major steps in diagnosis and treatment of stroke and identify the key points at which delays can occur.4,5 ● Detection: Rapid recognition of stroke symptoms ● Dispatch: Early activation and dispatch of emergency medical services (EMS) system by calling 911 ● Delivery: Rapid EMS identification, management, and transport ● Door: Appropriate triage to stroke center ● Data: Rapid triage, evaluation, and management within the emergency department (ED) ● Decision: Stroke expertise and therapy selection ● Drug: Fibrinolytic therapy, intra-arterial strategies ● Disposition: Rapid admission to stroke unit, critical-care unit This chapter summarizes the early management of acute ischemic stroke in adult patients. It describes care from out-of- hospital therapy through the first hours of in-hospital therapy. For additional information about the management of acute ischemic stroke, see the American Heart Association (AHA)/ American Stroke Association (ASA) guidelines for the manage- ment of acute ischemic stroke.3,6,7 Management Goals The overall goal of stroke care is to minimize acute brain injury and maximize patient recovery. The time-sensitive nature of stroke care is central to the establishment of successful stroke systems, hence the commonly used refrain “Time is Brain.” The AHA and ASA have developed a community-oriented “Stroke Chain of Survival” that links specific actions to be taken by patients and family members with recommended actions by out-of-hospital healthcare responders, ED personnel, and in- hospital specialty services. These links, which are similar to those in the Adult Chain of Survival for victims of sudden cardiac arrest, include rapid recognition of stroke warning signs and activation of the emergency response system (call 911); rapid EMS dispatch, transport, and prehospital notification; triage to a stroke center; and rapid diagnosis, treatment, and disposition in the hospital. The AHA ECC stroke guidelines focus on the initial out-of- hospital and ED assessment and management of the patient with acute stroke as depicted in the algorithm Goals for Management of Patients With Suspected Stroke (Figure). The time goals of the National Institute of Neurological Disorders and Stroke (NINDS)8 are illustrated on the left side of the algorithm as clocks. A sweep hand depicts the goal in minutes from ED arrival to task completion to remind the clinician of the time-sensitive nature of management of acute ischemic stroke. The sections below summarize the principles and goals of stroke system development and emergency assessment and man- agement, as well as highlight new recommendations and training issues. The text refers to the numbered boxes in the algorithm. Stroke Systems of Care The regionalization of stroke care was not widely considered in the era before availability of effective acute therapies. With the NINDS recombinant tissue plasminogen activator (rtPA) trial, the crucial need for local partnerships between academic medical centers and community hospitals became a reality.9 The American Heart Association requests that this document be cited as follows: Jauch EC, Cucchiara B, Adeoye O, Meurer W, Brice J, Chan Y-F, Gentile N, Hazinski MF. Part 11: adult stroke: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010;122(suppl 3):S818–S828. *Co-chairs and equal first co-authors. (Circulation. 2010;122[suppl 3]:S818–S828.) © 2010 American Heart Association, Inc. Circulation is available at http://circ.ahajournals.org DOI: 10.1161/CIRCULATIONAHA.110.971044 S818 by on October 22, 2010 circ.ahajournals.orgDownloaded from The time-sensitive nature of stroke requires such an approach, even in densely populated metropolitan centers. The idea of a “stroke-prepared” hospital emerged after the United States Food and Drug Administration (FDA) approved rtPA for stroke. In 2000 the Brain Attack Coalition provided a descrip- tion of “primary stroke centers,” which would ensure that best practices for stroke care (acute and beyond) would be offered in an organized fashion.7 The logic of having a multitiered system such as that provided for trauma was evident. There- fore, in 2005 the Brain Attack Coalition followed the state- ment on primary stroke centers with recommendations for comprehensive stroke centers.6 Following the establishment of primary stroke centers and comprehensive stroke centers, the new concept of a stroke-prepared hospital has recently emerged. This stroke-prepared hospital can access stroke expertise via telemedicine. The comparison with a trauma system with Level 1, 2, and 3 centers is rational and quite intuitive to emergency care providers familiar with such configurations. Substantial progress has been made toward regionalization of stroke care. Several states have passed legislation requiring prehospital providers to triage patients with suspected stroke to designated stroke centers. This is contingent on the accuracy of dispatch, an area where further improvement is Figure. Goals for management of patients with suspected stroke. Jauch et al Part 11: Adult Stroke S819 by on October 22, 2010 circ.ahajournals.orgDownloaded from needed.10 The integration of EMS into regional stroke models is crucial for improvement of patient outcomes.11 Efforts have been strong in many regions, especially in regions with relatively high population density and large critical mass of stroke centers to effectively create a model for stroke region- alization.12 Although a large proportion of the US population is now within close proximity to a stroke center, it is not clear how many stroke patients arrive at stroke-prepared hospitals. Additional work is needed to expand the reach of regional stroke networks. Healthcare professionals working in EMS, emergency medicine, or emergency nursing can also assist in this process by determining which hospitals in their commu- nity offer care concordant with the Brain Attack Coalition recommendations for primary stroke centers.7,11,13,14 Stroke Recognition and EMS Care (Box 1) Stroke Warning Signs Identifying clinical signs of possible stroke is important because recanalization strategies (intravenous [IV] fibrinoly- sis and intra-arterial/catheter-based approaches) must be pro- vided within the first few hours from onset of symptoms.9,15,16 Most strokes occur at home, and just over half of all victims of acute stroke use EMS for transport to the hospital.17–21 Stroke knowledge among the lay public remains poor.22,23 These factors can delay EMS access and treatment, resulting in increased morbidity and mortality. Community and pro- fessional education is essential22,24 and has successfully increased the proportion of stroke patients treated with fibrinolytic therapy.25–27 Patient education efforts are most effective when the message is clear and succinct. The signs and symptoms of stroke include sudden weakness or numbness of the face, arm, or leg, especially on one side of the body; sudden confusion; trouble speaking or understanding; sudden trouble seeing in one or both eyes; sudden trouble walking, dizziness, loss of balance or coordination; or sudden severe headache with no known cause. Educational efforts need to couple the knowledge of the signs and symptoms of stroke with action— call 911. 911 and EMS Dispatch EMS systems of care include both 911 emergency medical dispatch centers and EMS response personnel. It is imperative that the stroke system of care provide education and training to 911 and EMS personnel to minimize delays in prehospital dispatch, assessment, and transport. Emergency medical tele- communicators must identify and provide high-priority dis- patch to patients with stroke symptoms. Current literature suggests that 911 telecommunicators do not recognize stroke well and that the use of scripted stroke-specific screens during a 911 call may be helpful.10,28 Studies are ongoing to investigate the effectiveness of such a stroke assessment tool for 911 telecommunicators.29,30 In settings where ground transport to a stroke center is potentially long, air medical services may be used. Regional stroke resources work with EMS agencies to establish criteria for the use of air medical transport for patients with acute stroke and determine the most appropriate destination based on distance and the hospital’s stroke capability. As with ground transportation, prehospital notification should be per- formed to ensure appropriate activation of stroke resources. Stroke Assessment Tools EMS providers can identify stroke patients with reasonable sensitivity and specificity, using abbreviated out-of-hospital tools such as the Cincinnati Prehospital Stroke Scale (CPSS)31–34 (Table 1) or the Los Angeles Prehospital Stroke Screen (LAPSS).35,36 The CPSS is based on physical exam- ination only. The EMS provider checks for 3 physical findings: facial droop, arm weakness, and speech abnormal- ities. The presence of a single abnormality on the CPSS has a sensitivity of 59% and a specificity of 89% when scored by prehospital providers.33 Another assessment tool, the LAPSS, requires that the provider rule out other causes of altered level of consciousness (eg, history of seizures, hypoglycemia) and then identify asymmetry in any of 3 examination categories: facial smile or grimace, grip, and arm strength. The LAPSS has a sensitivity of 93% and a specificity of 97%.35,36 With standard training in stroke recognition, paramedics demonstrated a sensitivity of 61% to 66% for identifying patients with stroke.34,37,38 After receiving training in use of a stroke assessment tool, paramedic sensitivity for identifying patients with stroke increased to 86% to 97%.36,39,40 We recommend that all paramedics and emergency medical technicians-basic (EMT-basic) be trained in recognition of stroke using a validated, abbreviated out-of-hospital screen- ing tool such as the CPSS or LAPSS (Class I, LOE B). Prehospital Management and Triage (Box 2) As with any other time-sensitive acute illness, prehospital providers must perform an initial assessment and intervene if necessary to provide cardiopulmonary support. In addition, for stroke, providers must clearly establish the time of onset of symptoms. This time represents time zero for the patient. If the patient wakes from sleep or is found with symptoms of a stroke, the time of onset of symptoms is defined as the last time the patient was observed to be normal. EMS providers must be able to support cardiopulmonary function, perform rapid stroke assessment, establish time of onset of symptoms Table 1. The Cincinnati Prehospital Stroke Scale Facial droop (have patient show teeth or smile) ● Normal—both sides of face move equally ● Abnormal—one side of face does not move as well as the other side Arm drift (patient closes eyes and holds both arms straight out for 10 seconds) ● Normal—both arms move the same or both arms do not move at all (other findings, such as pronator drift, may be helpful) ● Abnormal—one arm does not move or one arm drifts down compared with the other Abnormal speech (have the patient say “you can’t teach an old dog new tricks”) ● Normal—patient uses correct words with no slurring ● Abnormal—patient slurs words, uses the wrong words, or is unable to speak Interpretation: If any 1 of these 3 signs is abnormal, the probability of a stroke is 72%. S820 Circulation November 2, 2010 by on October 22, 2010 circ.ahajournals.orgDownloaded from (or the last time the patient was known to be normal), triage and transport the patient, and provide prearrival notification to the most appropriate receiving hospital.31,41–44 Patients with acute stroke are at risk for respiratory compro- mise from aspiration, upper airway obstruction, hypoventilation, and (rarely) neurogenic pulmonary edema. The combination of poor perfusion and hypoxemia will exacerbate and extend ischemic brain injury and has been associated with worse outcome from stroke.45 Both out-of-hospital and in-hospital medical personnel should administer supplemental oxygen to hypoxemic (ie, oxygen saturation �94%) stroke patients (Class I, LOE C) or those with unknown oxygen saturation. Although blood pressure management is a component of the ED care of stroke patients, there are no data to support initiation of hypertension intervention in the prehospital environment. Unless the patient is hypotensive (systolic blood pressure �90 mm Hg), prehospital intervention for blood pressure is not recommended (Class III, LOE C). Transport and Destination Hospital EMS providers should consider transporting a witness, family member, or caregiver with the patient to verify the time of stroke symptom onset. En route to the facility, providers should continue to support cardiopulmonary function, moni- tor neurologic status, check blood glucose if possible, and provide prehospital notification. Prearrival hospital notification by the transporting EMS unit has been found to significantly increase the percentage of patients with acute stroke who receive fibrinolytic the- rapy.46–48 Bypass of community hospitals in favor of trans- porting patients directly to a stroke center has undergone investigations that merit attention. Investigators in New York, Canada, Italy, and Australia have performed before-and-after studies examining the difference in rates of rtPA administra- tion after implementation of a hospital bypass protocol for EMS. All have found significantly larger percentages of patients with ischemic stroke treated with rtPA when patients are transported directly to stroke centers.47,49,50 Recently investigators have begun to examine the impact of direct activation of stroke teams by EMS.50,51 EMS providers must rapidly deliver the patient to a medical facility capable of providing acute stroke care and provide prearrival notification to the receiving facility.41,46,48 Each re- ceiving hospital should define its capability for treating patients with acute stroke using the definitions established for stroke- prepared hospitals, primary stroke centers, and comprehensive stroke centers3,6,7 and should communicate this information to the EMS system and the community. Although not every hospital is capable of organizing the necessary resources to safely administer fibrinolytic therapy, every hospital with an ED should have a written plan that is communicated to EMS systems describing how patients with acute stroke are to be managed in that institution. The plan should detail the roles of healthcare professionals in the care of patients with acute stroke and define which patients will be treated with fibrinolytic therapy at that facility and when transfer to another hospital with a dedicated stroke unit is appropriate. The role of stroke centers and in particular stroke units continues to be defined, but a growing body of evi- dence47,49,50,52–58 indicates a favorable benefit from triage of stroke patients directly to designated stroke centers (Class I, LOE B). EMS systems should establish a stroke destination preplan to enable EMS providers to direct patients with acute stroke to appropriate facilities. When multiple stroke hospi- tals are within similar transport distances, EMS personnel should consider triage to the stroke center with the highest capability of stroke care. Multiple randomized clinical trials and meta-analyses in adults50,59–62 document consistent improvement in 1-year survival rate, functional outcome, and quality of life when patients hospitalized with acute stroke are cared for in a dedicated stroke unit by a multidisciplinary team experienced in managing stroke. Although the studies reported were conducted outside the United States at in-hospital units that provided both acute care and rehabilitation, the improved outcomes were apparent very early in stroke care. These results should be relevant to the outcome of dedicated stroke units staffed with experienced multidisciplinary teams in the United States. When such a facility is available within a reasonable transport interval, stroke patients who require hospitalization should be admitted there (Class I, LOE B). In-Hospital Care Initial ED Assessment and Stabilization (Box 3) Protocols should be used in the ED to minimize delay to definitive diagnosis and therapy: “Time is Brain.”43 As a goal, ED personnel should assess the patient with suspected stroke within 10 minutes of arrival in the ED. General care includes assessment, cardiopulmonary support (airway, breathing, circulation), and evaluation of baseline vital signs. Administration of oxygen to hypoxemic patients with stroke (oxygen saturation�94%) is recommended (Class I, LOE C). On arrival ED personnel should establish or confirm IV access and obtain blood samples for baseline studies (eg, complete blood count, coagulation studies, blood glucose). If not already identified in the prehospital setting, ED staff should promptly identify and treat hypoglycemia. The ED physician should perform a neurologic screening assessment, order an emer- gent computed tomography (CT) scan of the brain, and activate the stroke team or arrange for consultation with a stroke expert. A 12-lead electrocardiogram (ECG)