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ARE YOU ‘STROKE’ SMART?
Focus on Emergency Stroke Care – Part II
By M. P. RAVINDRA NATHAN, MD, FACC, FAHA
When Mr M.N, a 65-year-old diabetic, felt a little weakness in the right arm, he didn’t feel alarmed. Later, he couldn’t get the right words out when he tried to talk but felt better afterward. Then the symptoms started getting worse and his wife decided to drive him to the nearest Emergency Room in her car. The ER as usual was crowded and by the time the triage nurse got to him, Mr. M.N had already developed a stroke and both the neurologist and ER doctor agreed, “Too late to give tPA now, will treat conservatively.” Today Mr. M.N walks with a significant disability, a tragic outcome that could have been possibly avoided.
The incidence of stroke has increased over the past decade, from about 750,000 a year to almost 795,000 a year at present. However, the medical care for stroke victims has also improved considerably in recent years. Given the right treatment in a timely fashion, during the ‘window of opportunity’ (the first three hours after the onset of symptoms), the victim has a good chance for significant recovery.
For ischemic strokes, which account for 80 percent of the cases, the treatment is intravenous infusion of a clot busting drug called recombinant tissue plasminogen activator or rtPA. A new European study suggests that this window can be extended up to 4.5 hours, meaning more patients can be treated with this drug. Also, if tPA could be delivered intra-arterially to the site of the clot, this window could be extended up to six hours. The treatment is not without complications, the most fearsome being hemorrhage in the brain. The final outcomes data show patients treated with rtPA tend to do better and survive longer. There are strict eligibility criteria and usually only 10 percent cases end up getting this treatment when they present to the ER.
Recognition of the early stage of stroke by the patient and/or the relatives is the first step and awareness is the key ingredient for success. When symptoms are significant and rapidly progressive, there is no problem for anybody to recognize. But when they are subtle and slowly progressive, one may take a wait-and-watch policy that could be detrimental. Don’t do that, call 911 if you have even the slightest suspicion. Time is brain and every second counts. You may not realize that about 1.5 million neurons die every minute of ischemia in the brain. So, this is a crisis of monumental magnitude and the earlier the treatment can be initiated, the better the recovery.
Never take the patient in your car even if the hospital is close by. When you call 911, paramedics will respond and can initiate preliminary treatment in the ambulance and alert the nearest stroke center where the ER will get ready to receive the patient. When you hear “stroke alert in 5 minutes” coming through the overhead pager system in the hospital, it means the hospital is on hyper-alert and will be ready to administer the proper management by the time the patient arrives.
Not every hospital is equipped to handle the stroke patients and that is the reason you need to call 911 and paramedics know which is the nearest certified regional stroke center. These centers provide quality care to stroke victims across all phases of care ranging from emergency management to full rehabilitation. Many victims and care givers don’t realize the sheer amount of work and chain of care involved to achieve a positive outcome. This includes initial management by paramedics, ER doctor’s evaluation and work up, emergency CT scan or MRI of the brain, which should be done ideally within 25 minutes (door to CT time) of arrival, stat radiology interpretation, neurology consultation and appropriate therapy. The team approach based on standard stroke protocol has proved to be effective in reducing time to treatment, a critical determinant for a favorable outcome, the ideal door to treatment time being one hour or less.
recent survey of 1,000 people, 58 percent said they didn’t know if hospitals in
their community are stroke certified but 72 percent said they believe it’s
“very” important or “somewhat” important that they know where stroke-certified
hospitals are located in their area. “Even though we have conducted major pushes
through our ‘Get With The Guidelines®’ program and by working with The Joint
Commission to increase the number of certified hospitals in this country, the
public seems less aware of stroke-certified hospitals,” said Ralph Sacco, M.D.,
chairman of Neurology at the University of Miami-Miller School of Medicine. “The
survey results show the need for continuous reinforcement of public education to
maintain awareness of the stroke warning signs and symptoms as well as the
importance of stroke specialty hospitals. This issue must be at the top of
But in an emergency don’t worry about all these, just call 911 and paramedics know exactly where to take you to get the best treatment.
To be continued ….
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