Transcript Telestroke Orientation

Neuroscience Telemedicine Orientation
Nancy Turner, BSN, RN, CPAN
Neuroscience Telehealth Coordinator
David Jones, BSN, RN, CCRN, SCRN, CSRN
Neuroscience Telehealth Coordinator
Telestroke
Stroke Statistics
 Leading cause of serious long term disability in the U.S.
 5th leading cause of death – 1 American dies every 4 minutes1
 Costs $36.5 billion annually – lost productivity and treatment2
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130,000 Deaths each year - 1 in every 20 deaths.1
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>795,000 people in the US have a stroke.
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610,000 are first or new strokes.
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1 in 4 are recurrent strokes.2
1 Kochanek KD et al. National Vital Statistics Reports. 2011;60(3).
2. Roger VL et al. Circulation. 2012;125(1):e2–220.
Stroke Statistics
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SC is located in the buckle of the stroke belt
Highest and second highest stroke mortality rate in U.S. (1983-2005)
For 2011-2013, SC has the 4th highest stroke mortality rate in the U.S.
Stroke is the 3rd leading cause of death in South Carolina; although it is the 5th leading cause in
North America
Translation
In one minute
 1.9 million neurons are lost
 14 billion synapses are lost
 12 kilometers of myelinated fibers are lost
Saver, J. Time is Brain – Quantified. Stroke. 2006
Jan;37(1):263-6.
Translation
30 minutes = 10%!
(Khatri. Neurology, 2009)
What is a Stroke?
 A Stroke is a “Brain Attack”
 The brain is suddenly deprived of blood flow
and consequently, oxygen.
 Like STEMI’s and Traumas, stroke response
is a team sport.
 It is thusly named a “Brain Attack Team” or
BAT for short at MUSC*
*Names will vary among differing agencies
Types of Stroke
Ischemic
Hemorrhagic
• Loss of or significant reduction of blood flow to brain
• Expulsion of blood products out of the vascular space
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tissue
Comprises 80% of all strokes
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and into the tissue or tissue spaces of the brain
Comprises 20% of all strokes
Neuro-Anatomy
Neurovascular Anatomy
Stroke Deficit Vocabulary
 Apraxia – impaired planning and sequencing of movement despite having the
strength and coordinating to complete the task
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Ataxia – impaired coordination
Aphasia – loss of comprehension or expression of language
Dysphagia – difficulty swallowing
Dysarthria – slurring of speech without loss of language
Plegia – inability to activate any motor neurons. Paralysis
Paresis – reduced ability to activate motor neurons causing weakness
Extinction (to double simultaneous stimulation) – in ability to recognize that
two stimuli are being presented at once
 (Hemispatial) Neglect - inability to process or perceive stimuli from one
direction or features of one side of the body
Warning Signs of Stroke
Sudden onset of any symptoms
listed below:
 Impaired sensation or control of the face, arm or leg
 Confusion, impaired speech or ability to understand
 Impaired vision, gait, balance or coordination
 Severe headache, or neck pain
Ischemic Stroke S/S - Anterior
Left Hemisphere
 Left gaze preference (eyes
deviated to left)
 Right visual field loss
 Right-sided weakness
 Right-sided sensory changes
 Aphasia
Right Hemisphere
 Right gaze preference (eyes
deviated to right)
 Left visual field loss
 Left-sided weakness
 Left-sided sensory changes
 Left hemi-inattention (neglect)
Ischemic Stroke S/S - Posterior
Brainstem or Cerebellum
 Nausea and/or vomiting
 Double vision
 Abnormal eye movements
 Difficulty swallowing
 Vertigo
 Weakness on one side of the body or in all limbs
 Sensory loss on one side of the body or in all limbs
 Decreased consciousness
 Unsteady gait
 Limb ataxia
Hemorrhagic Stroke S/S
Subarachnoid hemorrhages
(SAH) occur on the outside of
the brain.
Intra-cerebral hemorrhage (ICH)
occur in the brain tissue itself.
S/S Include:
 Focal neurological deficits as in AIS
 Headache (especially in subarachnoid
hemorrhage)
 Neck pain
 Light intolerance
 Nausea, vomiting
 Decreased level of consciousness
Copyright © 2012 University of Washington
The Penumbra
 Hypoperfused brain tissue
 Has capacity to recover
 Only if perfusion is restored!
 Metabolically active
Astrup et al., 1981
Role of EMS Staff: Pre-Hospital
Early Recognition is Key!
If the signs are missed, time will slip by and the opportunity to treat
will be lost forever.
 Minimal scene time
 ABC’s, Neuro Assessment,
LKN, Medications, & Hx.,
Family Cell #
 IV Access
 2 Large Bore IV’s
 Antecubital Vein for
perfusion scanning
 FSBS
 Rapid Transport
 Early encoding to ED
What a Stroke Response Should Look Like
The Stroke Team
 EMS
 ED Physicians
 ED Nursing Staff
 Stroke MD (In-House and/or
Telemedicine)
 CT Technologist
 Pharmacy
 Phlebotomy (If used in ED setting)
The Goals
Door to Needle/t-PA:
CT Interpreted:
Door to CT Scan:
Door to Stroke MD:
Door to ED MD:
60 min
45 min
25 min
15 min
10 min
REMEMBER:
IF YOU USE THE FULL 60 MIN;
THE PATIENT JUST LOST 120 MILLION
NEURONS
AHA/ASA Target: Stroke Measures
What a Stroke Response Should Look Like
Code Stroke
Admitting
Patient ID
Registration
Room assign
CT
tech
Nurse
#1
ED
physician
Nurse
#2
ED
tech
CT scan
IV placement, lab draw
Vital sign monitoring
Weight estimate
Assist with exam
Obtain History
Meds/allergies
Review chart
for previous
visits
Order tPA
Activate telemedicine
system
Verify time of onset
with witnesses
Find ancillary info
Mix tPA
Emergent
transport of
bloods to lab
Decision
Bolus & Infuse tPA
Stroke Care in 2016
It is simple
Do it fast
Do it safely
Do it as a team
tPA Myth vs. Fact
 Alteplase(tPA) is Standard of Care for Ischemic Stroke since 1996
 NO SUBSTITUTIONS! (TNK)
 *Greater chance of litigation for not using vs. using and having a bad
outcome
 Genentech will replace any opened but unused Alteplase no questions
asked; so don’t hesitate to mix it!
*Liang and Zivin, 2008
tPA: Inclusion vs. Exclusion
Inclusion
Exclusion
 Significant head trauma or prior stroke in the previous 3 mo.
 Symptoms suggest SAH
 Arterial puncture at noncompressible site in previous 7 d
 History of previous intracranial hemorrhage
 Intracranial neoplasm, AVM, or aneurysm
 Recent intracranial or intraspinal surgery
 Elevated blood pressure (systolic >185 mm Hg or
diastolic >110 mm Hg)
 Active internal bleeding
 Acute bleeding diathesis, including but not limited to
 Platelet count <100 000/mm3
 Heparin received within 48 h resulting in abnormally elevated
aPTT above the upper limit of normal
 Current use of anticoagulant with INR >1.7 or PT >15 s
 Current use of direct thrombin inhibitors or direct factor Xa
inhibitors with elevated sensitive laboratory tests (eg, aPTT,
INR, platelet count, ECT, TT, or appropriate factor Xa activity
assays)
 Blood glucose concentration <50 mg/dL (2.7 mmol/L)
 CT demonstrates multilobar infarction (hypodensity >1/3 cerebral
hemisphere)
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>18 years old
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Diagnosed Ischemic Stroke with disabling neurological deficit
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Non-contrast CT head scan that does not demonstrate any hemorrhage,
tumor, or mass effect; Essentially normal CT.
tPA: Relative Exclusion
Recent experience suggests that under some circumstances, with careful consideration
and weighting of risk to benefit, patients may receive fibrinolytic therapy despite ≥1
relative contraindications.
Consider risk to benefit of intravenous tPA administration carefully if any of these relative
contraindications is present:
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Only minor or rapidly improving stroke symptoms (clearing spontaneously)
Pregnancy
Seizure at onset with postictal residual neurological impairments
Major surgery or serious trauma within previous 14 days
Recent gastrointestinal or urinary tract hemorrhage (within previous 21 days)
Recent acute myocardial infarction (within previous 3 months)
Pre-tPA Management
 Diagnose Ischemic Stroke
 Prepare Alteplase Bolus & Infusion
 Reduce blood pressure to <185 Systolic and <110 Diastolic before
administration
 Drugs of choice: Labetalol if HR > 70, Hydralazine, or Cardene Drip
 Maintain SBP of <180 & DBP <105 for the following 24 hours
 If patient will tolerate it: Keep HOB less than 30o to flat if possible!
During & Post tPA Infusion Management
 Maintain SBP < 180 & DBP <105 for 24 hours after
bolus
 Check V/S & Complete NIHSS
 Q15 min x2 hours; Q30 min x6 hours; Q1 x16 hours from time of tPA
Bolus
 Monitor for S/S of hemorrhagic transformation
 Sudden worsening of LOC and/or NIHSS
 Sudden onset headache, nausea, and/or vomiting
 Monitor for adverse reactions
 Angioedema
 Other new onset bleeding
 Remember that the greatest chance for bleeding is in the
first 24 hours!
Management of Bleeding
 STOP INFUSION IMMEDIATELY if S/S of hemorrhagic transformation
or any adverse reaction is noted
 Send for STAT head CT to R/O ICH
 Send STAT Hgb/Hct, Plt, PT, PTT, Fibrinogen
Transfuse
 PRBC Type & Cross x4 Units
 Cryoprecipitate 4-6 Units
 Consult Neurosurgery
 If no in-house Neurosurgery, Prep for transfer to nearest appropriate facility
Thrombectomy: The new Gold Standard in
Ischemic Stroke treatment
Thrombectomy is the intra-arterial revascularization of an occluded
vessel; A.K.A –
 The ESCAPE trial showed that 53% of patients who received thrombectomy had a
mRS of 0-2 at 90 days
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There were several trials being conducted on thrombectomy, all of which showed a 50% improvement in
outcome for reaching a mRS of <2
Number Needed to Treat (NNT) = 4
 There are a variety of techniques and devices available to perform thrombectomy
Role of EMS Inter-hospital Transport
 Potential thrombectomy patients should always be
transferred by air whenever possible
 TIME IS BRAIN – 1.9 Million Neurons lost per
minute
 Stroke patients that are
transferred to MUSC should
have the EMS Flowsheet
filled out.
 Sending ED Nursing staff
fills out the demographics
& tPA information
 EMS must document the
vitals & neuro exam per the
recommended time intervals
Role of EMS Inter-hospital Transport
 As before, it is imperative to maintain an acceptable blood
pressure
 Keep all tPA patients below 180 SBP and 105 DBP
 Don’t bottom them out!
 Permissive HTN is acceptable, in non-tPA patients
 <220 SBP
 Place the HOB 30o to flat IF they can tolerate it
 Stroke patients can be very susceptible to changes in position
 Cerebral collateral circulation can be improved in the flat
or head down position; providing vital blood flow to the affected
brain tissue
QUESTIONS?
Teleneurology &
Tele-EEG
What is Teleneurology
Many small hospitals do not have the population base
necessary to support access to local neurologists
around the clock
Expands on the well-established Telestroke program
at MUSC
Scheduled and urgent teleconsultation services
Additionally, allows for the appropriate determination
of the need for transfer to MUSC Health
Helps keep the patient within their own support
system in their community.
What is TeleEEG
 This test is essential in providing accurate determinations of
brainwave activity, particularly to help diagnose epilepsy
 Local hospitals may have the ability to perform an EEG, but are
not able to keep a specially trained neurophysiologist on staff
 Delays diagnosis and treatment
 Complementary service to MUSC Health’s Tele-Neurology
program
 Or as a stand-alone service
 Tele-EEG program provides specially-trained
neurophysiologists seven days a week for the interpretation of
both routine and urgent EEGs.
Teleneurology process
 Patient with Neurologic signs/symptoms presents to your
facility/service
 AMS, focal weakness, seizures, headache, multiple sclerosis, etc…
 Determine severity of condition for acute vs. scheduled consult
 Status or uncontrolled seizure vs. stable headache
 Call MUSC ATC and request a Neuro Consult
 Specify if request is for acute or scheduled
 Acute consults will be joined within 30 min
 Scheduled appointment times are currently in the afternoon hours
only
 Scheduled consults will be joined within 24 hours
Teleneurology Process:
Acute vs. Scheduled Neurology Consults
Neurology Consult
All Neurological conditions
EXCEPT STROKE!!
Call MUSC Neuro
Acute Consults
Scheduled Consults
(30 min. response)
Non-Acute (<24hr. Response)
Uncontrolled Seizure
or Status Epilepticus
All other neurology needs
including non-acute stroke,
TIA, post t-PA consult, AMS,
seizure, etc…
Initiating a Teleneurology Consult
As a MUSC Health Telestroke partner site, you should already have a
cart onsite for Telestroke calls that can be utilized for the Teleneurology
service as well.
 Sites with large enough volume to warrant it, additional carts will be
arranged
 Carts are supplied based on actual and expected consult volumes
 This is variable from site to site
 Teleneurology consults can be conducted in any area of the hospital
with adequate internet access
 This includes the emergency room, inpatient floors, and even the
PACU if you have boarders
Quick Start Reference
Technical Support: 1-855-894-1500
Email: [email protected]
Starting a Consult:
• Position the cart at the end of the bed, about 3-5 feet from the foot of the bed so that
the camera can be focused on the patient. PLEASE DO NOT TOUCH THE CAMERA
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Turn on the REACH system by moving the mouse
Double click on the REACH icon
Login using your specific username and password
Enter New Patient information: Name, Gender, Room #
Select appropriate template and give reason for consult – click SUBMIT
Once in consult, please enter the following important information:
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Treating physician name
RN name
*Last Known Well
Date of admission or Time in the ED
Vital Signs (including weight)
Pertinent diagnostic test results including labs, EEG, and imaging results
Brief history and any notable exam findings
Family Contact name & phone #
MUSC consultant will complete Neurologic assessment with RN assistance
Why to Call
Teleneurology Consults can be made for a variety of conditions/symptoms:
 Headaches, head pain
 Migraines (chronic, acute, or complex), Cluster headaches
 Trigeminal neuralgia
 Seizures
 Acute, chronic, status, or uncontrolled
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Progressive neurologic deficits, Bell’s Palsy, Radial nerve palsy
Encephalopathies, confusion, and coma
Diffuse weakness, paraplegia, or gait disturbance
Dizziness/vertigo
 Syncope
 Unusual movement disorders
QUESTIONS?
Tele-presenting: Assisted
assessment through
telemedicine
Why NIHSS:
 Focuses on impairment of function
 Consistent manner for exam between providers
 Easily communicated and understood
 Replicable
EMS
ER
ICU
Stroke Unit
NIHSS :
 Do the scale in the order listed.
 Do not skip items because you assume you know the answer.
 Do not go back and change scores.
 Scores should reflect what the patient does, not what you think
the patient can do.
 Record scores while administering the exam.
 Do not coach the patient.
 Work quickly.
 Each assessment is a snapshot of the patient at that moment.
1a. Level of Consciousness
Assess by greeting the patient, introducing yourself, and asking simple
questions.
“How are you feeling?”
“Do you have any pain?”
Scoring:
0 – Alert, answers readily and appears to comprehend
1 – Arousable by minor stimulation, examiner must
repeat the question because the patient doesn’t appear to
understand, or touch the patient to stimulate the patient.
2 – Arousable by repeated or strong stimulation
3 – Unresponsive or reflex responses only
1b Level of Consciousness Questions
Assess the ability to comprehend and answer questions:
“What month is it?”
“How old are you?”
*Remember do not coach the patient to achieve the answer*
Scoring:
0 – Answers both questions correctly
1 – Answers one question correctly
2 – Answers neither question correctly
*If patient can not speak, then ask if they can write, if so provide pen and paper. Spoken
and written answers score the same. Misspelling should be ignored as long and the
writing can be understood.*
1c Level of Consciousness Commands
Assess patient’s ability to follow simple commands:
“Open your eyes wide then close them tight.”
“Make a tight fist then open it.”
Make sure the patient is focusing on you and what you want them to do,
it is OK to demonstrate to the patient what you want them to do.
Scoring:
0 – Performs both task correctly
1 – Performs one task correctly
2 – Performs neither task correctly
*Remember to score the patient’s first attempt*
2 Best Gaze
Done to evaluate the horizontal movement of the eyes. Tested by asking
the patient to follow a finger with their eyes, or you can ask the less alert
patient to look at your face then move from one side of the patient to the
other.
Scoring:
0 – Normal
1 – Partial gaze palsy: gaze is abnormal in one or both
eyes, but forced deviation or total gaze paresis is not
present
2 – Forced deviation: total gaze paresis not overcome by
the oculocephalic maneuver.
3 Visual
Assessing visual fields by confrontation, using finger counting or visual
threat.
Scoring:
0 – No visual loss
1 – Partial hemianopia
2 – Complete hemianopia
3 – Bilateral hemianopia, or blind patient
Hemianopia: decreased vision or blindness in half of the visual field
**Note for the Telepresenter:
 Share the same visual field as the patient
 If they have a right gaze – get down on the right side to look them in the eye
 Use 1 or 2 fingers ONLY!!
4 Facial Palsy
Assess by asking or pantomime to encourage patient to:
“Show me your their teeth”
“Raise your eyebrows”
“Close your eyes”
Scoring:
0 – Normal (symmetrical movements)
1 – Minor paralysis (flattened nasolabial fold, asymmetry
on smiling).
2 – partial paralysis (total or near total paralysis of lower face)
3 – Complete paralysis one or both sides (absence of facial
movement in the upper and lower face)
5 Motor Arm (5a-left arm, 5b-right arm)
Assess the ability to hold the arm in a stable position without drifting.
Position limb palm side down at least 45 degrees from body and count
out loud for 10 seconds will monitoring for a drift. Each limb is scored
separately.
Scoring:
0 – No drift
1 – Drift (drifts down but does not hit bed or other
support)
2 – Some effort against gravity (limb can not get to or
maintain position, but has some effort against gravity)
3 – No effort against gravity (limb falls)
4 – No movement
UN – Amputation or joint fusion
6 Motor leg (6a-left leg 6b-right leg)
Assess the ability to hold the leg in a stable position without drifting.
Position limb at least 30 degrees from body and count out loud for 5
seconds will monitoring for a drift. Each limb is scored separately.
Scoring:
0 – No drift
1 – Drift (drifts down but does not hit bed or other
support)
2 – Some effort against gravity (limb can not get to or
maintain position, but has some effort against
gravity)
3 – No effort against gravity (limb falls)
4 – No movement
UN – Amputation or joint fusion
7 Limb Ataxia
Assesses muscle control and coordination, while differentiating these
from general weakness.
Finger – nose – finger test
Heel – shin test
Scoring:
0 – Absent
1 – Present in one limb
2 – Present in two limbs
UN – Amputation or joint fusion
*If patient can not perform task because of coma, paralysis, or lack of ability to understand
direction, then the score is 0*
8 Sensory
Assess sensation or grimace to pinprick.
Use the pointed end of a Q-tip, gently prick patient on face with eyes open; do
you feel this? Does it feel the same on each side?
Repeat on inner forearms and inner lower leg.
Scoring
0 – Normal, no sensory loss.
1 – Mild to moderate sensory loss, patient feels pinprick is dull on the affected side, or there
is loss of superficial pain with pinprick but patient is aware of being touched.
2 – Severe to total sensory loss, patient not aware of being touched.
**Note for the Telepresenter:
 This is a Sharp-Dull exercise; DO NOT use light touch
 Take one of the long Q-Tip applicators and break the stick to use the pointed end
9 Best Language
Assess by asking the patient to describe what is happening in the
attached picture, name the items, and to read from the standard list of
words/sentences
Make sure the if the patient wears glasses that they are on.
Scoring
0 – No aphasia, normal
1 – Mild to moderate aphasia, some obvious loss of fluency or
facility of comprehension.
2 – Severe aphasia, all communication is fragmented
3 – Mute, global aphasia
What do you see happening in this picture?
What is this?
Point to each item individually
**Note for the
Telepresenter:
 Remember the
consultant may be
unable to hear the
patient response.
Rely as needed
Read the sentences:
You know how.
Down to earth.
I got home from work.
Near the table in the dining room.
They heard him speak on the radio last night.
10. Dysarthria
Assess by asking the patient to read the attached list, or have them
repeat back to you.
Scoring
0 - Normal
1 - Mild to moderate dysarthria, patient slurs at least some words
but, can be understood
2 - Severe dysarthria; patient is either mute or speech is so
slurred they cannot be understood out of proportion to any
dysphagia that is present.
UN - intubated or other physical barriers
Say the words:
MAMA
TIP – TOP
FIFTY – FIFTY
THANKS
HUCKLEBERRY
BASEBALL PLAYER
11 Extinction and Inattention
Sufficient information to identify neglect may be obtained during the prior
testing (Sensory or visual fields).
Scoring
0 – No abnormality
1 – Visual, tactile, auditory, spatial, or personal inattention or extinction to bilateral
simultaneous stimulation in one of the sensory modalities.
2 – Profound hemi-inattention or extinction to more than one sensory modality.
**Note for the Telepresenter:
 When checking visual fields, remember to check simultaneous bi-lateral
vision
 Pt. may visualize each side individually but not simultaneously
 This also applies to sensory; remember to check simultaneous bi-lateral
sensation
 The Pt. may feel each side individually but not simultaneously
NIHSS Scoring:
Total scores range from 0-42 with higher values representing
more severe infarcts
>25
Very severe neurological impairment
15-24 Severe impairment
5-14
Moderately severe impairment
<5
Mild impairment
Adams, HP, et al. (1999). Neurology: 53: 126-131.
A 2-point (or greater) increase on the NIHSS administered serially
indicates stroke progression. It is advisable to report this increase.
Online NIHSS Certification
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Online NIHSS Certification available free through the
American Stroke Association.
The online program provides detailed instructions and
demonstration scenarios for practice in scoring the
NIHSS.
Certification is completed by scoring different patient
scenarios.
www.strokeassociation.org
QUESTIONS?