Acute Ischemic Stroke

: Audience: Emergency medicine residents. This simulation was designed for emergency medicine interns to teach the basics of stroke evaluation and care. 3) list appropriate imaging and laboratory orders for a CVA work-up, 4) determine appropriate subspecialty consultation, 5) discuss common stroke syndromes and associated cerebral locations, 6) review indications and contraindications for tissue plasminogen activator (tPA), 7) review hospital specific stroke protocol. Method: We recommend use of a standardized patient capable of replicating the details of the neurological exam descried. An oral boards format or high-fidelity simulator can also be used if a standardized patient is not available. Debriefing was left to the facilitator who was advised to give open ended questions to gauge reactions and assess understanding. criteria the American Heart Association (AHA) and American Stroke Association 12 refer your institution-specific protocol for

prior to beginning the simulation. An EM faculty member was assigned to this case to evaluate the team and troubleshoot any unexpected issues. This case can be modified for senior residents by introducing subtle CVA exam findings and relative contraindications for tPA. Given limited roles and decision makers, groups larger than three are not recommended for this case.
The faculty member in the room evaluated each team based on predetermined critical actions. Debriefing was done with an instructor guide that outlined objectives of the case as well as any notes taken by the operator. Learners evaluated the case at the end with an evaluation form. Of the 12 participants, 12 (100%) completed the survey. Surveys were anonymous and the study was approved by the Institutional Research Board. All 12 participants agreed or strongly agreed the simulation was realistic and useful. 11 (92%) agreed or strongly agreed they have confidence activating the stroke protocol at this institution. Selected comments are below: 5 Positive • "I liked that it was realistic and helped solidify prior knowledge and new info about pathways." • "Basic stroke eval and treatment of the patient was great to get a bit more comfortable." • "Very applicable for new ED interns." Of the surveys commenting on areas for improvement, two indicated that "more subtle signs" or "increased difficulty" of the case was desired. With regards to critical actions, the most commonly missed actions were ordering a fingerstick blood glucose or tPA.

Case Description & Diagnosis (short synopsis):
A 65-year-old male with a history notable for diabetes, hypertension, hyperlipidemia presents via emergency medical services (EMS) for "not acting right." Paramedics state the patient has been slurring his speech for about 15 minutes prior to their arrival. The learner should obtain a fingerstick blood glucose and activate a stroke alert. The learner should obtain a non-contrast computed tomography (CT) of the head and begin assessing for contraindications for tPA. The blood pressure will need to be acutely lowered and learners should emergently administer tPA.

Background and brief information:
The 65-year-old male patient is brought via EMS to a tertiary medical center with reports of not acting like himself.

Initial presentation:
The patient is brought in via EMS with no family present. He appears as an appropriately dressed middle aged male in moderate distress.
How the scenario unfolds: On arrival to the emergency room, learners should begin by assessing the patient's airway, breathing and circulation while performing a brief history leading to a focused physical exam. They should recognize the patient is exhibiting symptoms of a CVA and immediately obtain a fingerstick blood glucose which will be normal. They should immediately activate a stroke alert. If learners do not obtain a fingerstick blood glucose, pharmacy will ultimate refuse to dispense tPA until all contraindications are ruled out. They should obtain a non-contrast head CT and laboratory tests and work through indications and contraindications for tPA. Neurology will respond to the stroke code but will tell the learners they should review the indications and contraindications with the patient and order it if indicated. Learners should recognize the patient's significant hypertension and administer medications to make patient eligible for tPA. If blood pressure control is not done promptly, pharmacy will refuse to dispense tPA until it is corrected. Obtain fingerstick blood glucose prior to stroke activation. 5. Activate hospital-specific stroke protocol (this should vary based on your hospital protocol so that learners can understand the system they work in). 6. Obtains and correctly interprets head CT (does not need to identify the dense middle cerebral artery (MCA) sign, but does need to state no bleeding). 7. Order appropriate labs (CBC, CMP, coagulation studies, Type and screen). 8. Correctly addresses blood pressure (before pharmacy prompting) prior to tPA. 9. Order tPA (thrombectomy also acceptable) and recognize reason for indication (ie <4. 5 hours, not on anticoagulation, no contraindications). 10. Admits patient to the ICU for close monitoring. Primary Survey:

History:
• History of present illness: o Paramedic history The paramedics were called by patient's wife for patient "not acting right." Approximately 15 minutes prior to arrival the wife called after the patient was found to be slurring his speech. As a note, the patient had just taken his afternoon meds, which include oxycodone, and he thinks it is related to taking a few extras like he normally does, but his wife wanted to make sure he is alright. If head CT not obtained, nurse will ask if a head CT is needed, or pharmacy will refuse to dispense tPA.
If labs not obtained, pharmacy will refuse to dispense tPA.
If ECG not obtained, the nurse will ask what the patient's rhythm is. National Institutes of Health Stroke Scale (NIHSS): Developed in 1989, this is a scoring system based on 11 items to assess degree of impairment for patients demonstrating clinical concern for CVA 9 . Each item is scored from zero to four where zero is normal and higher numbers represent more impairment. We recommend instructors print out their institutional NIHSS scoring sheet so that learners can be familiar with the document they will use regularly. • Hemorrhagic strokes constitute the remaining 10% o The rupture of small penetrating arteries causes bleeding into the brain parenchyma and as the bleeding continues, the surrounding brain tissue is displaced and compressed. o Overall the most common cause is related to hypertension and in the elderly the most common cause is cerebral amyloid angiopathy. o Other causes to consider include acute vestibular syndrome, aneurysms and coagulopathies (congenital or acquired).  13 was a randomized control trial of 312 patients who were given alteplase within three hours of symptom onset.

Results
• Compared to the placebo group, tPA treated patients were at least 30% more likely to have better than minimal disability at three months on the assessment scales. • Within 36 hours of stroke, 6.4% of tPA given patients had symptomatic intracerebral hemorrhage compared to 0.6% in placebo group (P<0.001). • There was no significant difference in mortality between control and treatment groups.

Results
• Patients receiving tPA had favorable outcome 52.4% vs 45.2% in the placebo group. (p = 0.04). • While any intracranial hemorrhage was higher in the tPA group compared to placebo group, there was no difference in mortality between the two groups. • This study prompted the AHA/ASA guidelines to extend the time window for tPA administration from 3 to 4.5 hours. While eligibility criteria were similar, this study helps guide additional exclusion criteria to consider including patients older than 80 years, any use of oral anticoagulants, baseline NIHSS greater than 25, and patients with a history of stroke or diabetes.

Some Considerations Regarding tPA
The incidence of symptomatic intracerebral hemorrhage (sICH) post tPA ranges 2% to 7%.
• In the aforementioned NINDS trial, sICH with tPA versus placebo was 6.4% and 0.6%, respectively (p<0.01). This was similar in the ECASS III trial. • Selection criteria for tPA is very important because the risk of sICH increases with age, larger strokes, and diabetes. 15  There are many causes of atrial fibrillation including heart disease, chronic hypertension, infections, thyroid disease, ingestions, and electrolyte abnormalities. The disorganized activity of the atria predispose patients to ischemic stroke from embolism. 16 CHA 2 DS 2 -VASc Score is a tool to quantify the risk of stroke in patients with atrial fibrillation. This patient's CHA 2 DS 2 -VASc score is 5 which confers an annual stroke risk of 6.7%.

Wrap Up:
We recommend learners read more on cerebrovascular accidents in available emergency medicine textbooks and the Emergency Neurologic Life Support guidelines on stroke. Additionally, the American Heart Association provides pocket cards on this disease process (similar to Advanced Cardiovascular Life Support).

Critical Actions:
Obtains a basic history of symptoms. Obtains past medical history. Performs NIHSS and conducts a thorough physical exam.
Obtains fingerstick blood glucose prior to stroke activation. Activates hospital-specific stroke protocol (this should vary based on your hospital protocol so that learners can understand the system they work in).
Obtains and correctly interprets head CT (does not need to identify the dense MCA sign, but does need to state no bleeding).
Orders appropriate labs (CBC, CMP, coagulation studies, Type and screen).
Correctly addresses blood pressure (before pharmacy prompting) prior to tPA. Orders tPA (thrombectomy also acceptable) and recognizes reason for indication (ie <4.5 hours, not on anticoagulation, no contraindications).
Admits patient to the ICU for close monitoring.