Joseph E. Clinton, M.D.
Hennepin County Medical Center, Minneapolis, Minnesota
The recent FDA approval of t-PA for acute ischemic stroke has ushered in the era of thrombolysis for this condition. The new standard of care resulting from this shift of emphasis is forcing all disciplines involved in the care of stroke patients to reexamine their educational approach for this disease. Emergency personnel will need to reconsider educational efforts from both a content and a process perspective.
Emergency physicians and nurses have a solid understanding of ischemic and hemorrhagic stroke syndromes. Educational curricula in both disciplines include didactic and clinical experience that emphasizes recognition and management of neurological impairment from stroke, intracranial hemorrhage, infection, neoplasm, and metabolic causes. The core content topics that are the basis for emergency medicine residency training in nervous system disorders are listed in Figure 1 (1).
The topics are a simple listing of disease categories without subordinate details. Curricula are developed from this list by program directors, and these subjects are covered in emergency medicine training through a combination of clinical and didactic education. However, a sense of futility has accompanied education on acute stroke. Patients might be expected to improve but do so largely independent of therapeutic intervention. Excluding stroke patients with operative intracranial lesions, the medical task in the past was to support physiologic functions, prevent complications (e.g., pneumonia, bed sores), and hope for the best.
As in most emergencies, the diagnostic and management urgencies in patients with stroke are determined by the degree of actual or anticipated impairment of basic physiologic functioning. Patients with obviously impaired respiratory, hematological, or neurological function are treated with the highest dispatch. Airway, breathing, and circulation are restored and stabilized with impressive efficiency in today's emergency departments (EDs). Accordingly, the stroke patient who is cyanotic, severely hypotensive or hypertensive, or comatose receives immediate intervention to restore vital functions. Diagnostic efforts and therapeutic decisions are usually expedited under these extreme conditions. In contrast, the quietly hemiparetic stroke victim may receive an entirely different treatment regimen. In most EDs a stable respiratory and circulatory status often relegates a patient to an intermediate or lower level of urgency. Detailed and lengthy neurological examination is often carried out before diagnostic studies are considered. Once ordered, head CT of the stable stroke patient may be delayed because other ED patients are given higher priority.
The low priority given to acute treatment of stroke victims is an outgrowth of a frustrating period for modern medicine characterized by abundant research but little progress in the quest for a therapeutic breakthrough. A paradoxical situation now exists where the victims who might gain the most from aggressive diagnostic and therapeutic interventions are left alone to silently extend their damage while others, who have poorer prognoses and less to gain, are given the benefit of expedited care. The demonstrations that selected stroke patients can benefit from thrombolysis will put a new complexion on our approach to these patients. Along with the new approach will come an additional responsibility for emergency nurses and physicians to be cognizant of the subtle distinctions between stroke patients who might benefit from thrombolysis and those who might suffer serious harm. Eligible patient identification will be difficult. Rapid neurological assessment must be taught to triage nurses and physicians so stroke patients are identified rapidly for streamlined care. The implementation of the therapy will present yet another challenge. The whole process will be the subject of retrospective scrutiny as expected complications occur in appropriately treated patients and our experience increases.
Although it is never difficult to persuade emergency personnel that time is a critical element for successful intervention in an acute disease, they will now need to understand exactly how critical it is for patients suffering ischemic stroke. Extrapolation of ED experience with thrombolysis in acute myocardial infarction will facilitate this. Our successful experience with acute myocardial infarction will also help overcome system inertia and increase appreciation that established methods to expedite selected patients can be very successful. Table 1 lists key similarities and distinctions between thrombolytic therapy for acute ischemic stroke and myocardial infarction (2-4). The highly variable clinical presentation of acute stroke increases the complexity of the clinical problem.
The new urgency being brought to this disease process by the possibility of successful early therapy also helps to create categories of educational needs for emergency personnel. A more in-depth understanding of the pathophysiology of the disease process is only part of the educational challenge. An understanding of the treatment risks and complications forces attention to the process of care. Both nursing and physician personnel will need to understand the importance of timing, blood pressure control, and careful neurological and cardiovascular monitoring throughout the therapeutic process. Figures 2 and 3 list suggested pathophysiological and procedural content of educational programs for emergency personnel.
Common sense tells us that frequency is an important consideration when planning educational activities in any clinical situation. Staff awareness of clinical procedures, their comfort level with management protocol execution, and overall quality of care improve when they are exposed to a clinical situation more frequently. The practiced response that develops among team members improves as unanticipated glitches are worked out of the system. Details become incorporated into memory and efficiency improves. Conversely, uncommonly executed protocols are more sluggishly applied as details need to be reviewed each time. The need for staff refresher courses for skill maintenance increases in low-frequency states. The frequency factor is an important consideration when planning clinical educational activities.
Stroke is only one-third as common in our population as acute myocardial infarction. Each year there are 500,000 (80% ischemic) acute strokes in the United States and 1,500,000 acute myocardial infarctions, so in general practice an emergency team will see only one stroke patient for every three acute myocardial infarction patients (2). Only a small percentage of the stroke patients will be eligible for thrombolysis treatment but all will benefit from more expeditious treatment. Nevertheless, skillful application of a complex selection process and rapid execution within a tight time-frame will be required on an infrequent basis. The educational challenge to maintain such a state of readiness will be significant.
A high state of motivation can be attained and maintained in emergency staff by consistently accentuating the positive in our stroke management experience. Case conferences covering patient experience need to involve all members of the interdisciplinary team. Regularly updated reports of experience with stroke patients should be circulated to those involved. Successes need to be given much attention to create a sense of group gratification over the benefit afforded to victims of stroke from the diligent teamwork.
The low-frequency exposure expected for ischemic stroke patients eligible for thrombolysis calls for special efforts to keep a high level of awareness of the treatment initiative. Posters, people, and perseverance will be needed. Posters reminding staff of the need should be placed in lounges and work areas in EDs. The people in the multidisciplinary team need to attend conferences and receive in-service training and ongoing encouragement. The initial push to educate all must be followed by perseverance in reminding the team of the ongoing need. Complacency that all are in a state of readiness will not last long if 2 months go by without an eligible stroke patient.
Although a positive outlook must be maintained, recognition of the limitations of therapy must also be recognized in order to avoid a backlash due to disappointment with adverse outcomes. Emergency nurses and physicians need to thoroughly understand the likelihood that some patients will suffer intracranial hemorrhage after receiving thrombolysis. If this downside is not placed in proper perspective, it could threaten to undermine the effort to recruit patients in the critical timely fashion that is necessary to limit this complication.
Changing the standard of care for stroke patients will be a process of communication and education. Identification of stakeholders needing to understand and support the change will be critical to the success of the effort. Emergency physicians and nurses are the focus of this section of the report. Among physicians and nurses there exist subcategories of those currently practicing and those in training. The practicing group will need support in the form of continuing education activities covering the areas identified earlier. Nurses and physicians in training will require a shift in emphasis of their curricular activities dealing with stroke. The practicing group will require coordination with professional organizations representing the nursing groups. The second group will require graduate medical education training programs through nursing and medical schools. The most immediate task is to change the practice through communication and educational efforts in the clinical areas. The curriculum review processes of the educational institutions will incorporate the change in standards occurring in the community.
The multidisciplinary needs of the acute stroke victim mirror the needs of multiply injured patients and acute myocardial infarction patients. Delivery of acute resuscitation, definitive diagnosis, and therapeutic measures within the narrow time window for effective therapy will require coordinated action. Educational activities will need to involve the patient and all who have an impact on care from the time of the event until recovery. The role of the ED--identifying patients, providing early care, and mobilizing resources to definitively manage the disease for optimum outcome--will be critical to success. This will require a shift in attitude and educational emphasis toward emergency management of acute stroke victims.
Current attitudes toward stroke victims need to be shifted using persuasive evidence of need. Institutions treating stroke victims need to establish multidisciplinary working teams to accomplish the task. Emergency physicians and nurses must be educated to perform sophisticated selection of stroke victims for thrombolysis. Efficient communication and coordination of functions need to be practiced. Educational efforts must be tailored both to practicing physicians and nurses and to students. An encouraging approach that accentuates the positive while recognizing limitations will yield the best results. A state of readiness for the low-frequency patient can be maintained with an approach using posters, people, and perseverance promoting the need to act quickly to optimize results.
1. Task Force on the Core Content for Emergency Medicine Revision. Core content for emergency medicine. Ann Emerg Med 1997;29:7929-811.
2. Heart and Stroke Facts: 1996 Statistical Supplement. American Heart Association, Dallas, TX, 1996.
3. Gore JM, Granger CB, Simoons MS, et al. Stroke after thrombolysis. Mortality and functional outcomes in the GUSTO-I trial. Global use of strategies to open occluded coronary arteries. Circulation 1995;92:2811-2818.
4. The GUSTO investigators.An international randomized trial comparing four thrombolytic strategies for acute myocardial infarction. N Engl J Med 1993;329:673-682.
|Factors||Stroke||Acute Myocardial Infarction|
|Symptom||Variable neurological deficit||Chest pain|
|Diagnostic standard||CT scan||Electrocardiogram|
|Blood pressure||Exclusionary, |
|t-PA||0.9 mg/kg (10% bolus followed by 90% over 60 mins)||100 mg (15 mg bolus followed by 85 mg infusion over 90 mins)|
|Benefit||Long-term outcome improvement||Short- and long-term outcome improvement|
|Most severe complication||Intracranial hemorrhage, death||Intracranial hemorrhage, death|
|Recanalization||Up to 60%||Up to 60%|
|Risk||6.5% intracranial hemorrhage||< 2% intracranial hemorrhage|
11.0 Nervous System Disorders
11.1.1 Subarachnoid hemorrhage
220.127.116.11 Cerebral aneurysm
18.104.22.168 Arteriovenous malformation
11.1.2 Intracerebral hemorrhage
11.1.3 Ischemic stroke
11.1.4 Transient ischemic attack
Pathophysiological Education -- The Why
1. Natural history of stroke
a. Time factors in neuronal death
2. Patient identification
3. Thrombolysis in stroke
a. Differences from coronary
c. Potential benefit
4. Other acute interventional treatments
5. Computerized tomography interpretation
a. Subtle findings and impact on therapeutic decision-making
6. Blood pressure requirements
a. Impact on complications and outcome
b. Acceptable interventions in the stroke patient
7. Outcome modification
Procedural Education -- The How
1. Patient identification
2. Efficient neurological examination
3. Communication protocols
4. Stroke team
5. Essential tests
a. Computerized tomography of head
i. CBC, differential
ii. Electrolytes, BUN, creatinine
iii. Prothrombin and partial thromboplastin times
iv. Pregnancy test if indicated
c. Chest radiograph
6. Desirable imaging
a. Cardiac ultrasound for effusion
b. Abdominal ultrasound for aortic aneurysm
7. Monitoring requirements, type and frequency
b. Neurological reassessment
8. Quality assurance
a. Time standards
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National Institute of Neurological Disorders and Stroke
National Institutes of Health
Bethesda, MD 20892
Last Modified May 17, 2011