1. Prof. Dr / Atef Radwan The dean of the faculty of medicine zagazig unversityProf. Dr / Hanan Abdel Azim Professor at the Neurology departmentDr / Hala Hafez MD of neurologyDr/ Ahmed Abdul Sabour ALS instructor at the ERC & head of DMTCDr/ Shaimaa El-AidyResident doctor at the neurology department

2. Case 1 at the ER55 years old male with severe headache & slurred speech .What is your attitude as a house officer ? 3. Case 2Your Grandfather 65 years old male with history ofDM & Hypertension suffered sudden weakness inhis right arm & leg with mouth deviation-Will you give him Asprin ? No-What if symptoms relieved in 10 mins ?Its A TIA R/ Asprin 75 mg 1x2-What to do next ? Call EMS 123 4. Chain of Survival 5. When to suspect stroke ?1. Sudden numbness or weakness of the face, arm or leg (especially on one side of the body)2. Sudden confusion, trouble speaking or understanding speech3. Sudden trouble seeing in one or both eyes4. Sudden trouble walking, dizziness, loss of balance or coordination5. Sudden severe headache with no known causeACLS guidelines 2012 6. Pre-hospital EMS actionsSupport ABCs ( BLS )Pre-hospital Stroke assessment 3 orders ( Cincinnati Pre- Hospital Stroke scale )Ask the patient to1. Smile +/- deviation in one / both sides2. Close his eyes and both arms straight with palms up 10 seconds +/- Hand drift one / both sides3. Tell you the time or place or ( you cant teach an old dog new tricks ) Slurred speechTime Zero ?Alert the nearest hospital with stroke teamACLS guidelines 2012Check glucose ( If possible ) 7. Time zero : Def: Its The time when the patient is last seen normal Its important for thrombolytic therapy administration decision If > 8 hs or not identified absolute contraindication for r-TPAACLS guidelines 2012 8. ACLS guidelines 2012 9. Time Is brainACLS guidelines 2012 10. Our TimelineACLS guidelines 2012 11. In 10 minutesACLS guidelines 2012 12. In 10 minutesAirway - Check airway if needed ( Head tilt / Chin left or Jaw thrust ) - Clear the air way If obstructed and choose a suitable airway **ACLS guidelines 2012 13. In 10 minutesBreathing- Check for breathing ( Look , Listen & feel and count to 10) - Auscultate and Percuss the Chest / Tidal volume / equality - Apply pulse oximeter .. Oxygen for O2 Saturation < 92 %Circulation- Vital signs - IV lineACLS guidelines 2012 14. If No Pulse / No breath Start resuscitation Algorithm 15. In 10 minutesDisabilty- Neurological scoring - Lab (CBC , RBS , ABG , -- PT , PTT , INR -- , Cardiac enzymes )NB : Cardiac enzymes for suspected MI patients only . - R/ Thiamine 100 mg IV - Order CT& Call Acute stroke team / Neurologist - ECG for arrhythmias or acute MI ( Shouldnt delay Urgent CT ) - General examination ( pupil & signs of meningeal irritation)ACLS guidelines 2012 16. ** Pupil examination ( Light reflex )Pin point / sluggish reaction Pontine hemorrhage .. ( Do urgent CT )Intial dilatation + loss of light reactivity Trans-tentorial herniation** Signs of meningeal irritation1. Exam: Nuchal Rigidity2. Exam: Spinal Rigidity3. Exam: Kernigs Signs4. Exam: Brudzinskis Sign 17. In 25 minutes* Rapid History Taking* Determine Time Zero* Neurological Examination NIHSS* Do the head CTACLS guidelines 2012 18. Dont GiveAspirin / Heparin / Iv thrombolytic therapy Unless after reading CTACLS guidelines 2012 19. In 45 minutesRead CTTake decision according to CT result & Time ZeroACLS guidelines 2012 20. Decision Taking according to CT readingCheck for Hemorrhage Yes No Call a Neurologist Recanalisation Candidate ? Stable Patient ? - Check exclusion criteria- Rapid neurological reassessment Yes No Still candidate ?NoYesR/ Asprin ( 1x2 ) up to 325 mg/d Ward admissionCall Acute Stroke teamACLS guidelines 2012 ICU admissionThrombolytic therapy 21. 1 - AVPU score 2 - Glascow ( Total score = ... /15 ) 3 - NIHSS ( Total score = ... /42 ) - Modified NIHSS ( Total score = ... /31 )OXFORD neurology 2011 22. National Institutes of Health Stroke Scale Used for :-1- Thrombolytic therapy decision making2- Prognosis of strokeOXFORD neurology 2011 23. Level of conciousness LOC ** 3LOC questions2LOC Commands 2Best Gaze2Visual field 2Facial palsy **3Motor arm Rt. & lt.4+4Motor Leg Rt. & lt.4+4Limb Ataxia ** 2Sensory2Intinction & Extinction ** 2Language 3Dysarthria 3Total NIHSS42Total modifed NIHSS31 24. Penumbra :- Area at risk 25. ( Start within 1 hour from arrival to ED ) General ComplicationSupportive CareNeurological Reversal ofdetection & monitoringcoagulopathy&Palliative care management 26. General supportive care & palliative care : (A)(B)(C)1-Oxygenation1- Cardiac monitoring1- Head positioning2- Blood pressure1st 24 hours ( Elevated at 20-30 )( See BP control ) 2- Swallowing assessment 2- Body positioning3-Temperature(for nasogastric tube3- DVT prophylaxis( See Fever control )application & oral drug* Elastic stocking4-Blood glucoseadministration ) * Raise the legs( Measure 1x 4 x 3 & 3-Drugs* UFLMWH 5000 1x2control with Insulin ) * Anti-platelet After 48 hs.5- Hydration *Anticoagulant 4-Bowel & bladder care *NSAID 5-Skin Integrity6- Lab *Lipid lowering drugsInspect skin sacrum, heels, *Vitaminselbows, shoulders for 4- Treatment of otherpressure sores regularly co-morbidities 27. ( Start within 1 hour from arrival to ED ) General ComplicationSupportive CareNeurological Reversal ofdetection & monitoringcoagulopathy&Palliative care management 28. 1- Continuous scoring2- Increased intracranial tension ?? 29. 1- Glasgow Coma Scale (GCS)- Hourly for the first 24 hours- 2-4 hourly for next 48 hours if stableA decrease in GCS of 2 points from baseline Neurological decline ( urgent medical assessment is required )* GCS 8 is predictive of impending cardiorespiratory arrestOR NIHSS score from 42Score :->4 points increase in the score deteriorationOR Modified NIHSS score from 31Score :-< 12 Good prognosis12 Poor prognosis 30. 2- Increased intracranial pressure * Signs:-- Reduced consciousness- Headache , nausea , projectile vomiting- Visual disturbance- Seizures-Sudden increase in blood pressure* Treatment :-- Exclude ICH by CT- R/ Mannitol (0.25-1 gm/kg)- Lumber puncture for decompression- Hemi-Craniotomy 31. ( Start within 1 hour from arrival to ED ) General ComplicationSupportive CareNeurological Reversal ofdetection & monitoringcoagulopathy&Palliative care management 32. 1- Correct coagulopathy ( guided by PT , PTT , INR ) Treatment :- Platelets & Cryo precipitate2- Recanalisation therapy 33. ( Start within 1 hour from arrival to ED ) General ComplicationSupportive CareNeurological Reversal ofdetection & monitoringcoagulopathy&Palliative care management 34. 1- Seizures2- Increased intracranial pressure3- Complication of r-TPA & management : Intracranial hemorrhage Angiodema4- Venous thrombo-embolism ( ttt : IVC filter ) 35. 1. Ophthalmoscope2. Thrombolytic therapy3. Stroke suspecting culture ( 3 orders )4. NIHSS quick application in 25 mins from arrival5. Lab Facility in 10 mins 36. - ACLS 2012 guidelines- www.emedicine.com- Oxford press ( Neurology emergencies ) text book- http://www.fpnotebook.com/neuro/exam- www.pubmed.com- Egyptian ministry of health protocols 2012