Acute Stroke Management Using Acute Stroke Management Using HANDi Stroke Rx: A Palm-based HANDi Stroke Rx: A Palm-based

Education and Treatment AidEducation and Treatment Aid

Kevin Baumlin, MD, FACEP

Jason Shapiro, MD, and Michael Bessette, MD

Mount Sinai School of Medicine

Department of Emergency Medicine

IntroductionIntroduction

• 1%-2% of all ED charts from acute stroke patients have a documented NIHSS

• Using NIHSS as a measure allows Neurologists and EP’s to follow stroke severity

• Handi Stroke Rx is a palm-based handheld computer program designed to assist clinicians in their management of acute ischemic stroke patients. The public release version is available for free from the FERNE website at www.ferne.org

Why the NIHSS?Why the NIHSS?

• NINDS NIHSS Severity: median score = 14• NIHSS: 42 point scale, 11 categories• Mild facial paralysis: NIHSS = 1• Complete r hemiplegia with aphasia, gaze

deviation, visual field deficit, dysarthria, sensory loss: NIHSS = 25

• NIHSS severity is critical to pt selection

Primary Objective:

To create an easy to use clinical assessment and educational tool for emergency department evaluation of acute ischemic stroke patients. The tool includes:

1) A National Institutes of Health Stroke Scale Calculator (NIHSS)

2) An interactive checklist of inclusion and exclusion criteria

3) A r-TPA dose calculator

4) Reference materials such as sets of sample orders, a list of sequence of events in management of these patients, and suggestions for documentation of consent and

management of hypertension and intracerebral hemorrhage.

ObjectiveObjective

ObjectiveObjective

Secondary Objective:

• To develop this tool on a forms/database platform for use as a data collection tool in future clinical studies. The goal of this objective is to have data literally streaming from the point of care through data base software and statistical analysis software, leaving little or no room for human error.

MethodsMethods

• Satellite Forms version 4.1 from Puma Technology was chosen as the design platform for this project.. Advantages of this platform included:

– A WYSIWIG (What You See Is What You Get) PC environment for handheld forms creation.

– Ability to add large amounts of content and powerful functionality using visual basic scripting and embedded third-party extensions.

– Pumatech's Enterprise Intellisync® Server software which allows data to be synced over the internet from each user to a server-based database program.

DescriptionDescription

• The program is set up in a linear fashion allowing users to go sequentially through an NIHSS calculator followed by inclusion criteria, absolute contraindications and relative warnings for rt-PA therapy, followed by an rt-PA dose calculator based on patient weight.

DescriptionDescription

• Alternatively the user can chose the “Jump” buttons located throughout the program to use individual components of the program

from a table of contents or “Jump” menu.

DescriptionDescription

• The NIHSS portion of the program includes the standard 11 questions with full explanations available by tapping the “i” in the upper right hand corner of each screen. Standard NIHSS images are included in-line and a final score reporting screen with a scale relating risk of symptomatic intracranial hemorrhage to NIHSS score is included at the end.

NIHSSNIHSS

NIHSSNIHSS

NIHSSNIHSS

NIHSSNIHSS

NIHSSNIHSS

NIHSSNIHSS

Inclusion Criteria and Inclusion Criteria and ContraindicationsContraindications

• The inclusion criteria, absolute contraindications and relative warnings are set up as interactive check boxes.

tPa Dose CalculatortPa Dose Calculator

• The rt-PA dose calculator includes a simple input of the patients weight in kg, and a second screen that gives both bolus and infusion doses.

Sequence of EventsSequence of Events

This section allows users to be reminded of the appropriate protocol for treatment

Sample OrdersSample Orders

Management of ICHManagement of ICH

Blood Pressure ControlBlood Pressure Control

Current ProgressCurrent Progress

• The primary objectives have all been reached and we are currently in the process of developing the program for use in data collection in order to satisfy our secondary objective. Specifically we are retooling the program to gather important patient information such as laboratory and CT findings, as well as working on the back-end database and conduit to allow direct syncing of data from end users. Additionally we are planning a validation study comparing the use of this new handheld NIHSS with traditional paper and pencil.

ConclusionConclusion

• HandiStroke is a palm based stroke education and treatment aid. This free application will be an effective tool for clinicians in their management of acute ischemic stroke in the emergency department and in stroke units. It should facilitate further understanding of the current guidelines for management of the acute stroke patient.

Case OneCase One

• 44 yo Male h/o HTN, BIBEMS at 2:00pm post notification, for acute change in his ability to speak. EMS reports CSS = 3

• According to his co-workers he was talking on the phone at 1:15 when a colleague noticed slurred speech.

• Pt. Arrived. Code Stroke was called and the patient was immediately evaluated, labs were sent and CT was performed at 2:35.

Case One (cont.)Case One (cont.)

• BP 195/120, HR67, RR14, Temp 37

• Medications: aspirin qd, HCTZ (? Taking)

• On examination the patient was alert but had difficulty with speech. He was able to say “okay” “yes” and appeared frustrated with being unable to communicate. He had a partial right facial droop. Exam also revealed a pronator drift on the right with normal strength. .

• NIHSS was performed using HandiStroke demo

ResultsResults

• NIHSS = 9 (1b:2, 4:2,5a:1,9:2,10:2)

• Lab and EKG were within normal limits

• CT: ....

CT ScanCT Scan

• Image….

TreatmentTreatment

• Labatelol 10 mg IV was given ─ (see HTN guidelines)

• t-PA-- ─ Demo bolus and drip

tPa Dose CalculatortPa Dose Calculator

• The rt-PA dose calculator includes a simple input of the patients weight in kg, and a second screen that gives both bolus and infusion doses.

OutcomeOutcome

• Follow up– His aphasia and right hemi improved by

day 3. Carotid duplex showed no stenosis.

– The patient was discharged on Clopidogrel. (Plavix)

• Three months later he was back to work… – As a paramedic

DiscussionDiscussion

• Giving tPA to a patient on Aspirin is okay.– The protocol prohibits the use of aspirin AFTER

thrombolytics for 24hours..

– The original NINDS trial 1/3 of the patients had taken aspirin prior to stroke; no harmful interaction was noted.

• If stroke scale was 5-6 would you still have thrombolysed?– Yes. It depends on what the deficit is. If the deficit was

speech alone tPa would still be considered.