Mastering Stroke Codes
ฝัง
- เผยแพร่เมื่อ 28 มิ.ย. 2024
- TITLE: Mastering Stroke Codes
PROTOCOL: drive.google.com/file/d/1K9_r...
00:00 - Intro
01:43 - Activating a stroke code
02:02 - Gathering important data
02:52 - Initial stabilization
04:59 - Rapid neurological evaluation
06:48 - Addressing intracranial pressure crisis
08:01 - Basic imaging
09:31 - Review: The 7 "esses" of the stroke code
10:15 - Early management of intracranial hemorrhage
11:24 - Management of acute ischemic stroke
11:58 - Large vessel occlusion with disabling deficits
24:08 - Review
25:38 - Large vessel occlusion, non-disabling deficits
27:53 - Absent large vessel occlusion, disabling deficits
30:36 - Brief review
30:52 - Absent large vessel occlusion, non-disabling deficits
32:45 - PRACTICE
32:53 - Case 1
34:43 - Case 2
37:07 - Case 3
42:40 - Case 4
This video is intended for residents and fellows to understand the stroke code process and management of patients with acute ischemic stroke, with a specific focus on selecting patients for acute stroke interventions.
Created, produced, and narrated by:
Igor Rybinnik MD
Neurology Clerkship Director
Rutgers Robert Wood Johnson Medical School
Content experts:
Bhavika Kakadia MD,
Raymond Mirasol MD,
Deviyani Mehta MD,
Kiwon Lee MD
Division of Stroke and Neurocritical Care
Department of Neurology
Rutgers Robert Wood Johnson Medical School
Adam Ganzman, MSN, RN, APN-BC
Kimberly Hollender, MSN, RN, APN-BC
Joint Commission Certified Comprehensive Stroke Center
AHA Get With the Guidelines Stroke Gold Plus with Target: Stroke Honor Roll Elite
Robert Wood Johnson University Hospital
RWJBarnabus Health
References:
1. Huo X, ANGEL-ASPECT investigators, et al. N Engl J Med 2023; 388:1272-1283
2. Chen HS, SELECT2 investigators, et al. N Engl J Med 2023; 388:1259-1271
3. Albers GW, DEFUSE 3 investigators, et al. NEJM 2018; 378:708-718
4. Olthuis SGH, MR CLEAN-LATE investigators, et al. Lancet 2023; 401(10385):1371-80
5. Khatri P, PRISMS investigators, et al. JAMA 2018;320(2):156-166
6. Chen HS, ARAMIS investigators, et al. JAMA 2023;329(24):2135-2144
7. Kappelhof M, IRIS collaborator, et al. Presented at ISC 2023.
8. Nomani AZ, et al. Neurology 2021, 97:e2079-87.
9. Sarraj A, et al. Stroke 2021, 52(1):57-69
10. Menon BK, et al. J NeuroIntervent Surg 2019;11:1065-1069.
11. Goyal M, HERMES collaborators, et al. Lancet 2016; 387: 1723-31
12. Ma H, EXTEND Investigator, et al. NEJM 2019;380(19):1795-1803
13. Hacke W, ECASS Investigators, et al. N Engl J Med 2008; 359:1317-1329
14. Thomalla G, WAKE-UP Investigators, et al. N Engl J Med 2018; 379:611-622
15. Nouh A, et al. Stroke. 2022;53:e165-e175.
16. Berge E, et al. European Stroke Journal 2021, Vol. 6(1) I-LXII
17. Powers WJ, et al. Stroke. 2019;50:e344-e418.
Images adapted from:
- Kandel ER, et al. Principles of Neural Science 5th Edition. McGraw Hill, 2012
- Blumenfeld H. Neuroanatomy Through Clinical Cases, 2nd ed. Sinauer, 2010.
- Adobe Creative Cloud
Music:
- Hot & Cold · Haxhigeaszy
Disclaimer: Please note that this material was simplified for educational purposes. For patient management, please review your clinical society's guidelines and engage expert consultation where appropriate. Also, the opinions of the presenters do not necessarily reflect those of Rutgers Robert Wood Johnson Medical School, Robert Wood Johnson University Hospital, RWJBarnabus Health, or Rutgers University as a whole.
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It's hard to express how privileged we are to have access to such information presented so beautifully. Increadible work! Thank you!
Wow. Thank you! It’s my pleasure.
Wonderful, I love to learn from all of your presentations ....
Thanks a million
Please never stop making videos! These are the best thing I've ever seen
god bless the light sense of humor that shows up in these
Thank you so much for continuing to put out such high quality content. I have immensely appreciated your channel as I train.
My pleasure!
Thank you so much. I appreciate that you said from the beginning that there may be differences in the approach between the countries. Thank you for the cases; they help in clinical practice and enforce reason of thinking.😇
I'm so angry; it's been such a long time since I have witnessed such high-quality channel. Thank you so much!
welcome back!! Thanks for another fantastic video
This is the best stroke speaker/presentation I have ever heard. Thank you doctor
Wow! Thank you!
Thank you for your incredibly high quality lectures. Really appreciated and hope you don't stop.
Got a lot of insights from your work as always, greeting from somalia, and thank you
Excellent, really excellent. Thank you so much!
The Rybinnik strikes again--just in time for my second overnight as a freshly minted PGY2. Many thanks for what you do!
Nice! I hope it helps.
As high-quality as usual. Thank you for clearing up my mind when there are so much new evidences coming up which is definitely confusing!
awesome work!
Thank you soooo much for this lecutre! Cant wait for another lecture!
Thank u so much, for such a didactic way to teach neurology. makes me love even more this specialty
I’ve seem a lot of great teachers in my life, BUT you are the best 🎉
Such great and high quality content! Thank you for making these videos.
Anytime, Rebecca. I'm glad that this is useful.
Very interesting !! Thank you so much, we are waiting for more interesting videos
Really appreciate your channel, thank you for the tremendously good work! A great help in residency!!
Our pleasure!
I love your content !
Keep going
A neurohpil morning is an amazing morning 💙
Thanks for the awesome work!
You made my day!
Welcome back!
This was the lecture I didn't know I needed so THANK YOU VERY MUCH - if all my medical school lectures had been like this I could have been House by now XD.
Thank you!
Thank you for the video.
Truly a beautiful presentation.
Thank you so much from libya
Keep posting such fantastic contents
amazing as always
Much appreciated!🥰
gracias por lo que haces en pro de la educación ¡¡
Its a Masterpiece presentation❤
great lectures.
That was awesome!
Thanks for your share!
Great to revisit
Great lectures. May i suggest dementia as a future topic
Absolutely. We are working on it.
Good stuff. Just a minor correction. BP goal before administering TNK or TPA is
Thank you. Unfortunately the package inserts for TNK and ALT differ. The BP goal here is from the TNK’s package insert.
Thank you for the wonderful lecturer and quiz!! would like to ask, for case 3, shouldn't we start with thrombolysis at the first place as gait ataxia is consider disabling?
Ataxia is absolutely disabling. In case 3, I mentioned that the patient’s ataxia has resolved upon arrival to the emergency department and he only had vague sensory symptoms, which were not disabling. That’s the reason we proceeded to DAPT instead of TNK.
Dr Rybinnik, is there a possibility of you sharing the chart as a separate image? Thank you regardless for the amazing video as always
Sure. I put the link to the protocol in the video description
great
Thank you for yet again a great video! Such concise and useful information, now with recent studies to back it up! Question: case 2 had right field cut, but this is not common for right MCA stroke. Did she also have cardiogenic embolus in her left PCA?
Thank you for that very important question. Let me clarify. Field cut with MCA strokes is very very common. MCA supplies temporal and parietal optic radiations. In fact, since MCA strokes are much more common than PCA strokes, if you see a field cut (especially with other symptoms) you are likely dealing with MCA and not PCA. Take a look at our video on vascular territories: th-cam.com/video/5enB58kndj4/w-d-xo.html
Thank you for quick reply. I am aware field cut is a MCA stroke symptom. My question was regarding the side of field cut. Why did case 2 have right side field cut with right MCA stroke, but case 4 had left side field cut with right MCA stroke?
Oh. That might have been a typo. Thank you for catching that. I apologize. It should have been a field cut contralateral to the MCa lesion as expected.
Can you make a video for approach to neuropathy
Love your videos. Is the contraindication for thrombolytics a DOAC within 24 hrs or is it within 48 hrs? I have seen both
Thank you! After 24 hours (missing two doses of a DOAC), the level of anticoagulant is quite low. As long as, coags are normal, thrombolytic may be considered. If coags are not available, the safer time period is 48 hours.
Ok thanks for the clarification! Also when you say coags when talking about DOACs do you mean PT/PTT/INR or do you mean anti-Xa?@@theneurophile
Excellent. Thank you so much!
I'll be waiting for brain tumors.
A hugest amount of work offered to us for free. Thank you ❤ by an Italian emergency MD.
Why is rivaroxaban not included in the initial workup 2:31 circa?
Thank you! Sorry, I totally forgot about rivaroxaban (I mention it later). Yes, you should also ask about Rivaroxaban.
The European Stroke Organisation recommends IV tPA in the 4.5-9 hour window for patients triaged by advanced imaging even if endovascular treatment is not planned or indicated given a core of less than 70 mL, a mismatch of at least 1.2 and at least 10 mL. What is your opinion on this?
-Neuro PGY1 from Belgium
Yes you are correct. We are routinely treating patients with IV TNK within 9 hours of symptom discovery (or midpoint of sleep) as long as patients present within 4.5 hour from symptom discovery and a core is =1.2x (at least 10cc). However, in patients without a large vessel occlusion, we tend to skip CTP in favor of MRI (FLAIR/DWI mismatch) to select patients for TNK because CTP does not have a great resolution for small cortical or subcortical strokes.
@@theneurophile I understand, but my reading of Dutch guidelines and ESO seems to indicate that IVTL is also employed >4.5h of symptom discovery in known-onset, non-wakeup Strokes (e.g. AIS begins at 08:00 AM, IVTL at 16:00 PM). I suppose this is a European thing, and will be double-checking with my attendings. Thanks for the response!
@damiensegers3555 Unfortunately TIMELESS trial was negative, and that was supposed to establish TNK in the 6-24 hour window. So while we can make the argument that in patients with unknown symptom onset and favorable imaging, TNK may be beneficial, when symptom onset/symptom discovery time is known, we have to stick to the 4.5 hour window from that time.
@@theneurophile thank you very much for your time!
Very good. Can i have a downloadable version of flow chart?
Sure. Link is in the video description.
Is BP should be
The TNK package insert lists
Thank you. Perfect. DOAC within 24 or 48 hours in your center?
@@theneurophile thank you. I meant doac in the last 24 hour is a contraindication or 48 h? In video you said 24 but in our center it is 48 h
Oh you mean for TNK? 24 hours off drug with normal coags should be safe for TNK. ASA/AHA guidelines recommend 48 hours.@@mb5101
do you check anti-Xa in your center if patient is on eliquis?
Yes, we do. However, it takes a while to come back.
22:16 Deffuse 3 with core infract
Yep. When I said “any core infarct,” I was referring to SELECT 2 and ANGEL ASPECT trials.
movies?