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The Resus Room

Stroke Management; Roadside to Resus

The Resus Room

Simon Laing

Science, Emergencymedicine, Medicine, Health & Fitness, Em, Ae

4.8678 Ratings

🗓️ 15 August 2019

⏱️ 56 minutes

🧾️ Download transcript

Summary

Following on from our previous Roadside to Resus episode on Stroke, in this episode we look at the rapidly evolving area of stroke management. 

In the last 2 decades stroke management has progressed beyond recognition and keeping up with the evidence and available therapies is a significant challenge. We cover the following treatments, looking at the risks and benefits of each, with the goal of being able to offer our patients the best possible outcomes;

  • Aspirin
  • Thrombolysis; both prehospitally and in hospital
  • Thrombectomy
  • Decompressive Hemicraniectomy
  • Normoxia
  • Euglycaemia
  • Acute blood pressure management

As always we’d love to hear any thoughts or comments you have on the website and via twitter.

Enjoy!

SimonRob & James

References

Tissue plasminogen activator for acute ischemic stroke. National Institute of Neurological Disorders and Stroke rt-PA.Stroke Study Group. N Engl J Med. 1995 

Aspirin in Stroke;NNT

Stroke Thrombolysis; Life in The Fast Lane

Effects of Prehospital Thrombolysis in Stroke Patients With Prestroke Dependency. Nolte CH. Stroke. 2018

Effect of the use of ambulance based thrombolysis on time to thrombolysis in acute ischemic stroke: a randomized clinical trial. Ebinger M. JAMA. 2014

Indications for thrombectomy in acute ischemic stroke from emergent large vessel occlusion (ELVO): report of the SNIS Standards and Guidelines Committee. Mokin M. J Neurointerv Surg. 2019

Revolution in acute ischaemic stroke care: a practical guide to mechanical thrombectomy. Evans MRB. Pract Neurol. 2017

Extend; The Bottom Line

Stroke and transient ischaemic attack in over 16s: diagnosis and initial management. NICE guideline.Published: 1 May 2019

MR CLEAN, a multicenter randomized clinical trial of endovascular treatment for acute ischemic stroke in the Netherlands: study protocol for a randomized controlled trial.Fransen PS. Trials. 2014

A multicenter, randomized, controlled study to investigate EXtending the time for Thrombolysis in Emergency Neurological Deficits with Intra-Arterial therapy (EXTEND-IA).Campbell BC. Int J Stroke. 2014

Stent-Retriever Thrombectomy after Intravenous t-PA vs. t-PA Alone in Stroke. Jeffrey L. Saver. NEJM. 2015 

Thrombectomy for Stroke at 6 to 16 Hours with Selection by Perfusion Imaging.Gregory W. Albers. NEJM. 2018

Thrombectomy 6 to 24 Hours after Stroke with a Mismatch between Deficit and Infarct.Raul G. Nogueira.NEJM. 2018

Transcript

Click on a timestamp to play from that location

0:00.0

Welcome to the Recess Room podcast.

0:03.2

Five, four, three, two, one, fire.

0:11.3

So hi, and welcome back to the Reeser Room podcast.

0:15.0

I'm Simon Lang.

0:16.4

I'm Rob Penwick.

0:17.4

And I'm still James Yates.

0:18.7

And we're back with the second half of stroke. And this

0:22.8

time the really important part and sometimes difficult to get your head around part of stroke

0:29.0

management. Yes indeed. So we've gone over how we're actually going to identify that on the previous

0:33.3

podcast. So identify these patients who are at risk or potentially having a stroke or TIA.

0:38.4

And now it's on to the bit that really matters, I guess, is what are we actually going to do

0:42.5

for them.

0:43.3

So before we get into it, a big thanks to our partners, S.J. Trem, the Scandinavian Journal of

0:47.9

Trauma, Resuscitation and Emergency Medicine.

0:50.9

They are a free, open access, online journal that cover all the sorts of articles that we

0:56.0

cover here in the podcast. So go over and have a look on the hyperlink on our website to the

1:01.2

fantastic articles that they're publishing. So without further ado, let's get on with the podcast.

1:09.1

So just to recap, our previous podcast we talked about identification of stroke and the fact that a really good history and examination and set of investigations is going to get us to a point where hopefully we've dismissed the differentials of these stroke mimics and we've got to a point of being convinced that the patient in front of us has got a stroke.

1:32.3

But there is that unnerving fact that we don't have a test that's necessarily going to confirm that fact 100%.

1:40.7

Now, the really exciting thing about stroke management is that it has really evolved over the last few decades.

1:48.5

And it isn't much of a stretch of the imagination to remember back in the day when those patients that presented with a stroke were essentially put on to a ward, had some imaging, had a confirmed stroke a few days down the line, and then started

2:02.5

to get their aspirin and started to get their rehab. But delighted to say that the management

...

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