New Stroke Guidelines Stress Treatment Within One Hour of Arrival in ER
Calling 911, going to a stroke center, getting care quickly combine to improve outcomes, experts say
Thursday, January 31, 2013
"We have incorporated a lot of learning and experience in the past five years in developing stroke systems of care," said guideline author Dr. Edward Jauch, director of the division of emergency medicine at the Medical University of South Carolina, in Charleston.
"It's not just a single person managing a stroke that makes a difference. It's creating a process that involves patients, people around patients, pre-hospital care and hospitals," he said. "When all these pieces are in place, the patient has the best chance for having a good outcome."
The new guidelines, from the American Stroke Association, were published online Jan. 31 and will appear in the March print issue of the journal Stroke.
The most common type of stroke, called an ischemic stroke, is caused by a blood clot in an artery in the brain. Ischemic strokes account for 90 percent of all strokes.
Once doctors determine that a patient is suffering a stroke, treatment usually begins with a brain scan to find the clot. A drug called tissue plasminogen activator (tPA) is then injected to break up the clot. To be most effective, tPA needs to be given within four and a half hours of the first appearance of symptoms, the experts said.
To get treatment within this narrow window of time, the new guidelines stress calling 911 and getting to the hospital by ambulance. Not only is an ambulance faster, but it also allows emergency-room doctors to prepare for the patient's arrival.
"If you arrive at a hospital by [ambulance], you get treated very differently than if you arrive in our lobby," Jauch said. Patients see a doctor faster, get a CT scan faster and get treated faster with treatments that are time-dependent, he explained.
"And you are more likely to go to the right hospital," he added, such as one with a stroke center.
Stroke centers offer specialized treatment for all types of stroke. In some cases, a patient will be taken to a comprehensive stroke center, which can provide even greater levels of care.
Advanced care may include using so-called stent retrievers, which are catheters that are threaded through the affected brain artery that expand the vessel, snag the clot and remove it. This is faster than tPA, but works only on the largest clots, Jauch explained.
When a hospital that specializes in stroke isn't nearby, patients can be treated in a community hospital under direction from a stroke expert via telemedicine, Jauch said. After initial treatment, a decision on whether to transfer the patient to a stroke center can be made, he said.
The guidelines also call for continued quality improvement through hospital committees that review and monitor stroke care.
"Time is brain," said Dr. Roger Bonomo, a neurologist at Lenox Hill Hospital in New York City.
People who need tPA aren't getting it because they get to the hospital too late for it to be used, he said. "Not enough people are calling 911 when they are having symptoms of a stroke," he added.
An easy way to remember the sudden signs of a stroke is the acronym F.A.S.T.:
- Face drooping: Does one side of the face droop or is it numb?
- Arm weakness: Is one arm weak or numb?
- Speech difficulty: Is speech slurred, are you unable to speak or are you hard to understand?
- Time to call 911: If you have any of these symptoms -- even if they go away -- call 911 and get to the hospital immediately.