EM and Stroke

[IMGforNeuro]

hi guys ,
I am new to the EM forum.
I wanted to know the role of EM residents and physicians in a case of acute stroke ischemic as well as hemorrhagic.
All of us docs know about the theoritical aspects of management.
I want to know about what happens when a suspected case of acute stroke arrives in the ER , what an EM physician does and when the stroke team ( neurologist and neuroradiologist ) takes over?
I intend to specialise in neurology and then in Stroke and Critical Care. I have been a resident in neurosurgery for some time.
I know the aspects of stroke management in the realm of neuro.
But i want to know the role of EM ( they are ER experts ) untill the stroke team takes over.
I wanted to know the experiences of all the EM physicians , residents and med students interested in EM about the extent to which they manage or have observed (med students) stroke untill the stroke team takes over.

---

Members don't see this ad.

 

[EMT036]

At the hospital I worked, the EDMD did all the initial management... i.e. initial assesment, ordering of CT/labs, and initial therapy (TPA, etc.) The neurosurgeon usually stepped in at this point to take over contininuing care... (which in one case was to drill burr holes in the ED, since all the OR were booked...)

 

[Seaglass]

Yeah, I would say it's very institution dependant. FWIW I think it would be reasonable to say that EP's do the diagnosis and any imaging with an eye on the clock, and attempt to see if thrombolytics are indicated which, despite Newsweek's best efforts to convinve us otherwise, they usually aren't. If they are indicated then, at smaller hospitals, the EP gives them and arranges for a transfer if necessary, at larger centers the stroke team may be called to adminisiter and manage TPA sequelae.

These, of course, are just my observations based on the few ED's I have worked in.

C

 

[Scrubbs]

At our hospital, we (the ED) do the initial assessment, order labs, stat CT, etc. If the story is good and the timeframe is right, I call Neuro pretty much immediately (after I talk to the patient but before everything else gets done). We usually make the decision on TPA together. Of course, smaller community hospitals don't necessarily have in-house Neuro residents at their fingertips, so the ED usually manages/makes decisions and then works out the admission details. Very environment dependent I would think...

 

[sweetfynesse]

At my medical school with had a stroke team that was assembled as soon as a suspected stroke was high in the differential, and they basically took over the case from there.

At my residency, however, we manage the stroke paient when they walk, or rather are wheeled, into the ER, ie CT, labs, ekg, meds. If however, they are in time window for lytics then we go ahead and call the sstoke team immedicately of hearing the story, place IV, take labs, and the stoke attending or one of our residents accompanies the pt to CT while lytics are being prepared, and if they meet guidelines, they get lytics literally while they're in CT or on their way back to CT. Just last week, I had a patient with acute right sided paralysis, and left eye deviation of 2 hours 20 mins duration, the stroke attending was called during initial evaluation-we all made the decision to push lytics and she got ekg, iv access, labs sent,neg ct, and lytics started in 28 minutes total. It was great. And it would have been even faster if we had CT available in the ED.

 

[IMGforNeuro]

Thanks guys.
I do understand that time is a very critical factor in acute stroke.
Do EM physicians continue to manage the patient after admission or it is eventually referred to the stroke neurologist. Secondly, once the stroke team arrives , do EM physicians let them immediately take over ? Basically i wanted to know when the job of EM expert ends and that of the neurologist (actually the stroke team) begins.
Is it that the neuro team takes over as soon as they reach meanwhile the EM physicians do the initial management?

 

[Seaglass]

generally speaking EP's have nothing to do with inpt. management once the patient is out of the ER. Exceptions would be EP's with critical care training who do shifts in the ICU. In my experience the TPA decision is mostly the pt's and the neurologists. Once the stroke team is involved the EP typically manages any other significant medical problems that may be involved and leaves the stroke care to the stroke team. This has been my experience at primarily large university programs, but that first bit applies pretty much to all EP's working in places where immediate IM/Neuro consult is available. The exception might be small country hospitals, and in that situation you are likely to be arranging for transfer to a facility with neuro/neurosurg if appropriate.

C

 

[DrQuinn]

At our program, EMS gives us a "stroke alert" if they meet the Cincinatti criteria...
we fill out a "stroke alert" package, do the H&P, send them up for CT, and give thrombolytics if indicated. The neurologist on "stroke call" will usually show up 1-2 hours after the inital arrival, unless they're in house.

Q, DO

 

[Apollyon]

We call a "stroke code" - there's the emergency 3 digit number (not 911) in-house, which gets the operator, who sends out the pages that get: neuro resident, neuro attending (if in-house), neurosurg resident, and priority on the CT scanner (ie, can go from ED to back in less than 10 minutes), and goes from there.

 

[beyond all hope]

Unfortunately, our population sits on strokes until they're older than 3 hours. Actually, 8 hours is the window for IR to remove clots, but we don't have that around here.

So they come in, we scan them, find a ischemic stroke, call neuro, give ASA/Plavix, and wait for complications. If we find a hemorrhagic stroke we call neurosurg, no ASA/Plavix. Usually nothing to do.

They often sit in our crit area for days upon a time, waiting for a neuro ICU bed, and start to develop ICP, bleed/rebleed, code, etc. I've even seen one herniate right in front of me. (one side started to stiffen up in the UMN pattern, and I watched his pupil dilate in a matter of 1-2 minutes. Scary. Chickensh*t attending wouldn't intubate/hyperventillate)