《心肺复苏指南》参考资料（英文版）Part 9：Adult Stroke.pdf

Part 9: Adult stroke E ach year in the United States about 700 000 people of all Stroke Recognition and EMS Care ages suffer a new or repeat stroke. Approximately 158 000 of these people will die, making stroke the third Stroke Warning Signs eading cause of death in the United States . Many advances important because fibrinolytic treatment must be provided itation 3.4 For example, fibrinolytic therapy can limit the within a few hours of onset of symptoms.5. 12 Most strokes extent of neurologic damage from stroke and improve out- occur at home, and only half of all victims of acute stroke use EMS for transport to the hospital. 3-15 In addition, stroke come, but the time available for treatment is limited.5.b victims often deny or rationalize16 their symptoms. This can Healthcare provider velop systems to increase the efficiency and effectiveness of delay EMs access and treatment and result in increased stroke care 3 The "7 D's of Stroke Care"detection. dis- morbidity and mortality. Even high-risk patients fail to recognize the signs of a stroke. 6 Community and profes- patch, delivery, door(arrival and urgent triage in the emer- sional education is essential, I7 and it has successfully in gency department ED]), data, decision, and drug administra tion--highlight the major steps in diagnosis and treatment lytic therapy.19 creased the proportion of stroke victims treated with fibrino- This chapter sum the management of acute stroke The signs and symptoms of a stroke may be subtle. They in the adult patient. It summarizes out-of-hospital include sudden weakness or numbness of the face, arm, or leg, especially on one side of the body; sudden confusion, about the management of acute ischemic stroke, see the trouble speaking or understanding: sudden trouble seeing in AHA/American Stroke Association(ASA)guidelines for the one or both eyes; sudden trouble walking, dizziness, loss of management of acute ischemic stroke. 9 balance or coordination: or sudden severe headache with no Management goals EMS Dispatch The goal of stroke care is to minimize brain injury and maximize patient recovery. The AHA and AsA developed urrently <10% of patients with acute ischemic stroke are community-oriented"Stroke Chain of Survival"that links ultimately eligible for fibrinolytic therapy because they fail to actions to be taken by patients, family members, and health arrive at the receiving hospital within 3 hours of onset of care providers to maximize stroke recovery. These links are symptoms. 20-24 EMS systems must provide education and training to Rapid recognition and reaction to stroke warning signs minimize delays in prehospital dispatch, assessment, and Rapid emergency medical services(EMS ) dispatch transport. Emergency medical dispatchers must identify po Rapid EMS system transport and hospital prenotification tential stroke victims and provide high-priority dispatch to Rapid diagnosis and treatment in the hospital patients with possible stroke. EMS providers must be able to the initial support cardiopulmonary function, perform rapid stroke as The AHA ECC stroke guidelines focus on the initial sessment, establish time of onset of symptoms (or last time out-of-hospital and ED assessment and management of the the patient was known to be normal), triage and transport the patient with acute stroke as depicted in the algorithm Goals patient, and provide prearrival notification to the receiving for Management of Patients With Suspected Stroke(Figure). hospital(Box 2). 25-22 The time goals of the National Institute of Neurological Disorders and Stroke(NINDS) I are illustrated along the left Stroke assessment Tools side of the algorithm as clocks with a sweep hand depicting EMS providers can identify stroke patients with reasonable the goal in minutes from ED arrival to task completion to sensitivity and specificity, using abbreviated out-of-hospital remind the clinician of the time-sensitive nature of manage- tools such as the Cincinnati Prehospital Stroke Scale ment of acute ischemic stroke (CPSS)7,( Table 1)or the Los Angeles Prehospital The sections below summarize the principles and goals of Stroke Screen(LAPSS)(Table 2). 32.33 The CPSS is based or stroke assessment and management, highlighting key contro- physical examination only. The EMS provider checks for 3 ries, new recommendations, and training issues. The text physical findings: facial droop, arm weakness, and speech refers to the numbered boxes in the algorithm abnormalities. The presence of a single abnormality on the CPSS has a sensitivity of 59% and a specificity of 89% when scored by prehospital providers. 0 The LAPSS requires the (Circulation. 2005: 112: IV-1ll-IV-120) examiner to rule out other causes of altered level of con o 2005 American Heart Association sciousness(eg, history of seizures, hypoglycemia) and ther This special supplement to Circulation is freely available at identify asymmetry in any of 3 examination categories: facial smile or grimace, grip, and arm strength. The LAPSS has a DOI: 10.1161/CIRCULATIONAHA. 105.166562 pecificity of 97% and a sensitivity of 93% IV-IlI

Part 9: Adult Stroke Each year in the United States about 700 000 people of all ages suffer a new or repeat stroke. Approximately 158 000 of these people will die, making stroke the third leading cause of death in the United States.1,2 Many advances have been made in stroke prevention, treatment, and rehabilitation.3,4 For example, fibrinolytic therapy can limit the extent of neurologic damage from stroke and improve outcome, but the time available for treatment is limited.5,6 Healthcare providers, hospitals, and communities must develop systems to increase the efficiency and effectiveness of stroke care.3 The “7 D’s of Stroke Care”— detection, dispatch, delivery, door (arrival and urgent triage in the emergency department [ED]), data, decision, and drug administration— highlight the major steps in diagnosis and treatment and the key points at which delays can occur.7,8 This chapter summarizes the management of acute stroke in the adult patient. It summarizes out-of-hospital care through the first hours of therapy. For additional information about the management of acute ischemic stroke, see the AHA/American Stroke Association (ASA) guidelines for the management of acute ischemic stroke.9,10 Management Goals The goal of stroke care is to minimize brain injury and maximize patient recovery. The AHA and ASA developed a community-oriented “Stroke Chain of Survival” that links actions to be taken by patients, family members, and healthcare providers to maximize stroke recovery. These links are ● Rapid recognition and reaction to stroke warning signs ● Rapid emergency medical services (EMS) dispatch ● Rapid EMS system transport and hospital prenotification ● Rapid diagnosis and treatment in the hospital The AHA ECC stroke guidelines focus on the initial out-of-hospital and ED assessment and management of the patient with acute stroke as depicted in the algorithm Goals for Management of Patients With Suspected Stroke (Figure). The time goals of the National Institute of Neurological Disorders and Stroke (NINDS)11 are illustrated along the left side of the algorithm as clocks with a sweep hand depicting the goal in minutes from ED arrival to task completion to remind the clinician of the time-sensitive nature of management of acute ischemic stroke. The sections below summarize the principles and goals of stroke assessment and management, highlighting key controversies, new recommendations, and training issues. The text refers to the numbered boxes in the algorithm. Stroke Recognition and EMS Care Stroke Warning Signs Identifying clinical signs of possible stroke (Box 1) is important because fibrinolytic treatment must be provided within a few hours of onset of symptoms.5,12 Most strokes occur at home, and only half of all victims of acute stroke use EMS for transport to the hospital.13–15 In addition, stroke victims often deny or rationalize16 their symptoms. This can delay EMS access and treatment and result in increased morbidity and mortality. Even high-risk patients fail to recognize the signs of a stroke.16 Community and professional education is essential,17 and it has successfully increased the proportion of stroke victims treated with fibrinolytic therapy.18,19 The signs and symptoms of a stroke may be subtle. They include sudden weakness or numbness of the face, arm, or leg, especially on one side of the body; sudden confusion, trouble speaking or understanding; sudden trouble seeing in one or both eyes; sudden trouble walking, dizziness, loss of balance or coordination; or sudden severe headache with no known cause. EMS Dispatch Currently 10% of patients with acute ischemic stroke are ultimately eligible for fibrinolytic therapy because they fail to arrive at the receiving hospital within 3 hours of onset of symptoms.20 –24 EMS systems must provide education and training to minimize delays in prehospital dispatch, assessment, and transport. Emergency medical dispatchers must identify potential stroke victims and provide high-priority dispatch to patients with possible stroke. EMS providers must be able to support cardiopulmonary function, perform rapid stroke assessment, establish time of onset of symptoms (or last time the patient was known to be normal), triage and transport the patient, and provide prearrival notification to the receiving hospital (Box 2).25–28 Stroke Assessment Tools EMS providers can identify stroke patients with reasonable sensitivity and specificity, using abbreviated out-of-hospital tools such as the Cincinnati Prehospital Stroke Scale (CPSS)27,29 –31 (Table 1) or the Los Angeles Prehospital Stroke Screen (LAPSS) (Table 2).32,33 The CPSS is based on physical examination only. The EMS provider checks for 3 physical findings: facial droop, arm weakness, and speech abnormalities. The presence of a single abnormality on the CPSS has a sensitivity of 59% and a specificity of 89% when scored by prehospital providers.30 The LAPSS requires the examiner to rule out other causes of altered level of consciousness (eg, history of seizures, hypoglycemia) and then identify asymmetry in any of 3 examination categories: facial smile or grimace, grip, and arm strength. The LAPSS has a specificity of 97% and a sensitivity of 93%.32,33 (Circulation. 2005;112:IV-111-IV-120.) © 2005 American Heart Association. This special supplement to Circulation is freely available at http://www.circulationaha.org DOI: 10.1161/CIRCULATIONAHA.105.166562 IV-111

Part 9: Adult Stroke / V-113 Facial D 1. The Cincinnati Prehospital Stroke Scale providers should support cardiopulmonary function, monitor Droop(have patient show teeth or smile): neurologic status, and if authorized by medical control, check Normahboth sides of face move equally Abnormak-one side of face does not move as well as the other side Patients with acute stroke are at risk for respiratory ompromise from aspiration, upper airway obstruction, hy Left: normal. Right: stroke patient with facial droop(right side of face Kothari R, et al. Acad Emerg Med. 1997; 4: 986-990 poventilation, and (rarely) neurogenic pulmonary edema. The combination of poor perfusion and hypoxemia will exacer bate and extend ischemic brain injury and it has been associated with worse outcome from stroke. 38 Although one small randomized clinical trial (LoE 2)39 of selected stroke patients suggested a transient improvement in clinical deficit and mri abnormalities following 8 hours of high-flow (by face mask ), a laI randomized trial (oe 3) 0 did not show any clinical benefit from routine administration of low-flow (3 L/min)oxygen for 24 hours to all patients with ischemic stroke. In contrast, the administration of supplementary oxygen to the subset of stroke patients who are hypoxemic is indirectly supported by several studies showing improved functional outcomes and survival of stroke patients treated in dedicated stroke units in which higher supplementary oxygen concentrations were Arm Drift(patient closes eyes and holds both arms straight out for 10 used(LOE7).38.394142 Both out-of-hospital and in-hospital medical Normakboth arms move the same or both arms do not move at all should administer supplementary oxygen to hypoxemic (ie, (other findings, such as pronator drift, may be helpful oxygen saturation <92%0) stroke patients( Class I)or those e Abnormakone arm does not move or one arm drifts down compared with unknown oxygen saturation. Clinicians may consider th the other giving oxygen to patients who are not hypoxemic(Class llb) Abnormal Speech(have the patient say"you can't teach an old dog The role of stroke centers and stroke units continues to be new tricks") debated.43 Initial evidence44-50 indicated a favorable benefit from triage of stroke patients directly to designated stroke Abnormal-patient slurs words, uses the wrong words, or is unable to centers(Class IIb), but the concept of routine out-of-hospital speak triage of stroke patients requires more rigorous evaluation. Interpretation: If any 1 of these 3 signs is abnormal, the probability of a Each receiving hospital should define its capability for stroke is 72%% treating patients with acute stroke and should communica this information to the EMS system and the community. With standard training in stroke recognition, paramedics Although not every hospital is capable of organizing the ing patients with stroke. 31,34,35 After training in using a stroke evel ry hospital with an ED should have a written plan assessment tool, paramedic sensitivity for identifying patients describing how patients with acute stroke are to be managed with stroke increased to 86% to 97%(Loe 3 to 5).33.36,37 in that institution. The plan should detail the roles of Therefore, all paramedics and emergency medical healthcare professionals in the care of patients with acute technicians-basic (EMT-basic) should be trained in the rec- stroke and define which patients will be treated with fibrino- ognition of stroke using a validated, abbreviated out-of- lytic therapy at that facility and when transfer to another hospital screening tool, such as the CPSS or the LAPSS hospital with a dedicated stroke unit is appropriate( Class lla) (Class Ila) Multiple randomized clinical trials and meta-analyses Transport and Care year survival rate, functional outcomes, and quality of life Once EMS providers suspect the diagnosis of stroke, they when patients hospitalized with acute stroke are cared for in should establish the time of onset of symptoms. This time a dedicated stroke unit by a multidisciplinary team experi- represents time zero for the patient. If the patient wakes from enced in managing stroke. Although the studies reported were sleep or is found with symptoms of a stroke, time zero is the conducted outside the United States in in-hospital units that last time the patient was observed to be normal. EMs provided both acute care and rehabilitation, the improved roviders must rapidly deliver the patient to a medical facility outcomes were apparent very early in the stroke care. These capable of providing acute stroke care and provide prearrival results should be relevant to the outcome of dedicated stroke notification to the receiving facility. 25 units staffed with experienced multidisciplinary teams in the EMS providers should consider transporting a witness, United States. When such a facility is available within a family member, or caregiver with the patient to verify the reasonable transport interval, stroke time of onset of stroke symptoms. En route to the facility hospitalization should be admitted there( Class D)

With standard training in stroke recognition, paramedics have demonstrated a sensitivity of 61% to 66% for identifying patients with stroke.31,34,35 After training in using a stroke assessment tool, paramedic sensitivity for identifying patients with stroke increased to 86% to 97% (LOE 3 to 5).33,36,37 Therefore, all paramedics and emergency medical technicians-basic (EMT-basic) should be trained in the recognition of stroke using a validated, abbreviated out-ofhospital screening tool, such as the CPSS or the LAPSS (Class IIa). Transport and Care Once EMS providers suspect the diagnosis of stroke, they should establish the time of onset of symptoms. This time represents time zero for the patient. If the patient wakes from sleep or is found with symptoms of a stroke, time zero is the last time the patient was observed to be normal. EMS providers must rapidly deliver the patient to a medical facility capable of providing acute stroke care and provide prearrival notification to the receiving facility.25 EMS providers should consider transporting a witness, family member, or caregiver with the patient to verify the time of onset of stroke symptoms. En route to the facility providers should support cardiopulmonary function, monitor neurologic status, and if authorized by medical control, check blood glucose. Patients with acute stroke are at risk for respiratory compromise from aspiration, upper airway obstruction, hypoventilation, and (rarely) neurogenic pulmonary edema. The combination of poor perfusion and hypoxemia will exacerbate and extend ischemic brain injury, and it has been associated with worse outcome from stroke.38 Although one small randomized clinical trial (LOE 2)39 of selected stroke patients suggested a transient improvement in clinical deficit and MRI abnormalities following 8 hours of high-flow supplementary oxygen (by face mask), a larger quasirandomized trial (LOE 3)40 did not show any clinical benefit from routine administration of low-flow (3 L/min) oxygen for 24 hours to all patients with ischemic stroke. In contrast, the administration of supplementary oxygen to the subset of stroke patients who are hypoxemic is indirectly supported by several studies showing improved functional outcomes and survival of stroke patients treated in dedicated stroke units in which higher supplementary oxygen concentrations were used (LOE 7).38,39,41,42 Both out-of-hospital and in-hospital medical personnel should administer supplementary oxygen to hypoxemic (ie, oxygen saturation 92%) stroke patients (Class I) or those with unknown oxygen saturation. Clinicians may consider giving oxygen to patients who are not hypoxemic (Class IIb). The role of stroke centers and stroke units continues to be debated.43 Initial evidence44 –50 indicated a favorable benefit from triage of stroke patients directly to designated stroke centers (Class IIb), but the concept of routine out-of-hospital triage of stroke patients requires more rigorous evaluation. Each receiving hospital should define its capability for treating patients with acute stroke and should communicate this information to the EMS system and the community. Although not every hospital is capable of organizing the necessary resources to safely administer fibrinolytic therapy, every hospital with an ED should have a written plan describing how patients with acute stroke are to be managed in that institution. The plan should detail the roles of healthcare professionals in the care of patients with acute stroke and define which patients will be treated with fibrinolytic therapy at that facility and when transfer to another hospital with a dedicated stroke unit is appropriate (Class IIa). Multiple randomized clinical trials and meta-analyses in adults (LOE 1)51–54 document consistent improvement in 1-year survival rate, functional outcomes, and quality of life when patients hospitalized with acute stroke are cared for in a dedicated stroke unit by a multidisciplinary team experienced in managing stroke. Although the studies reported were conducted outside the United States in in-hospital units that provided both acute care and rehabilitation, the improved outcomes were apparent very early in the stroke care. These results should be relevant to the outcome of dedicated stroke units staffed with experienced multidisciplinary teams in the United States. When such a facility is available within a reasonable transport interval, stroke patients who require hospitalization should be admitted there (Class I). TABLE 1. The Cincinnati Prehospital Stroke Scale Facial Droop (have patient show teeth or smile): ● Normal— both sides of face move equally ● Abnormal— one side of face does not move as well as the other side Left: normal. Right: stroke patient with facial droop (right side of face). Kothari R, et al. Acad Emerg Med. 1997;4:986 –990. Arm Drift (patient closes eyes and holds both arms straight out for 10 seconds): ● Normal— both arms move the same or both arms do not move at all (other findings, such as pronator drift, may be helpful) ● Abnormal— one arm does not move or one arm drifts down compared with the other Abnormal Speech (have the patient say “you can’t teach an old dog new tricks”): ● Normal—patient uses correct words with no slurring ● Abnormal—patient slurs words, uses the wrong words, or is unable to speak Interpretation: If any 1 of these 3 signs is abnormal, the probability of a stroke is 72%. Part 9: Adult Stroke IV-113

IV-14 Circulation December 13. 2005 TABLE 2. Los Angeles Prehospital Stroke Screen(LAPSS) For evaluation of acute, noncomatose, nontraumatic neurologic complaint If items 1 through 6 are all checked "Yes"(or " Unknown"), provide prearrival notification to hospital of potential stroke patient. If any item is checked"No retum to appropriate treatment protocol Interpretation: 93% of patients with stroke will have a positive LAPSS score(sensitivity=93%), and 97%of those with a positive LAPSS score will have a stroke(specificity =97%). Note that the patient may still be experiencing a stroke if LAPSS criteria Criteria Unknown 1. Age >45 years 2. History of seizures or epilepsy absent 3. Symptom duration <24 hours 4. At baseline, patient is not wheelchair bound or bedridden 5. Blood glucose between 60 and 400 口口口口口口口口口口口口 6. Obvious asymmetry ( right vs left) in any of the following 3 exam categories Equal R Weak L Weak Facial smile/grimace 口 Droop 口口口口 Weak grip 口 Weak grip 口 No grip 口 No grip Arm strength □ Drifts down 口 Drifts down 口 Falls rapidly 口 Falls rapidly One-sided motor weakness(night arm) dwell CS, Saver儿L, ert GB, Eckstein M, Starkman S Design and retrospective analysis of the Los Angeles prehospital stroke screen(LAPSS). Prehosp Emerg Care.1998;2:267-273 Kidwell CS, Starkman S, Eckstein M, Weems K, Saver JL. Identifying stroke in the field: prospective validation of the Los Angeles Prehospital Stroke Screen(LAPSS) Stke.200031:71-76 In-Hospital Care assessment and support of airway, breathing, and circulation Initial ED Assessment and Stabilization, delay to and evaluation of baseline vital signs. We recommend that Protocols should be used in the ed to minimi definitive diagnosis and therapy 28 As a goal, ED personnel providers administer oxygen to hypoxemic patients in the ED should assess the patient with suspected stroke within 10( Class I)and consider oxygen administration for patients minutes of arrival in the ED(Box 3). General care includes without hypoxemia( Class IIb)

In-Hospital Care Initial ED Assessment and Stabilization Protocols should be used in the ED to minimize delay to definitive diagnosis and therapy.28 As a goal, ED personnel should assess the patient with suspected stroke within 10 minutes of arrival in the ED (Box 3). General care includes assessment and support of airway, breathing, and circulation and evaluation of baseline vital signs. We recommend that providers administer oxygen to hypoxemic patients in the ED (Class I) and consider oxygen administration for patients without hypoxemia (Class IIb). TABLE 2. Los Angeles Prehospital Stroke Screen (LAPSS) For evaluation of acute, noncomatose, nontraumatic neurologic complaint. If items 1 through 6 are all checked “Yes” (or “Unknown”), provide prearrival notification to hospital of potential stroke patient. If any item is checked “No,” return to appropriate treatment protocol. Interpretation: 93% of patients with stroke will have a positive LAPSS score (sensitivity93%), and 97% of those with a positive LAPSS score will have a stroke (specificity97%). Note that the patient may still be experiencing a stroke if LAPSS criteria are not met. Criteria Yes Unknown No 1. Age 45 years 2. History of seizures or epilepsy absent 3. Symptom duration 24 hours 4. At baseline, patient is not wheelchair bound or bedridden 5. Blood glucose between 60 and 400 6. Obvious asymmetry (right vs left) in any of the following 3 exam categories (must be unilateral): Equal R Weak L Weak Facial smile/grimace Droop Droop Grip Weak grip No grip Weak grip No grip Arm strength Drifts down Falls rapidly Drifts down Falls rapidly One-sided motor weakness (right arm). Kidwell CS, Saver JL, Schubert GB, Eckstein M, Starkman S. Design and retrospective analysis of the Los Angeles prehospital stroke screen (LAPSS). Prehosp Emerg Care. 1998;2:267–273. Kidwell CS, Starkman S, Eckstein M, Weems K, Saver JL. Identifying stroke in the field: prospective validation of the Los Angeles Prehospital Stroke Screen (LAPSS). Stroke. 2000;31:71–76. IV-114 Circulation December 13, 2005