Acute Management of the Stroke Patient:

Authors

• Valerie Goss BSN, RN • Chrissie Gribbins BSN, RN

Stroke: Content Outline

• Epidemiology • Stroke types and pathophysiology • The Golden Hour ~ Triage ~ Stroke Alert ~ CT ~ tPA

Stroke: Epidemiology

• About 795,000 strokes occur each year…..about one every 40 seconds

• Stoke is the 5th leading cause of death & a leading cause of disability in the U.S.

• Stroke causes 1 of every 20 deaths in the U.S. • Stroke occurs more in woman (60%) than in men

(40%) • Stroke is the leading preventable cause of

disability

American Heart Association/American Stroke Association (2015). Heart disease and stroke statistics –at a glance. Retrieved from http://www.heart.org/idc/groups/ahamah-public/@wcm/@sop/@smd/documents/downloadable/ucm_470704.pdf

What is a stroke?

A stroke occurs when a vessel in the brain is

blocked by a clot or when the vessel ruptures.

This causes the brain to be deprived of blood

resulting in lack of oxygen. Without oxygen, brain

cells die within minutes.

Stroke Types

Hemorrhagic Stroke

Ischemic Stroke

Hemorrhagic vs. Ischemic Stroke

Hemorrhagic • Results from a weakened

vessel that ruptures & bleeds • Accounts for about 13% of all

strokes • 2 types: ~Aneurysms ~Arteriovenous Malformations (AVM) American Heart Association/American Stroke Association (2015). Hemorrhagic strokes (bleeds). Retrieved from http://www.strokeassociation.org/STROKEORG/AboutStroke/TypesofStroke/HemorrhagicBleeds/Hemorrhagic-Strokes-Bleeds_UCM_310940_Article.jsp

Ischemic • Results from an obstruction in a

blood vessel to the brain • Accounts for about 87% of all

strokes • 2 types: ~Cerebral thrombosis ~Cerebral embolism

Hemorrhagic Subarachnoid Hemorrhage (SAH) • Bleeding artery on or

near the surface of the brain bursts spilling blood into space between surface of brain & skull (subarachnoid space)

• Often caused by bursting aneurysm

• Sudden, severe headache

Intracerebral Hemorrhage (ICH) • Bleeding vessel in the

brain bursts spilling into surrounding tissue

• Most common cause is High blood pressure

Causes of Hemorrhagic Strokes Most common cause: • High blood pressure-

Constant force of high blood pressure on vessel walls can weaken them resulting in bleeding in the brain or hemorrhage

Other causes: • Arteriovenous

malformation (AVM)-malformed, thin walled vessels present at birth that over time burst leaking blood into the brain

• Trauma • Blood thinners • Aneurysm leak or rupture

Hemorrhagic

Subtypes of Ischemic Stroke 2 Types

1. Thrombotic 2. Embolic

These 2 types are broken down into further categories or subsets

5 Categories/Subtypes: 1. Large vessel occlusion

Small vessel occlusion-lacunar

2. Cardioembolism 3. Stroke of other unusual

determined etiology 4. Stroke of undetermined

etiology (cryptogenic) • Chung, J., Park, S., Kim, N., Kim, W., Park, J., Ko, Y.,…&

Bae, H et al. (2014). Trial of org 10172 in acute stroke treatment (TOAST) classification and vascular territory of ischemic stroke lesions diagnosed by diffusion weighted imaging. Journal of American Heart Association, 3(4), doi: 10.1161/JAHA.114.001119

What Goes Where??

Thrombotic • Large vessel occlusion Stenosis Atherosclerosis • Small vessel occlusion (lacunar) Stenosis Hypertension

Embolic • Cardioembolism Heart is a common source due to atrial fibrillation, heart failure, decreased ejection fraction, valve disease, patent foramen ovale • Other unusual determined etiology • Undetermined-Cryptogenic

Causes of Ischemic Strokes

• Stenosis-Narrowing of arteries in neck or head

• Atherosclerosis • Hyperlipidemia • Blood clots (Atrial Fibrillation) • Heart attack • Abnormalities in heart valves • Street drugs • Traumatic injury • Disorders of blood clotting

Thrombotic Causes of Ischemic Strokes

Most Common: • Atherosclerosis- Plaque builds up inside the arteries causing a blood clot (thrombus) blocking blood flow to the brain. This is a thrombotic stroke

Embolic Causes of Ischemic Stroke A blood clot or other material may break free from another area of the body and travel to the brain. The blood flow is then blocked resulting in an embolic stroke Atrial Fibrillation (Afib) is a good example. The blood clot develops in the atria and when ejected, travels to the brain.

Cryptogenic Stroke • Ischemic stroke without a well defined

etiology • Brain infarction NOT attributable to

definite cardioembolism, large artery atherosclerosis, or small artery disease

• Also termed unknown, uncertain, or undetermined cause

• 25-40% of all ischemic strokes

Prabhakaran, S., & Elkind, M. (2015). Cryptogenic stroke. Retrieved from http://www.uptodate.com/contents/cryptogenic-stroke

Golden Hour • The term golden hour is used to

designate the hour immediately following the onset of stroke symptoms.

• The reason it’s golden is that stroke patients have a much greater chance of surviving and avoiding long-term brain damage if they arrive at the hospital and receive treatment within that first hour.

Time is Brain quantified Neurons Lost

Synapses Lost

Myelinated Fibers Lost

Accelerated Aging

Per Stroke 1.2 billion 8.3 trillion 7140 km/4470miles 36 years

Per Hour 120 million 830 billion 714 km/ 447 miles 3.6 years

Per Minute 1.9 million 14 billion 12 km/7.5 miles 3.1 weeks

Per Second 32, 000 230 million 200 meters/218 yards 8.7 hours

Saver, J Stroke. 2006;37:263-266

R E C O G N I T I O N

O F S T R O K E

The

Five

S’s

Rapid Triage Assessment

Source: Cummins RO (Ed). Advanced Cardiac Life Support. New York. American Heart Association, 1997. Barsan WG. In: Rapid Identification and Treatment of Acute Stroke. NINDS, 1997.

60 minutes!!! Door to drug administration

Time to Treatment Goals

Door to Doctor

Door to CT completion

Door to CT Read

Roles of Team Primary Nurse: • Stroke Triage sheet & Accu √ Initiates “Team D alert” Assessment & documentation of care Completes Med. Rec. Transports to CT/stays w/ pt.

Desk Clerk: • Calls “Team D alert” &/or “Team D” overhead

x3 Pages Stroke beeper stat per MD request • Notifies CT of Team D pt. (x8285)

Primary nurse’s Pod mate: • Cares for/delegates care for the primary

nurse’s other patients

Floor Tech: • Disrobes pt into gown/ bags clothes • Applies monitors; EKG after CT Complete set of VS if not done • Put O2 tank/monitor on bed • Transports labs in Team D bag

Secondary nurse (float RN or opposite Pod) • Starts IV (18g or >) in Rt. AC • Draws labs per protocol; extra green top

tube for I-Stat Creat. • Obtains/gives meds/insert FC as ordered • Assists upon return from CT • Starts 2nd IV after CT, if tPA anticipated

Charge Nurse: Delineates Secondary RN at shift report Alerts Pharm. of possible need for tPA Notifies Pharm. to mix tPA/sends runner Cancels tPA with Pharm as indicated • Ensures completion of Team D packet • Assists with tPA administration

Figure 3. Decision matrix figure illustrating the benefits and risks of intravenous TPA in the <3-hour window based on data from the 2 NINDS-TPA trials.

Jigneshkumar Gadhia et al. Stroke. 2010;41:300-306 Copyright © American Heart Association, Inc. All rights reserved.

Reperfusion Therapy: TIME IS BRAIN!

• tPA – Used in treatment of ischemic stroke

<3hours from last known well.

• Only FDA approved medication to treat ischemic stroke

tPA Flowsheet

TIME

Init Q15 Q15 Q15 Q15 Q15 Q15 Q15 Q15 Q30 Q30 Q30 Q30 Q30 Q30

Level of Consciousness

A = Alert V = Verbal P = Responds to pain U = Unresponsive

Questions: Month Patient’s age

0 = Answers both correctly 1 = Answers 1 correctly 2 = Both incorrect

Commands: Open/close eyes Grip/release hands

0 = Performs both correctly 1 = Performs one correctly 2 = Both incorrect

Facial Droop

N = Normal; equal # of teeth on both sides when smiling R = Right facial droop L = Left facial droop

Visual Fields N = Normal; recognizes finger movements in all 4 quadrants R = Right visual field deficit L = Left visual field deficit

Horizontal Gaze N = No deficit: follows finger to left & right R = Right gaze preference L = Left gaze preference

Motor Arm-arm drift (eyes closed) test both arms together

Raised arms (palms up) do not drift down: N = No drift or Designate arm with deficit: RA = Right arm LA = Left arm

Motor Leg (eyes open) test individually

Each raised leg does not drift down: N = No drift or Designate leg with deficit: RL = Right leg LL = Left leg

Sensory-Arm & Leg (eyes closed)

N = Feels light pinch normally or Designate limb with deficit: RA = Right arm; LA = Left arm RL = Right leg; LL = Left leg

Speech: Have pt say: “I am going to get better, no if’s, and’s or but’s about it”

N = No wrong words, no slurring W = Wrong words S = Slurring M = Mute

Comparison to previous exam B = Better S = Same W = Worse

Blood pressure

SpO2/Liters of 02

Heart Rate

Headache Y = yes N = no

Initials

Time Trackers

ACUTE ISCHEMIC STROKE TREATMENT: Patient Sticker EMS Pre – Arrival Notification Y N NIHSS ________ date/time _______________ Last Known Well date/time _______________

Clock starts for Door-to-Needle (DTN) Date+ Clock Time

Patient Arrival: __________ __________

Stroke Team Activation: __________ __________

Stroke Team Arrival: __________ __________

ED Physician Assessment: __________ __________

Brain Imaging Ordered: __________ __________

Brain Imaging Initiated: __________ __________

Brain Imaging Interpreted: __________ __________

Lab Tests Ordered: __________ __________

Lab Test Completed: __________ __________

IV tPA Ordered: __________ __________

IV tPA Initiated: __________ __________

Weight: (kg) Total IV tPA Dose: (mg) IV tPA Bolus: (mg)

Reason for no tPA ____________________________________________________________ Documented Reason for door to tPA over 60 minutes_________________________________ To OR for intervention __________ __________ Patient’s Care Team Members