Stroke: Nursing Evaluation andInterventionJessica Dickman DNP, APRN, FNP-C, CNRN, SCRNSSM Health Saint Louis University Hospital

Disclosures

None

Objectives

Blood clot

Plaque

Intracerebral HemorrhageAcute Ischemic Stroke

Discuss how to improve patient outcomes by avoiding common practice mistakes in nursing for the diagnoses of:

Case: ICH with Suboptimal BP Control

49 yo male called 911 because he had sudden numbness in his left arm and left leg and noted the left hand was weaker.

• EMS was called for possible stroke (No Code Stroke activated en route, BG not checked, no IV access)

• Arrives to rural hospital at 00:50• ED Stroke standing orders at 00:56• ED MD at bedside at 00:56 & Code Stroke Activated• 1st slice of head CT 00:57• 1st set of vitals 01:01 BP: 223/121, HR 93, sPO2 90%,

RR 14, No BG• IV Access obtained at 01:06• CT Resulted at 01:15• NIHSS Documented at 15 at 01:26• PT/INR: 10/0.97at 01:31

Right Pontine ICH –– 80191380003

CONCLUSION:

1. Exam is positive for a 9 mm acute intraparenchymal hemorrhage in the right parasagittal pontomedullary junction. No otherhemorrhage.

2. No gross acute major vessel infarct. Mild small vessel ischemic change and brain volume loss is present. Moderately severe intracranial vascularcalcifications.

Further Action

• PT/INR: 10/0.97at 01:31• CMP revealed BG was 156 mg/dl at 01:56• Alert/oriented and joking with staff at 01:59• BP’s remained >220/110.• Called stroke transfer center at 02:15• Orders placed

• Hydralazine 10mg IVP Q 15min PRN• Labetolol 10mg IVP Q15min PRN• Cardene 20mg in 200ml infusion titration

• ED Hemorrhagic order set not utilized

BP’s Elevated

Patient status at 02:38

• Slowly giving hydralazine and patient began to become slightly lethargic and had some small jerking movements.

• Pt had snoring respirations and was not responding to staff.

• Pt continues to have some posturing of bilateral arms, eyes closed, very diaphoretic, had an episode of bradycardia with HR in the 40's

• Intubated at 03:15

BP’s Elevated

Further Action

Further Action

• Exited hospitalat 05:40

• Door in Door Out:4 hours and50 minutes

Recommendations

• Collaboration with EMS• Code Stroke Protocols

• Field Activation• BG

• IV access if possible• Intensive BP lowering in ED• Utilization of order sets in ED

for hemorrhagic stroke• Rapid transport of patient to

next level center

Case Presentation

Background

90 y/o female found on the floor by her neighbor that checks on her every day. Normally fixes a cup of coffee in the morning, microwave was beeping, but water was cold. Hx. of afib. Patient opens eyes to name, but unable to say anything. Moving both legs, but will moan when hips are palpated. R wrist looked swollen, splint was placed. Hematoma to the back of the head, no bleeding.

EMS Run Sheet

• LKW- Last evening at 20:00• BP 102/50, P 82 irregular, Resp 16, O2 95%RA• BS- 134• C-Collar placed• IV access- Unsuccessful x2• Stroke Scale-Positive• Trauma Score - 11• Pre-notification of code trauma class II -09:40

ED Assessment and Treatment

• ED arrival – 09:49• CT Head – 10:15, results negative• Code Stroke called – 10:13• NIH-16, Decreased LOC, disoriented but

following commands, right facial droop, right hemiplegia, aphasic, and neglect

• CTA- thrombosis or thrombosed dissection of the upper left ICA

• Transfer to CSC 11:07• Patient arrived at CSC to receive endovascular

treatment with successful thrombectomy

Outcome

Patient was discharged 3 days later to rehab

With an NIH of a… ZERO.

Recommendations

• Education• Trauma and Stroke are not

mutually exclusive• Time is Brain

• Cincinnati Scale Positive• Focal Symptoms

• Door to Exit Goal• 60 Minutes

• Think transfer when patients symptoms align with LVO.

• Example: NIHSS >5

Case PresentationBackground EMS Report

• 33 y.o male • Wakes up at 8 pm and told his mother that he was

vomiting blood, had blood in his stool and was not tolerating po. Stated he needed to go to the hospital.

• Went back to bed woke up at 10pm and was altered.• EMS arrives and patient is incoherently mumbling.• No drugs were found nearby.

• Received 4 mg Narcan, 2 mg IN and 2 mg IM, without significant improvement.

• En route to hospital• Pt less responsive

• Pt's mother denies history or suspicion of drug use. He does have a prescription for hydrocodone, but mother states that the pt. is very reluctant to take pain medication.

• Hx – recently admitted 12/17-12/23 due to splenic and renal infarcts.

ED Assessment ED arrival- 00:16

Pt is currently unresponsive.

Vitals- BP 106/61, P 83, T 97.7, R 14, Sp02 100%. Pin point pupils.

00:27, patient intubated to protect airway

No documentation of NIH. Neuro exam is limited. Visual exam not attempted.

CT Head ordered 00:46. CT started 01:16, read negative 01:36

Transferred to ICU 03:07

CTA ordered d/t the recent findings of new renal cortical infarcts in the setting of splenic infarcts, a new embolic event that involves the brain as well is a possibility. (Ordered at 02:59, test ended at 03:45)

CTA positive for basilar artery thrombus (resulted at 04:36)

Transferred to CSC 05:30

Treatment

Basilar Artery Symptoms

Dizziness/Vertigo (Common early symptom)

Altered mental status

Slurred speech

Oculomotor palsies

Quadriparesis

Progression to stupor or coma

Recommendations

• Very complex case• Recent renal and splenic infarcts

• What’s the etiology?

• Consider CT and CTA STAT to evaluate for potential posterior circulation occlusions based upon symptoms.

• Basilar Occlusions• Must not miss diagnosis

Questions/Comments