today’s presentation: emergent stroke care
TRANSCRIPT
Today’s presentation: Emergent Stroke Care
Is brought to you by:
In partnership with:
www.oregonstrokenetwork.org
Emergent Stroke Care Pam Almandinger BSN, RN, CNRN, SCRN
Stroke Program Coordinator Adventist Medical Center
Portland, Oregon
September 10, 2014
Objectives • Review the signs and symptoms of acute stroke • Discuss the impact of hyper-acute stroke
management on patient outcomes • Identify implementation strategies for rapid
stroke assessment and treatment
Who is at Risk? • Almost everybody! • Almost everybody!
• Hypertension • Diabetes • Uses tobacco • Hyperlipidemia • Hx vascular disease • Old age
• Substance use o Meth, Cocaine, Marijuana
• Migraine • Infection • Atrial Fibrillation • Inactivity • Ethnicity, gender, … etc. . . . .
Signs & Symptoms
Cincinnati Prehospital Stroke Scale
Signs & Symptoms • Sudden onset:
o Weakness o Numbness o Confusion o Difficulty speaking o Visual difficulty o Incoordination / Balance problem / Dizziness o Severe headache without a known cause
Maybe not a stroke if… • Symptoms came on gradually • Symptoms are not unilateral • Symptoms do not fit a typical “vascular
distribution” • Generalized weakness
Stroke Mimics • If it quacks like a duck . . . It could still be
something else! • Common stroke mimics include:
o Toxic metabolic disorders o Seizure (Todd’s Paralysis) o Conversion Disorder o Hemiplegic Migraine o Positional vertigo o Brain Tumors o Systemic Infection
Goals of Early Treatment • Penumbra Care
o Penumbra: Ischemic tissue potentially destined for infarction, but not yet irreversibly injured. (The target of acute stroke therapies)
• Prevention of Complications • Begin risk profile
Penumbra Care • Increase Cerebral Perfusion Pressure
o Head of Bed as flat as is tolerated o Permissive Hypertension
• No tPA: Do not treat BP unless greater than 220/120 • tPA administered: Keep BP less than 180/110
o Bedrest
• Reperfuse injured brain tissue o Intravenous tPA o Interventional Therapy
What about tPA? • IV tPA (Alteplase / Activase) approved for
stroke therapy in 1996 • Despite increased incidence of symptomatic
ICH, treating with IV tPA within 3 hours of symptom onset improved clinical outcome at 3 months
• Outcome was better than with placebo regardless of the type of stroke
Is this patient a candidate? • Early assessment must include LKW time
o Is this patient within the 3 hour window since seen normal? o Increased length of time since onset reduces efficacy and
increases risk
• Inclusion Criteria o Stroke – causing measurable neuro deficit o Symptom onset less than 3 hours before start of treatment o Age greater than 18 years of age
Exclusion Criteria • BP >185/110 • Active internal bleed • Acute bleeding
diathesis • Current anticoag use • BG < 50 • CT w/hypodensity >
1/3 cerebral hemisph
• Head trauma/stroke in previous 3 mo
• Sx suggest SAH • Arterial puncture (at a
noncompressible site < 7d)
• Hx of previous ICH • AVM, aneurysm,
intracranial neoplasm • Recent brain/spine
surgery
Relative Exclusion Criteria • Only minor / rapidly improving sx present • Pregnancy • Seizure at onset • Major surgery or serious trauma within past 14 d • Recent GI or urinary hemorrhage (within 21 d) • Recent acute MI within prev 3 m
*Recent experience suggests that under some circumstances, with careful consideration and weighting of risk to benefit, patients may receive tPA despite 1 or more of these relative contraindications.
Stroke. 2010;41:300-306; originally published online January 7, 2010
Consent • Informed patient consent is indicated • Usually verbal consent
o Documented by physician o Can be consent by proxy if patient unable to consent
• In an emergency, (patient not competent and no other able to consent) it is ethically and legally permissible to proceed with fibrinolysis.
A Bigger Window? • In 2009, American Stroke Association (ASA)
issued a new guideline to expand the window for IV tPA to 4.5 hours from onset for selected patients
• Relative exclusion criteria for the 3 – 4.5 h window: o Age > 80 years o Severe stroke (NIHSS > 25) o Taking an oral anticoagulant regardless of INR o History of BOTH diabetes and prior ischemic stroke
The Evidence: ECASS - 3 • Multicenter, prospective, placebo-controlled RCT • tPA (or placebo) given at 3.0 to 4.5 hrs after onset of stroke
symptoms • Used traditional tPA inclusion & exclusion criteria but ADDED the
expanded exclusion criteria (previous slide)
• Primary outcome: o mRS 0 – 1: tPA group 52.4% vs placebo group 45.2% o Symptomatic ICH: tPA group 7.9% vs placebo group 3.5% o Mortality: tPA group 7.7% vs placebo 8.4%
• 2009 American Heart Association
Dosing • Total Dose: 0.9 mg / kg (do not exceed total
dose of 90 mg) • Start with bolus
o 10% of total dose – administer over 1 minute
• Infusion o Remainder of dose to infuse over 1 hour
• Reconstitution, Dosing, and Administration video can be viewed at www.activase.com
tPA Side Effects • Major side effect is bleeding
o Close surveillance is required o Neuro decline must be responded to promptly o Ask patient to report any s/s bleeding
• Less common side effect is angioedema o Look in mouth/throat at baseline o Check again at least every 30 minutes for 2 hours o Caution patient to report feeling of throat /
tongue swelling or difficulty breathing
Can we “wait and see”? • Remember: Brain cells are DYING! • For every 15 minute delay, in 1000 patients
o 18 will have worse ambulation at discharge o 13 more will be discharged to a less independent
environment o 4 more will die prior to discharge
JAMA 2013;309:2480-8
Time is Brain!
In a typical acute ischemic stroke, every minute the brain loses
1.9 million neurons
Goal Times • Door to physician - < 10 min • Door to neurological expertise – < 15 min • Door to CT Scan – < 25 min • Door to CT Scan, ECG, and Labs resulted – < 45 min • Door to needle (DTN) - < 60 min
Having a Plan
Code Stroke Plan, cont…
Immediate Diagnostics • Noncontrast CT brain (or MRI) • Blood glucose (can be fingerstick) • Oxygen saturation • *Serum electrolytes / renal function • *CBC, including platelets • *Markers of cardiac ischemia • *PT/INR, aPTT • *ECG * Should not delay initiation of tPA
STROKE 2013 Early Management of Acute Ischemic Stroke
Selected Patients may need…
• TT and/or ECT if suspected to be taking direct thrombin or direct factor Xa Inhibitors
• Hepatic function tests • Toxicology screen • Blood alcohol • Pregnancy test • ABG • CXR • Lumbar Puncture
Pre-infusion • If foley needed, insert it now • If NG needed, insert it now • Start 2 IV sites • Baseline NIHSS • Physical assessment • Provide patient education flyer
tPA Infusion Notes • The infusion must immediately follow the bolus • Attach a normal saline “chaser” to the tubing
at the end of the infusion to clear remaining dose out of the tubing
Documentation! • The frequency of checks is specified in CPGs • After the bolus, VS and neuro checks are done:
• q 15 minutes X 8 (for 2 hours), then • q 30 minutes for 6 hours, then • Hourly X 16 hours
• If neuro decline noted, patient requires STAT non-contrast head CT to check for hemorrhage. Notify physician immediately!
What about Interventions? • If the stroke patient is going to receive
interventional therapy, he/she still should get tPA started if not contraindicated and in the window
• If outside the window but still only 6 or 8 hours from LKW, consider interventional treatment. (Do it quickly; time is still vital)
In-Hospital Strokes • Hospital patients are at higher risk of stroke
• Procedures • Surgeries • Disease process risk factors
• All hospital staff need to have heightened awareness of stroke risk factors, recognition of symptoms, and the appropriate response!
In-Hospital Strokes, cont…
• Patient will need: o non-contrast head CT o blood glucose o ECG
• Need for lab tests will vary, depending on when done last
Post tPA Care • ICU with close monitoring on day 1 • Nothing goes in the mouth until the Swallow
Screen is done! • Penumbra precautions • Blood glucose monitoring (even if the patient
is not diabetic!) • No antithrombotics until 24 hours post tPA • Don’t forget VTE prophylaxis (SCDs are OK)
Not a Candidate? • Admit to the Stroke Unit!
o Stroke patients cared for on a specified stroke unit by stroke trained staff have lower mortality and morbidity.
• Penumbra precautions are still important
Next Lecture • Attend the 3rd in this stroke lecture series on
December 10, when Sandy Dancer will talk about “Care for the Other Ninety-five Percent”.
• Learn what routine stroke care in the hospital looks like. What do we do, and why do we do it?
Continuing Ed Credit • Do you need stroke continuing education
credit? o Email to [email protected] Thank you for attending!