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 pam.Almandinger@ah.org Thank you for attending!