Transcript Slide 1

Care of the Stroke Patient
Improving Patient Outcomes
University Medical Center
Tucson, Arizona
Christine Pasquet, RN, MSN
Michelle Strand, RN,
Leslie Ritter, RN, PhD
Jeremy Payne, MD, PhD
Mary Ann Matter, RN, MSN
Learning Objectives
After completion of this Self Learning Module you
will be able to:
• Describe the significance of stroke, types of
stroke and risk factors for stroke
• Describe the prehospital assessment and
management of stroke patients
• Explain how the use of evidence based
guidelines improves care of the stroke patient
• Discuss stroke prevention strategies
What is a Stroke?
• Stroke is the acute onset of a focal neurologic
deficit resulting from decreased perfusion to the
brain, causing permanent tissue damage (an
infarction)
• Strokes are usually the result of vascular
disease
• The symptoms of a stroke depend on the part of
the brain involved
• 85% are ischemic (interruption of blood)
• 15% are hemorrhagic (bleeding)
Old TIA Definition
• TIA stands for “transient ischemic attack” –
stroke symptoms that improve without causing
damage to the brain
• The old definition was improvement in 24 hours,
BUT:
– Some patients have brain injury on MRI after less
than an hour, even if symptoms improve
– Some patients can have symptoms longer than 24
hours without brain injury on MRI
– Even brief TIAs predict increased risk of upcoming
stroke
Updated TIA Definition
• “A brief episode of neurological dysfunction
caused by focal brain ischemia with clinical
symptoms typically lasting less than one hour
and without evidence of acute brain infarction”
• It’s not always clear if acute neurologic
symptoms are a stroke or TIA until the patient is
thoroughly evaluated, so we treat these the
same at first
• Other terms such as “mini-stroke” are confusing
and shouldn’t be used
Significance, Types, and Risk
Factors for Stroke
Significance of Stroke
• Stroke is the third leading cause of death and
the leading cause of disability for adults
• Approximately 700,000 strokes occur annually in
the US
– About 176,000 result in death
– About 200,000 are not the patient’s first stroke
– About 350,000 are minimally to severely disabled
• Of patients still alive at six months, about one third remain
dependent on others for help with daily activities
• Transient Ischemic Attacks (TIAs) occur even
more frequently
Types of Strokes
• There are two general types of stroke – ischemic
and hemorrhagic
• Ischemic stroke occurs when blood supply to the
brain is reduced or interrupted and accounts for
around 85% of all strokes
• Hemorrhagic stroke occurs when a blood vessel
in the brain ruptures
– Sometimes an ischemic stroke can “convert” to a
hemorrhagic stroke, since blood vessels are also
injured in an area of infarction
Types of Strokes
Ischemic Stroke
Hemorrhagic stroke
Ischemic Stroke
Large ischemic stroke
Plaque in the wall of an artery or clots
from the heart or large blood vessels
can break loose and travel downstream
to occlude blood vessels in the brain, or
injured brain arteries can form local
clots to interrupt blood supply.
Small strokes can
also cause major
symptoms
Hemorrhagic Stroke
Bleeding in the brain can occur after injured blood vessels burst.
Longstanding hypertension is a common cause, and some patients have
congenital blood vessel anomalies such as aneurysms that are prone to
rupture. Sometimes ischemic strokes later bleed, as blood vessels
themselves are also injured in a stroke.
Stroke Subtypes and Incidence
Rare causes of stroke
include things like
coagulation disorders,
drug abuse, etc.
There is lots we still
don’t understand
about stroke, and
sometimes there are
no clear reasons for
one.
Hemorrhagic stroke
15%
Other
5%
Cryptogenic
30%
Cardiogenic
embolism
20%
Atherosclerotic
cerebrovascular
disease
20%
Small vessel
disease
“lacunes”
25%
Like heart disease:
atherosclerotic plaque
causes clot or debris
to dislodge and
occlude brain arteries.
Ischemic stroke
85%
Clots from the heart
travel to the brain (e.g.
in atrial fibrillation).
Chronic injury causes
local injury to small
vessels directly in the
brain.
Risk Factors for Stroke
Non-modifiable risk factors
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Older age
Male gender
Non-white genetic background
Family history
Prior stroke or TIA
Modifiable risk factors
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Hypertension
Diabetes mellitus
Atrial fibrillation
Carotid artery disease
Dyslipidemia
Cardiac disease
Cigarette smoking
Obesity
Others…
Previous TIA or stroke is the most important
risk factor for stroke.
Hypertension is the most prevalent.
Risk Factors:
Modifiable Risks
• Risk factors such as lifestyle habits and disease
processes can be modified or controlled
– Hypertension – the higher the blood pressure the
higher the risk of stroke
– Cholesterol – high cholesterol increases the risk of
stroke: eat low fat diet
– LDH < 130mg/dl
– HDL > 45mg/dl
– Diabetes – controlling blood sugar may reduce stroke
risk
– Smoking – smokers have twice the risk of nonsmokers: STOP!
– Alcohol – excessive alcohol use increases the risk for
stroke: more than 2 drinks a day
– Sedentary lifestyle – low activity level increases the
chances of stroke: workout 30-60 min 3 X week
– Obesity and increased abdominal fat – (waist
circumference greater than 40” for man and 35” for
women) increases the risk for stroke
– Atrial fibrillation – this arrhythmia is associated with 34 times greater stroke risk
Medications and lifestyle changes can dramatically
reduce many of these risks
Risk Factors:
Non-Modifiable Risks
• Age – stroke increases with age and doubles for
each decade after 55
• Gender – men have an increased risk of stroke
but more women die as a result of stroke
• Race and Ethnicity – African Americans have
the highest risk followed by Hispanic Americans
• Family history – having parent, grand-parents or
siblings with stroke increases one’s risk
Risk of Stroke with TIA
• 10% of patients who present to ED and are
diagnosed with a TIA will have a stroke in the
next 30 days
• 50% of those patients have their stroke in the
next 48 hours
• Risk of major stroke is increased by about 15%
for 3 months after a mild stroke or TIA
 We treat TIAs like actual strokes in order to
prevent a major stroke
Know the Signs of Stroke
• Sudden numbness or weakness of the face, arm, or leg
(especially on one side of the body)
• Sudden confusion, trouble speaking or understanding
speech
• Sudden trouble seeing in one or both eyes
• Sudden trouble walking, dizziness, loss of balance or
coordination
• Sudden severe headache with no known cause
Call 911!
Know the Signs of Stroke
Medical Priority Dispatch
Key 911 caller questions that elicit any of the
following will result in an emergency ALS
dispatch:
• Not alert
• Abnormal breathing
• Speech problems
• Sudden onset of severe pain
• Numbness or paralysis
• Change in behavior
Assessment of Stroke
• Chief complaint
• Stroke assessment test (Cincinnati Stroke
Scale):
– Facial droop
– Arm drift
– Slurred speech
• Symptom onset time
• Vital signs to include FSBG
Cincinnati Stroke Scale
Differential Diagnosis
• Rule out other causes of weakness or altered
mental status:
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Hypoglycemia
Trauma (recent head injury or fall)
Tumor (slow onset)
Seizure disorder (post seizure paralysis)
Management of Ischemic Stroke
Management of Ischemic Stroke
• Perform appropriate initial and ongoing
assessments
• Implement SAEMS Stroke Standing Order
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Initiate IV normal saline TKO
Monitor oxygenation
Monitor cardiac rhythm (12-Lead if able)
Consider airway management if GCS less than 8
Rapid transport to a primary stroke center
• Attention to limb deficits
– Assist, positioning, slings, safety
Blood Pressure in Acute Stroke
• Elevated blood pressure is a significant
risk factor for stroke. It is often erratic
during acute stroke.
• Over a wide range of blood pressures
the brain can adjust its own perfusion
(“autoregulation”), but this can be
disrupted in acute stroke.
• More than 60% have at least transient
SBP greater than 160
• It is not clear if adjusting BP
changes outcomes
• Consensus is permissive BP to
220/120 before lowering in acute
ischemic stroke.
Monitoring Parameters
• Blood pressure
– Generally elevated and
labile for first few days
– Stability is important
• Blood glucose
– Elevated glucose may
suggest stress response
– Glycemic control
correlates with much
better outcomes
Monitoring Parameters
• Temperature
– Increased temperature
causes increased
metabolic demand
• Cardiac rhythm & rate
– Risk of arrhythmia and MI
Monitoring Parameters
• Neurologic exam
– Level of consciousness
– Cognitive function
– Physical status
• Oxygenation
• Hydration
• Anticipate complications
Treatment of Ischemic Stroke
• All new strokes and TIAs should be admitted to
the hospital despite requests to stay home
• Some acute stroke patients may qualify for
thrombolytic therapy
• Risk factors must be identified and addressed
• Treatable causes may be present
• Remember that even in a TIA, there is a high
stroke risk—and cardiac risk—in the next few
days
Stroke Management Issues
• Even though neurons begin to die after about 4
minutes without blood, there will be billions whose
blood supply is tenuous, and dependant on how
the patient is managed (the penumbra - area of
potential infarct)
– Outcome in stroke depends on good acute management
• Many patients will need rehab and swallowing
support
• Most patients will need significant education
• Stroke patients are at risk for various acute
complications
Timing of Stroke Management
Hospitalization
3 hrs
tPA
Other interventions
~6 hrs
~24-48 hrs
Instability
~3-5 days
Peak Edema
~2-3 weeks
Bleeding
~1-3 months
Recurrence
~3 months
Recovery
onset
day
week
month
Standards of Care
1. Rapid recognition
2. Rapid transport to a Primary Stroke Center
3. tPA when indicated
4. DVT prophylaxis
5. Discharge with anti-thrombotic Rx (eg, aspirin)
6. Anticoagulation for atrial fibrillation
7. Dysphagia screening
8. Stroke education (risk factors, prevention, etc.)
9. Smoking cessation
10. Plan for rehab
Acute Stroke Thrombolysis: tPA
• Tissue plasminogen activator (tPA) is a synthetic
version of one of the body’s natural molecules
that break down blood clots
• tPA is the only FDA approved treatment for
acute ischemic stroke proven to improve
outcomes:
– Judicious use results in excellent outcomes in an
additional 11-13% patients
– Chances of complete recovery 39% vs 26%
– 48% vs 36% chance of discharge to home
– Every 8 patients treated prevents 1 case of disability
tPA Cautions
• tPA can be dangerous too:
– Brain hemorrhage rate: 6.4% overall
– Hemorrhage and similar bad outcomes correlate with
protocol violations
• Nationwide estimates are that <5% of stroke
patients are able to receive this treatment:
– Must be given within 3 hours of stroke onset or
bleeding becomes a big risk
– Patients often delay seeking care
– Concern over bleeding when in inexperienced hands
Benefits of tPA are greatest when delivered
early after stroke onset
Marler et al., Neurology 2000; 55:1649
Administration of IV tPA
• tPA is administered intravenously by bolus and
continuous infusion.
• Some rural Arizona hospitals may have the
capability of initiating tPA therapy followed by
subsequent air transport to a primary stroke
center.
Common Complications of Stroke
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Hyper- and hypotension
Hemorrhage
Edema, increased intracerebral pressure
Recurrent stroke or progression of initial one
Arrhythmia, MI
Infection
Aspiration
Falls, neglect
Decompensation (transient worsening of prior
deficit because of other illness)
• Seizures
Evidence Based Guidelines
• Our ability to decrease mortality and morbidity from
stroke is limited because:
– Patients and families do not recognize signs and symptoms of
stroke, and therefore do not seek care at all
– Many patients with stroke delay seeking treatment, limiting the
possibility of treatment with tPA
• Studies indicate that use of evidence-based, clinical
practice guidelines for stroke improves outcomes from
stroke
– One strategy to ensure use of guidelines and improve outcomes
after stroke is through the development of Primary Stroke
Centers
Primary Stroke Center Certification
• Primary Stroke Center Certification by the Joint
Commission is considered the “gold standard”
in the United States and indicates formal,
rigorous, independent review of a hospital’s
ability to deliver comprehensive stroke care
Time is Brain
EMS is a CRUCIAL Component!