Case Scenario: Acute Ischemic Stroke

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Case Scenario Acute Ischemic Stroke

• Learning Objectives
• Recognize stroke signs
• Recognize principles of prehospital and ED care
• Understand potential use of thrombolytics for
  some patients with acute ischemic stroke

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Phase 1 Prehospital

• Learning Objectives
• Recognize stroke signs
• Use the Cincinnati Prehospital Stroke Scale
• Appreciate the importance of rapid transportand
  prearrival notification of ED
• Understand some differences between presentation
  of ischemic and hemorrhagic stroke

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Differential Diagnosis

• 630 PM
• You are dispatched to a shopping mall to a
  collapsed female.

What is your differential diagnosis?
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Differential Diagnosis

• 635 PM
• Upon arrival, you find an African-American woman
  sitting on a bench. She is confused but
  responsive to verbal stimuli.
• Summary clincial signs and symptoms
• Regular heart rate and adequate perfusion
• No evidence of ischemic chest pain
• Adequate airway and ventilation
• Right-sided paralysis
• Dysarthria
• Hypertension

1. What additional information do you need? 2.
What is your differential diagnosis now?
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Differential Diagnosis of Focal Neurological
Deficit

• Hemorrhagic stroke
• Ischemic stroke
• Craniocerebral/cervical trauma
• Meningitis/encephalitis
• Hypertensive encephalopathy

• Intracranial mass
• Seizure
• Migraine
• Metabolic problems (including hypoglycemia or
  hyperglycemia, drug overdose)

What further information would be helpful?
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Case Development

• The daughter reports that her mother felt fine
  while shopping, then suddenly said her arm felt
  funny. She then fell to the ground. She did not
  hit her head or lose consciousness. With further
  questioning the daughter reveals that her mother
  did not complain of a headache and had no signs
  or history of seizures, diabetes, chest pain, or
  palpitations.

What additional assessments may be helpful now?
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Cincinnati Prehospital Stroke Scale

• Facial droop (ask patient to show teeth and
  smile)
• Arm drift (ask patient to extend arms, palms
  down, with eyes closed)
• Speech (ask patient to say You cant teach an
  old dog new tricks)

Look for abnormalities.
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Case Development

• 643 PM
• Patient demonstrates a right-sided facial droop,
  right-arm weakness, and slurred speech.

What is your conclusion from your examination?
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Case Development
1. What are your priorities of care? 2. Do you
need further information?

• Obtain as much information as possible during
  transport bring the family member along if
  possible.

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Summary of Priorities of Prehospital Care of
Patients With Possible Stroke

• Assessment and support of cardiorespiratory
  function and serum glucose
• Determination of precise time of onset of signs
  and symptoms
• Rapid transport to ED
• Prearrival notification of ED
• Assessment of neurological function
• Rapid determination of essential medical
  information

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Case Development

• The daughter states that her mothers symptoms
  developed shortly before the call to EMS, but she
  is not sure of the exact time.

How can you help clarify the information?
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Case Development

• The daughter remembers that she and her mother
  were walking past an electronics store, and her
  mother stopped to watch the weather on the local
  news program. The weather report always airs at
  620 PM.

1. What should you do with this information? 2.
What are appropriate assessment and   
    management priorities during transport?
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Case Development

• During transport the patients vital signs are
  again obtained
• HR 92 (normal sinus rhythm)
• RR 22 and comfortable
• BP 198/120 mm Hg700 PM (40 minutes after
  onset)Patient arrives in ED.

Do you want to request orders for therapy?
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Phase 2 Emergency Department

• Learning Objectives
• Understand the importance of rapid triage and CT
  for potential stroke victims
• Understand the use of the National Institutes of
  Health Stroke Scale (NIHSS)
• Be familiar with guidelines for managing
  hypertension in stroke patients
• Differentiate between clinical course and
  potential management of patients with ischemic
  and hemorrhagic stroke

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Case Development

• The ED has been notified by radio (at 643 PM) of
  a 63-year-old African-American woman who
  collapsed at a shopping mall. EMS personnel
  report right facial droop, right-sided weakness,
  and difficulty speaking when the Cincinnati
  Prehospital Stroke Scale is performed. Vital
  signs are stable, and airway and ventilation are
  adequate.

1. What additional information would you
like? 2. What can be done to prepare for the
arrival of the patient?
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Case Development

• 700 PM (40 minutes after symptom onset)
• Patient arrives in the ED, where the triage nurse
  is awaiting her. The nurse immediately triages
  the patient to the critical care area of the ED
  and notifies the physician of the arrival and
  that she is a possible thrombolytic candidate.

What are the priorities of initial care?
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Key Target Times Recommended by NINDS

• The ED team should be aware of the
  NINDS-recommended targets for stroke evaluation
  of potential thrombolytic candidates.

What are the key target times in the
recommendations?
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Table 3. NINDS-Recommended Stroke Evaluation
Targets for Potential Thrombolytic Candidates

• Time TargetDoor to doctor 10 minutes
• Door to CT completion 25 minutes
• Door to CT read 45 minutes
• Door to treatment 60 minutes
• Access to neurological expertise 15 minutes
• Access to neurosurgical expertise 2 hours
• Admit to monitored bed 3 hours
• By phone or in person

1. What neurological assessments are appropriate
at this time? 2. What is the role of the NIH
Stroke Scale (NIHSS)?
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Immediate General Assessment Arrival

• Assess ABCs, vital signs
• Provide oxygen by nasal cannula
• Obtain IV access obtain blood samples(CBC,
  electrolytes, coagulation studies)
• Check blood sugar treat if indicated
• Perform general neurological screening assessment
• Alert Stroke Team neurologist, radiologist,CT
  technician

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Immediate Neurological Assessment From Arrival

• Review patient history
• Establish onset (thrombolytics)
• Perform physical examination
• Perform neurological examination? Determine
  level of consciousness (Glasgow Coma Scale)?
  Determine level of stroke severity (NIH Stroke
  Scale or Hunt and Hess Scale)
• Order urgent noncontrast CT scan(door-toCT scan
  performed goal
• Read CT scan (door-toCT read goal arrival)
• Perform lateral cervical spine x-ray (if patient
  comatose/history of trauma)

The NIHSS is 14.
What is the next step?
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Case Development

• The patient is transported to CT.
• During the scan her blood pressure is 190/100 mm
  Hg.

1. How should blood pressure be managed? 2.
When is aggressive management of hypertension
appropriate for the patient with acute stroke?
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Emergency Antihypertensive Therapy for Acute
Ischemic Stroke

• Blood Pressure Treatment
• Nonthrombolytic candidates
• 1. DBP 140 mm Hg

Sodium nitroprusside (0.5 ?g/kg per minute). Aim
for 10 to 20 reduction in DBP.
10 to 20 mg labetalol IV push over 1 to 2
minutes. May repeat or double labetalol every 20
minutes to a maximum dose of 150 mg.
2. SBP 220, or DBP 121 to 140, or MAP 130
mm Hg
Emergency antihypertensive therapy is deferred in
the absence of aortic dissection, acute
myocardial infarction, severe congestive heart
failure, or hypertensive encephalopathy.
3. SBP
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Emergency Antihypertensive Therapy for Acute
Ischemic Stroke

• Blood Pressure Treatment
• Thrombolytic candidates
• 1. SBP 185 or DBP 110 mm Hg

Pretreatment
1 to 2 inches of nitropaste or 1 to 2 doses of 10
to 20 mg labetalol IV push. If BP is not reduced
and maintained to should not be treated with TPA.
During and after treatment
1. Monitor BP
BP is monitored every 15 minutes for 2 hours,
then every 30 minutes for 6 hours, and then every
hour for 16 hours.
2. DBP 140 mm Hg
Sodium nitroprusside (0.5 ?g/kg per minute).
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Emergency Antihypertensive Therapy for Acute
Ischemic Stroke

• Blood Pressure Treatment
• Thrombolytic candidates
• 3. SBP 230 or DBP 121 to140 mm Hg

During and after treatment (continued)
(1) 10 mg labetalol IVP over 1 to 2 minutes. May
repeat or double labetalol every 10 minutes to a
maximum dose of 150 mg or give the initial
labetalol bolus and then start a labetalol drip
at 2 to 8 mg/min. (2) If BP is not controlled by
labetalol, consider sodium niroprusside. 10 mg
labetalol IVP. May repeat or double labetalol
every 10 to 20 minutes to a maximum dose of 150
mg or give initial labetalol bolus and then start
a labetalol drip at 2 to 8 mg/min.
4. SBP 180 to 230 or DBP 105 to 120 mm Hg
How do these recommendations differ if
hemorrhagic stroke rather than ischemic stroke is
suspected?
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Emergency Antihypertensive Therapy for
Hemorrhagic Stroke

• Blood Pressure Treatment
• 1. SBP 230 or DBP 120 mm Hg

Sodium nitroprusside (0.5 to 10 ?g/kg per
minute)or nitroglycerin drip (at 10 to 20
?g/min).
2. SBP 181 to 230 or DBP 106 to 120 mm Hg
Consider 10 mg labetalol IVP. May repeat or
double labetalol every 10 to 20 minutes to a
maximum dose of 300 mg. Or give initial labetalol
bolus and then start a labetalol drip at 2 to 8
mg/min.
3. For hypertension relative to prestroke
condition
If prehemorrhage BP is estimated to have been
considerably lower (eg, 120/80 mm Hg), then
antihypertensive therapy may be appropriate to
approximate premorbid pressures, particularly in
the first hours after subarachnoid hemorrhage.
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Case Development

• 740 PM (1 hour and 20 minutes after onset)
• Patient returns after CT scan. Her blood
  pressure is now 175/100 mm Hg without treatment.
  Discuss the effect of CT on management plans.

1. What do you expect the CT scan to show? 2.
How will that affect your plan of care?
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ACLS Case 10
What is significant about this CT scan?

• American Heart Association, Inc.

Acute Coronary Syndromes Case 10
30
ACLS Case 10
What is significant about this CT scan?

• American Heart Association, Inc.

Acute Coronary Syndromes Case 10
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ACLS Case 10
What is significant about this CT scan?

• American Heart Association, Inc.

Acute Coronary Syndromes Case 10
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Case Development

• While awaiting the reading of the CT scan, review
  inclusion and exclusion criteria for
  thrombolytics.

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Phase 3 Thrombolytic Therapy

• Learning Objectives
• Demonstrate familiarity with major inclusion and
  exclusion criteria for thrombolytic therapy for
  patients with acute ischemic stroke
• Demonstrate knowledge of potential benefits and
  complications of thrombolytic therapy for acute
  ischemic stroke

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Inclusion and Exclusion Criteria for TPA

• What are the inclusion and exclusion criteria for
  TPA?

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Thrombolytic Therapy Checklist for Ischemic Stroke

• All of the YES boxes and all of the NO boxes must
  be checked before thrombolytic therapy can be
  given.
• Inclusion Criteria (all YES boxes must be checked
  before treatment)
• YES
• ? Age 18 years or older
• ? Clinical diagnosis of ischemic stroke causing a
  measurable      neurological deficit
• ? Time of symptom onset well established to be
  180 minutes or      less before treatment would
  begin

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Thrombolytic Therapy Checklist for Ischemic Stroke

• Exclusion Criteria (all NO boxes must be checked
  before treatment)
• NO
• ? Evidence of intracranial hemorrhage on
  noncontrast head CT
• ? Only minor or rapidly improving stroke symptoms
• ? High clinical suspicion of subarachnoid
  hemorrhage even with normal CT
• ? Active internal bleeding (eg, gastrointestinal
  bleeding or urinary bleeding  within last 21
  days)
• ? Known bleeding diathesis, including but not
  limited to Platelet count Patient has received heparin within 48 hours and
  had an elevated activated   partial
  thromboplastin time (greater than upper limit of
  normal for laboratory) Recent use of
  anticoagulant (eg, warfarin sodium) and elevated
  prothrombin   time 15 seconds

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Thrombolytic Therapy Checklist for Ischemic Stroke

• Exclusion Criteria continued (all NO boxes must
  be checked before treatment)
• NO
• ? Within 3 months of intracranial surgery,
  serious head trauma, or previous        stroke
• ? Within 14 days of major surgery or serious
  trauma
• ? Recent arterial puncture at noncompressible
  site
• ? Lumbar puncture within 7 days
• ? History of intracranial hemorrhage,
  arteriovenous malformation, or aneurysm
• ? Witnessed seizure at stroke onset
• ? Recent acute myocardial infarction
• ? On repeated measurements, SBP 185 mm Hg or DBP
  110 mm Hg at time      of treatment, requiring
  aggressive treatment to reduce BP within these
  limits

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Branch A Ischemic Stroke With Potential for
Thrombolytic Therapy

• Case Development
• The nurse reports that the patients blood
  pressure is 190/100 mm Hg. The nurse notes that,
  according to the 1997 ECC Handbook, this blood
  pressure should be treated if thrombolytic
  therapy is contemplated.

What are your recommendations?
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Case Development

• Labetalol is administered, and blood pressure is
  reduced to 175/100 mm Hg.

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Case Development

• 750 PM (1 hour and 30 minutes from symptom
  onset)
• The CT scan is read as normal.

1. What therapeutic options are available? 2.
What are the potential benefits and complications
of TPA to be discussed with the patient and
family?
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Information for Patient and Family About
Thrombolytics

• Information for patients and families about
  thrombolytic therapy for acute ischemic stroke
• 30 likelihood of improvement to minimal or 
  no disability
• Increase in brain hemorrhage (0.6 to 6.4)
• No increase in mortality

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Case Development

• The patient and her family agree to TPA therapy.
  The patient weighs 80 kg.

1. What is the dose of TPA for this patient? 2.
What are the signs of complications of TPA
therapy,and how can they be detected and
treated?
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Case Development

• Should any other therapy be provided?

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Branch A Case Conclusion

• 24 hours after TPA treatment
• Patient has only mild weakness of the right arm,
  with an NIHSS score of 2.

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Branch B Hemorrhagic Stroke With Clinical
Deterioration

• Case Development
• 740 PM (1 hour and 20 minutes after symptom
  onset)
• Patient returns to ED after CT scan. She is
  markedly more lethargic, with shallow
  respirations and audible upper airway obstruction.

1. What therapy should be instituted? 2. What
information would be helpful at this point?
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Case Development

• 750 PM (1 hour and 30 minutes from symptom
  onset)
• The CT scan reveals a left basal ganglia
  hemorrhage measuring 40 mL with mass effect but
  no intraventricular extension. The patients
  blood pressure is 220/125 mm Hg.

What options for therapy are available?
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Case Development

• 800 PM (1 hour and 30 minutes after symptom
  onset)
• Labetalol has reduced blood pressure to 180/100
  mm Hg. A neurosurgeon is examining the patient.

Should any other therapy be provided?
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Post-CT Management for Branches A and B
Does CT scan showintracerebral orsubarachnoid
hemorrhage?
No
Yes
??Data
Probable acute ischemic stroke ??Review CT
exclusions are any observed? ??Repeat neurologic
exam are deficits variable or rapidly
improving? ??Review thrombolytic exclusions are
any observed? ??Review patient data is symptom
onset now 3 hours?
Consult neurosurgery
Initiate actions for acute hemorrhage Reverse
any anticoagulants Reverse any bleeding
disorder Monitor neurologic condition Treat
hypertension in awake patients
If high suspicion of subarachnoid hemorrhage
remains despite negative findings on CT scan,
perform lumbar puncture. (Lumbar puncture
excludes use of thrombolytic therapy.)
No to Allof Above
Blood on LP
??Decision
No Blood on LP
Patient remains candidate forthombolytic therapy?
No
Yes
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Post-CT Management for Branches A and B
??Decision
Initiate supportive therapy as
indicated Consider admission Consider
anticoagulation Consider additional conditions
needing treatment Consider alternative
diagnoses
Patient remains candidate forthombolytic therapy?
No
Yes
??Drug
Review risks/benefits with patient and family
If acceptableBegin thrombolytic treatment
(door-to-treatment goal neurologic status emergent CT if
deterioration Monitor BP treat as
indicated Admit to Critical Care Unit No
anticoagulants or antiplatelet treatment x 24
hours