ACUTE STROKE

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ACUTE STROKE
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DEFINITION

• defined as a neurological deficit that has a
  sudden onset, lasting more than 24 hours and
  results from cerebrovascular disease
• Occurs when there is a disruption of blood flow
  to a region of the brain caused by obstruction of
  a vessel, thrombus or embolus, or the rupture of
  a vessel

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Stroke Statistics

• Affects 750,000 people a year in US.
• 3rd leading cause of death in the US
• 2nd leading cause of death in the world.
• Leading cause of disability and long term
  institutionalization in the US.
• Economic impact approx. 30 billion/yr.

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Stroke Statistics

• Most common in the elderly, but do occur in
  children and young adults.
• Kills twice as many women in the US than breast
  cancer.
• 8 of Men and 11 of Women will have a stroke
  within 6 years of having a heart attack.

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Are all ischemic strokes the same?

• 3 Types of ischemic strokes
• (88 of all strokes are ischemic)
• 1. Thrombotic stroke
• 2. Embolic stroke
• 3. Systemic Hypoperfusion

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Subarachnoid Hemorrhage

• Occurs when a blood vessel outside of the brain
  ruptures.
• Happens often at the site of cerebral aneurysms.
• Coiling less invasive than clipping.

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Aneurysm Clipping
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Intracerebral Hemorrhage

• Occurs when diseased blood vessel in brain burst.
• Medical Emergency must go to surgery.
• High mortality associated with ICH.
• 12 of all strokes.

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Stroke Risk FactorsNon-modifiable

• AGE
• Gender - Female
• Race Blacks gt Asians or Hispanicsgt Whites
• Family Hx.
• Coagulation Disorders
• Cardiac Disease

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Stroke Risk FactorsModifiable

• Hypertension
• Diabetes mellitus
• Hypercholesterolemia
• Elevated LDL or Low HDL
• Elevated homocystein
• Smoking
• Drug abuse

• Alcohol Abuse
• Oral Contraceptives
• Pregnancy
• Migraine Headaches
• Obesity
• Sleep apnea
• Carotid stenosis
• A combination of these risk factors will increase
  risk of stroke!

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Brain AttackSigns and Symptoms

• SUDDEN onset of symptoms
• Weakness, clumsiness, numbness or tingling on ONE
  side of the body
• Drooping on ONE side of the face
• Slurred speech or difficulty understanding
  language

• SUDDEN
• - Dizziness or imbalance
• - Unusually severe headache, worst headache in
  my life - SAH

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Brain AttackSigns and Symptoms F.A.S.T.

• F FACE sudden drooping of ONE side of the face.
• A ARM sudden numbness, clumsiness, or weakness
  of ONE arm/leg.
• S SPEECH sudden difficulty speaking or
  understanding language slurred speech.
• T TIME call 911 and get to the hospital
  immediately

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NIH STROKE SCALE

• http//asa.trainingcampus.net/uas/modules/trees/wi
  ndex.aspx
• Free online training program for healthcare
  professionals.
• Earn 2 contact hours for initial certification.

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EMS response to 911 call

• WILL QUESTION
• Time of onset of stroke symptoms.
• Determine nature of neurological symptoms
  (F.A.S.T.).
• NIH Stroke Scale or Glasgow Coma Scale
  (language/motor response/eye movement).
• Hx recent illness, surgery or trauma.
• Recent use of medication/illicit drugs/etoh.
• Notify receiving hospital that patient appears to
  be an acute stroke and gives time window.

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Stroke Alert

• EMS notifies receiving hospital of incoming acute
  stroke running hot
• 2 peripheral 18G IV of NS at 100 mls/hr
• Oxygen at 2 L/min
• HOB flat and monitor BP HR
• ECC staff prepare to meet the patient and notify
  radiology (CT) Staff of incoming possible stroke
  patient.

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Stroke Alert

• ECC staff receive patient from the EMS staff (RN
  and MD) goal Accomplish w/in 10 mins. of
  arrival
• Bedside Neuro exam (NIH Stroke Scale)
• Lab CHEM 8, CBC, Coags, Type Cross, Pregnancy
  test and drug screen if appropriate
• Vital signs-(treat blood pressure if indicated
  fever)
• 12 lead EKG (common problems w/ ICH and SAH)
• R/O seizure activity at the scene or in the ECC

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Stroke Alert

• ECC physician confirms acute stroke
• Neurology stat consult Stroke Alert
• Neurointerventional radiology standby
• Neuroscience Program coordinator (Rhonda
  Anderson, RN, MSN)
• Notifies ICU and 9WT re potential admission
• Notifies study coordinators of potential
  candidates
• Take patient to Radiology.

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Stroke Alert

• After the head CTRadiologist will discuss
  findings with Neurologist Goal is to complete
  within 25 mins of presentation.
• Determination made re best course of treatment
• Patient is screened for appropriateness for any
  current research studies.

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Stroke Alert

• If patient is candidate, then will proceed with
  thrombolytic therapy (t-PA).
• Dosing 0.9 mg/kg maximum dose less than or
  equal to 90mg.
• 10 of the total dose is administered as an IV
  bolus over 1 minute.
• Remaining 90 is infused over 60 minutes
• Follow up admit to ICU or Stroke Unit, monitor
  Vital signs, Maintain SBP greater than 185 mmHg
  No anticoagulant therapy for 24 hours.

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GOAL

• Provide thrombolytic within 60 mins of the
  patient reaching the ECC.
• Within the 3 hours of beginning signs and
  symptoms (or within 6 hours for basilar or
  vertebral arteries)
• Must be informed on time of start of symptoms in
  order to treat with thrombolytic.

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Contraindications for t-PA in Acute Stroke

• ICH/SAH on CT scan
• Recent intracranial surgery, serious head trauma,
  or previous stroke
• Hx of ICH
• Uncontrolled HTN at time of treatment
• Seizure at onset of stroke
• Active internal bleeding

• Intracranial neoplasm
• AV malformation
• Intracranial aneurysm
• Known bleeding diathesis
• Warfarin/Coumadin w/ PT greater than 5 secs or
  INR greater than 1.5.
• Administration of heparin within 48 hours
  preceding the stroke onset and an elevated aPTT.
• Platelet count less than 100,000.

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After T-PA Administration

• Watch for signs and symptoms of bleeding!
• Neuro changes occur quickly
• STAT call to MD
• 1st signs are HEADACHE AND VOMITING

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If you receive a Stroke pt. from the ECC

• Continue therapies begun in the ECC (Stroke Order
  Set in Carevision)
• Initiation of interventions to prevent medical or
  neurologic complications.
• Treating serious comorbid disease(s) or risk
  factors for stroke
• Evaluate for cause of stroke, which will affect
  plans for treatments to prevent recurrent stroke
• Discharge planning is initiated (stroke team
  eval PT/OT/Speech/ICM/Neuroscience coordinator)

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General Stroke Management

• NURSING CARE
• Vital signs and Neuro checks every 4 hours (NIHSS
  on neuro and ICU) Continue neuro checks up until
  discharge.
• Oxygen per NC and titrate for Sat greater than
  95
• Cardiac monitor
• DVT prophylaxis
• GI prophylaxis
• Euglycemia
• IO
• Pressure Ulcer Prevention
• Passive R.O.M. to prevent contractures or begin
  mobility.
• Pain management H/A tylenol is preferred, but
  for SAH, opiates may be needed antiemetics for
  NV.
• Activity
• PT/OT to evaluate for discharge planning
• GOAL Prevent Falls and mobilize within 24-48
  hours.

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General Acute Stroke Management

• DIAGNOSTIC TESTING
• 2D Echo ventricular or atrial clots/valve
  disease
• Carotid Doppler studies
• 12 lead EKG atrial fibrillation
• EEG if seizure activity noted
• MRI or MRA

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Medical Acute Stroke Management

• Strategies to control any seizure activity or
  brain edema begun in the ECC will continue
  Mannitol or Phenytoin/Depakote.
• Antihypertensive management
• Cholesterol lowering agents
• Aspirin, if ischemic stroke
• Beta Blockers to prevent cardiac complication

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General Management following admission to the
Hospital

• 10-20 of all stroke patients will experience a
  deterioration during the first 24 hours and
  outcomes in these patients are worse.

• Neurological worsening can be due to
• Brain edema
• Acute hydrocephalus
• Seizures
• Progression of thrombosis
• Early recurrent embolization
• Vasospasm -gtbrain ischemia
• Continued bleeding
• Recurrent hemorrhage
• Medical Complications

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In-House Stroke AlertsRAPID RESPONSE TEAM

• For sudden changes in Level of Consciousness or
  suspected stroke, call x3911 and tell the
  operator to page the Rapid Response Team to
  room______! Staff should also STAT page the
  attending/primary treating physician.
• RRT ICU nurse and RT will respond, assess the
  patient as would EMS, and can activate the STROKE
  ALERT order set. ICU or Intervention RN should
  accompany patient to radiology.

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Complications of Stroke

• Brain edema
• Hydrocephalus
• Elevated ICP
• Seizures
• Hemorrhagic transformation of infarction
• Recurrent Hemorrhage
• Acute delirium

• Recurrent ischemic stroke
• Depression
• Aspiration
• Atelectasis
• Pneumonia
• AMI
• CHF
• DVT
• Pulmonary Embolism

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Complications of Stroke, cont.

• Cardiac arrhythmias
• Hypertension
• Stress ulcers
• GI bleeds
• Constipation
• Dehydration
• Electrolyte Imbalance
• Malnutrition

• Hyperglycemia
• Urinary incontinence
• UTI
• Pressure Ulcers
• Contractures
• FALLS with/without fractures

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Lifestyle changes to prevent a second stroke

• STOP SMOKING!
• STOP SMOKING!
• STOP SMOKING!
• Provide smoking cessation information and
  document your education!

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American Heart Association Eating Plan for
Healthy Americans Include

• Eat a variety of fruits and vegetables5
  servings/day.
• Eat a variety of whole grain products6
  servings/day.
• Include fat-free and low-fat milk products, fish,
  legumes, skinless poultry and lean meats.
• Choose fats and oils with 2 grams or less
  saturated fat/tablespoon such as liquid and tub
  margarines, canola oil and olive oil.

• Limit intake of food with high calories and low
  nutrition including soft drinks and candy.
• Limit saturated fat, trans fat and cholesterol by
  avoiding full-fat milk, fatty meats, tropical
  oils, partially hydrogenated vegetable oils and
  egg yolks.
• Aim for less than 200 mg of cholesterol each day.
  

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Eating a Healthy Diet

• Eating a healthy diet can help to change 3
  modifiable risk factors for a second stroke
• Lower high cholesterol
• Lower high blood pressure
• Decrease extra body weight!
• Stroke survivors should get less than 30 of
  their calories from fat, and less than 7 from
  saturated fat. For a 2,000 cal diet that
  translated into less than 67 grams of fat/day.

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MANAGE CHOLESTEROLLDL and HDL

• GET MOVING!

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LOWER BLOOD PRESSURE

• HYPERTENSION is a major risk factor for a primary
  and secondary stroke.
• Compliance with medical management of
  hypertension is crucial.
• Blood Pressure readings should be below 120/80.

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LIMIT AMOUNT OF ALCOHOL INTAKE

• Women should have no more than one drink per day
  and men no more than two per day.
• NO Illegal Drug use IV drug abuse has high
  incident of stroke. (Cocaine, Meth, Heroine)

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MAINTAIN GOOD CONTROL OVER BLOOD GLUCOSE LEVELS

• Having good glycemic control will reduce the
  occurrence of microvascular complications that
  could lead to a stroke.

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ANTIPLATELET ANGENTS

• Stress the importance of compliance with
  antiplatelet agents.
• Aspirin, Plavix, ticlopidine or Aggrenox will
  help prevent the formation of clots in small
  arteries as platelets stick together.

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EDUCATION IS KEY!

• Educate patients and family members of stroke
  victims on modifiable risk factors and lifestyle
  changes that will prevent disability or death
  caused by a second ischemic stroke.

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FLOWSHEET DOCUMENTATION
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Document Neurological Education
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Patient Family Stroke Education Classes
Tuesdays at 1100 a.m. or Thursdays at 200 p.m.
in the 9WT waiting room.

• Patients Families are encouraged to attend a 45
  minute class to learn about
• Signs Symptoms of Stroke
• Risk Factor modification to prevent a second
  stroke
• Medications
• Stroke Recovery Rehabilitation therapy
• Discharge planning

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EDUCATION TOPICS FOR THE STROKE PATIENT

• Stop Smoking
• Healthy Diet
• Manage Cholesterol
• Increase physical activity
• Lower blood pressure
• Limit alcohol, no illicit drugs
• Maintain good blood sugar
• Take antiplatelet agents as prescribed