Title text

1
(No Transcript)
2
Objective

• Review the Canadian Best Practice Recommendations
  for Stroke Care 2006 related to Acute Stroke
  Management
• Stroke Unit Care
• Brain Imaging
• Blood Glucose
• Acute Thrombolytic Treatment
• Carotid Artery Imaging
• Dysphagia Assessment
• Acute Aspirin Therapy
• Management of Subarachnoid and Intracerebral
  Hemorrhage

3
Canadian Best Practice Recommendations for Stroke
Care 2006

• Public Awareness and Responsiveness
• Patient and Caregiver Education
• Stroke Prevention
• Acute Stroke Management
• Stroke Rehabilitation and Community Reintegration
• Follow-up and Community Reintegration after
  Stroke

4
Canadian Best Practice Recommendations for Acute
Ischemic Stroke Management

• Acute Stroke Unit Care
• Brain Imaging
• Blood Glucose
• Acute Thrombolytic Treatment
• Carotid Artery Imaging
• Dysphagia Assessment
• Acute Aspirin Therapy
• Management of Subarachnoid and Intracerebral
  Hemorrhage

5
Management of Patients with Acute Ischemic Stroke
6
Objectives

• To review the goals of acute ischemic stroke
  management
• To review contributing factors to ischemic
  damage
• Blood pressure
• Blood Glucose
• Body Temperature
• Oxygen saturation
• To review the Best Practice Recommendations
  related to assessment
• Brain Imaging
• Carotid Artery Imaging
• Dysphagia Assessment

7
Objectives

• To review the Best Practice Recommendations
  related to interventions
• Acute Aspirin Therapy
• Acute Thrombolytic Treatment
• Acute Stroke Unit
• To review the Best Practice Recommendations
  related to Mgt of Subarachnoid and Intracerebral
  Hemorrhage
• To review acute complications of stroke
• Increased intracranial pressure
• Cerebral edema
• Hemorrhagic transformation
• Seizures
• Shoulder pain assessment and treatment

8
Goals of Acute Ischemic Stroke Management

• Reduce or minimize ischemic damage
• Reduce cerebral edema
• Prevent secondary complications
• Determine etiology of stroke
• Prevent recurrent stroke
• Facilitate access to rehabilitation and community
  reintegration

9
Contributing Factors to Ischemic Damage

• Blood pressure
• Blood glucose
• Body temperature
• Oxygen saturation

10
Contributing Factors to Ischemic Damage
Normal Brain Tissue
Dying Brain Tissue
Necrosis
Infarcted Brain Tissue
www.heartandstroke.ca/profed
11
Contributing Factors to Ischemic Damage Blood
Pressure

• Commonly seen in stroke patients
• Labile and may have spontaneous resolution
• May act as a compensatory mechanism to maintain
  cerebral perfusion

12
Contributing Factors to Ischemic Damage Blood
Pressure

• Blood pressure reduction
• Unclear guidelines, address cautiously
• Measure accurately, continuous monitoring
• AHA/ASA Guidelines recommend
• Initiate treatment if SBPgt220mmHg or DBPgt120mmHg
• tPA candidates Initiate treatment if SBPgt185mmHG
  or DBPgt110mmHG
• Lower blood pressure by 15-25 within 24 hours
• Medication selection on case by case basis but
  consider ability to lower blood pressure quickly
  but ability for rapid reversal

13
Contributing Factors to Ischemic Damage Blood
Pressure

• Timing of restarting blood pressure medications
  and selection of medications dependant on neuro
  status, stroke mechanism, swallowing ability and
  presence of other diseases

14
Blood Glucose Recommendation

• All patients with suspected acute stroke should
  have their blood glucose concentration checked
  immediately
• Blood glucose measurement should be repeated if
  the first value is abnormal or if the patient is
  known to have diabetes
• Hypoglycemia should be corrected immediately
• Markedly elevated blood glucose concentrations
  should be treated with glucose lowering agents
  (CSQCS, AustralianEvidence Level B-C)

15
Contributing Factors to Ischemic Damage Blood
Glucose

• Hyperglycemia
• Associated with worse stroke outcomes
• Independent adverse effect on prognosis
• Risk factor for hemorrhagic transformation
• Hypoglycemia
• Associated with focal neurological deficits
• Aphasia, hemiparesis, mental status changes

16
Contributing Factors to Ischemic Damage Body
Temperature

• Hyperthermia
• Adverse effect on outcome
• May be secondary to a cause of stroke
• Reduction of fever may improve prognosis

17
Contributing Factors to Ischemic Damage Oxygen
Saturation

• Hypoxia may exacerbate and worsen ischemic damage
• Consider possible causes of respiratory
  compromise
• Pneumonia
• Partial airway obstruction
• Hypoventilation
• Atelectasis
• Supplemental oxygen if pulse oximetry lt92

18
Brain ImagingCarotid Artery ImagingDysphagia
Assessment
19
Brain Imaging Recommendation

• All patients with suspected acute stroke should
  undergo brain imaging immediately
• In most instances, the modality of choice is a
  non-contrast CT scan
• If MRI is performed, the scan should include
  diffusion-weighted sequences to detect ischemia,
  and gradient echo and FLAIR sequences for
  hemorrhage. (CSQCS,RCP,NZEvidence Level B)

20
Non-Contrast CT Scan Acute Stroke

• www.strokecenter.org

21
Diffusion Weighted MRI Acute Stroke

• Gladstone, 2005

22
Carotid Artery Imaging Recommendation

• Carotid artery imaging should be performed within
  24 hours of a carotid territory TIA or
  non-disabling ischemic stroke unless the patient
  is not clearly a candidate for carotid
  endarterectomy. (CSQCS,BPS-WG,SIGN 14Evidence
  Level B)

23
Carotid Artery Doppler Ultra Sound
www.pacificvascular.com
www.texasheartinstitute.org
24
Dysphagia Assessment Recommendation

• All patients with stroke should have their
  swallow screened prior to initiating oral intake
  of fluids or food utilizing a simple valid
  reliable bedside testing protocol.
  (CSQCS,SCORE,SIGN 78,NZEvidence Level B)
• Patients with stroke presenting with features
  indicating dysphagia or pulmonary aspiration
  should receive a full clinical assessment of
  swallowing by an SLP or appropriately trained
  specialist who should advise on safe swallow and
  consistency of diet and fluids.
  (RCP,CSQCS,SCORE,NZEvidence Level A)

25

• Acute Aspirin TherapyAcute Thrombolytic Therapy
• Stroke Unit Care

26
Acute Aspirin Therapy

• After brain imaging has excluded intracranial
  hemorrhage, all acute stroke patients should be
  given at least 160mg of acetylsalicylic acid
  immediately as a one time loading dose
  (RCP,NZ,SIGN13Evidence Level A)
• In patients treated with tPA, ASA should be
  delayed until after the 24 hour post thrombolysis
  scan has excluded intracranial hemorrhage
  (RCP,NZEvidence Level A)
• ASA (50-325mg daily) should then be continued
  indefinitely or until an alternative
  antithrombotic regime is started (RCPEvidence
  Level A)
• Dysphagic patients,may be given ASA by enteral
  feeding tube or by rectal suppository
  (RCPEvidence Level A)

27
Acute Thrombolytic Treatment

• All acute ischemic stroke patients should be
  evaluated to determine their eligibility for
  treatment with intravenous tPA using the criteria
  from the NINDS tPA Stroke Study
• Administration of tPA should follow the ASA
  Guidelines (ASA, CSQCS,RCPEvidence Level A-B)
• All eligible patients should receive tPA within
  one hour of hospital arrival (CSQCS,RCPEvidence
  Level B-C)

28
Acute Thrombolytic Treatment

• Medical Redirect and Repatriation
• Triage
• Eligibilty and exclusionary criteria
• Stroke team
• tPA orders
• Target times

29
Acute Thrombolytic TreatmentMedical Redirect
and Repatriation

• Formal medical redirect and transfer agreements
• Ensure identified eligible stroke patients access
  to tPA
• EMS/Paramedics trained to assess and identify
  possible eligible candidates and activate Code
  Stroke
• Ambulance directed to Regional Stroke Centre
• Information needed estimated time of arrival,
  patient symptoms, established time of stroke
  onset
• Patients not meeting eligibility criteria are
  transported to nearest emergency facility
• Repatriation agreements
• Facilitate patient care closer to home after
  stroke centre care completed

30
Acute Thrombolytic TreatmentPre-Hospital Triage
and Eligibility Criteria

• Pre-hospital triage
• Rapid assessment using an acute stroke protocol
  with eligibility criteria
• Primary and secondary assessment
• Eligibility criteria
• Acute onset of new neurological deficits with
  reliably known time of onset and consistent with
  cerebrovascular disease in the cerebral
  hemispheres
• The deficit should be of a severity that would
  lead to decreased quality of life
• Ability to complete all investigations within the
  3 hour window
• Informed consent

31
Acute Thrombolytic Treatment Triage

• Emergency department triage
• Canadian Triage and Acuity Scale (CTAS) Level ll
  Emergent
• Triage of suspected stroke patients
• Airway, breathing, circulation (ABC)
• Neurological Level of consciousness, limb
  weakness, speech impairment, visual disturbance
• Quick history Previous functional independence
  level
• Time of onset Confirmed lt3 hours

32
Acute Thrombolytic Treatment Triage and
Exclusion Criteria

• Exclusion criteria (ASA Guidelines 2007)
• Neurological signs that are clearing
  spontaneously
• Symptoms of stroke that are suggestive of
  subarachnoid hemorrhage
• Onset of symptoms gt3 hours
• Head trauma or prior stroke within previous 3
  months
• Myocardial infarction within previous 3 months
• Gastrointestinal or urinary tract hemorrhage in
  previous 21 days
• Major surgery within the previous 14 days
• Arterial puncture at a noncompressible site in
  the previous 7 days
• History of previous intracranial hemorrhage

33
Acute Thrombolytic Treatment Triage and
Exclusion Criteria

• Exclusion criteria for intravenous tPA (AHA 2007)
• Elevated blood pressure gt185/110 mmHG that does
  not respond to treatment
• Evidence of active bleeding or acute trauma
  (fracture) on examination
• Taking oral anticoagulant and INR gt/1.5 ( 1.7)
• Receiving heparin in previous 48 hours with
  abnormal aPTT
• Platelet countlt100,000mm3
• Blood glucose lt2.7 mmol/L or gt22mmol/L
• Seizure with postictal residual neurological
  deficits
• CT evidence of multilobar infarction involving
  gt1/3 cerebral hemisphere or reveals cerebral
  hemorrhage
• The patient and family do not give consent for
  treatment

34
Optimal Stroke Management With tPA Stroke Team

• Benefits
• Reduces time to definitive treatment
• Early notification and mobilization further
  reduces time
• Critical to rapid diagnosis and treatment
• Composition
• Stage of care
• Stroke expert, emergency or family physician
• Medical, nursing staff, allied healthcare
  professionals
• Stroke survivor, family, support network central
  to team

35
Optimal Stroke Management With tPAStroke Orders

• Record stroke onset (last seen normal)
• Vital signs including temperature, O2 saturation,
  neuro assessment
• Capillary blood glucose
• STAT blood electrolytes, BUN, creatinine,
  glucose, CBC, PTT, INR, pregnancy test
• 12-lead ECG
• O2 at 2 L/minute by nasal cannula for oxygen
  saturation lt92
• IV NS TKVO, Saline lok
• Estimate patients weight (kg)
• STAT noncontrast CT of head
• Activate Code Stroke if lt3 hours
• Minimize invasive procedures, like catheterization

36
Optimal Stroke Management With tPA tPA Target
Times

• Rapid coordinated emergency response facilitates
  early diagnosis and treatment
• Door-to-triage 1 minute
• Door-to-stroke team notification 15 minutes
• Door-to-CT scan 25 minutes
• Door-to-needle 60 minutes

37
Adverse Effects of tPA Hemorrhage

• Superficial bleeding
• Observe potential bleeding sites venous
  arterial puncture, lacerations, etc.
• Avoid invasive procedures during tPA and for 24
  hours after
• Treat with compression
• Monitor all secretions for bleeding
• Intracranial hemorrhage
• Observe for deterioration of neuro status
• If suspected, stop tPA
• Obtain CT scan and coagulation workup

38
Adverse Effects of tPA Angioedema

• Risk assessment
• Inquire if patient has had angioedema in past
• Take ACE inhibitor history
• Although angiotensin II (ATII) receptor
  antagonists have not been implicated in the
  angioedema reaction, caution is advised in
  patients reporting a history of ATII antagonist
  use

39
Adverse Effects of tPA Angioedema

• Monitoring
• Observe for facial, tongue, and/or pharyngeal
  angioedema 30 minutes, 45 minutes, 60 minutes and
  75 minutes after initiation of IV tPA infusion
  and periodically for 24 hours afterwards

www.heartandstroke.ca/profed
40
Stroke Unit Care Recommendation

• Patients admitted to hospital because of an acute
  stroke should be treated in an interdisciplinary
  stroke unit. (CSQCS,SCORE,SIGN64 Evidence Level
  A)

www.healthsystem.virginia.edu/internet/neurology-t
raining/images/fellowship_stroke/6C_conversation.j
pg
41
Stroke Unit Care Recommendation

• Key components
• A stroke unit is a specialized, geographically
  defined hospital unit dedicated to the management
  of stroke patients (Australian,RCPEvidence
  LevelA/1)

42
Stroke Unit Care Recommendation

• The core interdisciplinary team should consist of
  appropriate levels of medical, nursing,
  nutrition, occupational therapy, physiotherapy,
  social work and speech-language pathology staff
• Additional disciplines may include pharmacy,
  (neuro)psychology and recreation therapy

43
Stroke Unit Care Recommendation

• The interdisciplinary team should assess patients
  within 48 hours of admission and formulate a
  management plan
• Clinicians should use standardized, valid
  assessments to evaluate the patients stroke
  related impairments and functional status
  (RCP,BPS-WGEvidence Level lll)

44
Canadian Best Practice RecommendationsManagement
of Subarachnoid and Intracerebral Hemorrhage
45
Management of Subarachnoid and Intracerebral
Hemorrhage

• Patients with suspected subarachnoid hemorrhage
  should have an urgent neurosurgical consultation
  for diagnosis and treatments (BPS-WGEvidence
  Level B)
• Patients with cerebellar hemorrhage should have
  an urgent neurosurgical consultation for
  consideration of craniotomy and evacuation of the
  hemorrhage (BPS-WGEvidence Level C)
• Patients with supratentorial intracerebral
  hemorrhage should be cared for on a stroke unit
  (BPS-WGEvidence Level B-C)

46
Management of Patients with Acute Ischemic Stroke
Acute Stroke Complications
47
Increased Intracranial Pressure and Cerebral Edema

• Typically occurs between 3 and 5 days
• Common with patients who have occlusion of the
  stem of the MCA
• Early swelling has been attributed to reperfusion
  edema and possible effects of tPA (ASA,2007)
• Malignant brain swelling patients with large
  territorial infarct that swells within 24 hours
  causing brain herniation.
• Cerebellar infarcts sudden apnea with brain stem
  compression and cardiac arrhythmias
• Anterior circulation strokes low risk (10-20)
  (Alexandrov Grotto,2002 del Zoppo et al, 1998)
• Incidence of edema in posterior circulation
  strokes in unknown

48
Increased Intracranial Pressure and Cerebral Edema

• Few signs predict clinical deterioration
• Multivariate analysis history of hypertension,
  heart failure, elevated white blood cell count,
  presence of gt50 MCA hypodensity and involvement
  of additional vascular territory (Kasner et al,
  2001)
• Management goal Prevention of further
  deterioration

49
Increased Intracranial Pressure

• Signs and Symptoms-Early
• ?LOC due to oxygen change and compression of RAS
• Pupil dysfunction due to CN 111 compression
• Motor weakness due to pyramidal tract pressure
• Sensory deficit due to compression of ascending
  tracts
• Cranial Nerve- extraoccular motor (3,4,6)
  compression
• Headache

50
Increased Intracranial Pressure

• Signs and Symptoms-Late
• ?LOC-coma
• Vomiting due to compression of 4th ventricle and
  brainstem
• Pupil- larger?fixed
• Hemiplegia
• Posturing-flexion (decorticate), extension
  (decerebrate)
• Vital signs- widening PP,?HR,RR changes
• Loss of corneal, gag reflexes

51
Cerebral Edema
P pressure
www.heartandstroke.ca/profed
52
Increased Intracranial Pressure and Cerebral Edema

• Management Strategies
• Assessment (Glasgow Coma Scale)
• Fluid restriction
• Treat hypoxia, hypercarbia and hyperthermia
• Elevate HOB 30
• Avoid hypertensive agents that cause vasdilation
• Late Stage hyperventilation, osmotic diuretics,
  drainage of cerebral spinal fluid, decompressive
  surgery, hypothermia

53
Hemorrhagic Transformation

• Many infarcts have some element of petechial
  hemorrhage present
• More common in 2nd week after stroke and larger
  strokes
• Location, size and cause of stroke
• Use of all antithrombotics, especially
  anticoagulants and thrombolytics increase risk
• Management depends on amount of bleeding and
  clinical presentation

54
Seizures

• Frequency in first few days 2-23
• Management is the same as neurological illness
• Prophylactic anticonvulsants not recommended

55
Shoulder Pain Assessment and Treatment

• Assessment should be conducted throughout the
  continuum of care
• Factors that contribute to or exacerbate shoulder
  pain should be identified and managed
  appropriately
• Staff and caregivers should be educated on
  correct handling (RCP,SCOREEvidence Level B)
• Consider use of supports for the arm
  (RCPEvidence Level A)

56
Shoulder Pain Assessment and Treatment

• Joint protection strategies should be instituted
  to minimize joint trauma
• The shoulder should not be passively moved past
  90 degrees of flexion and abduction unless the
  scapula is upwardly rotated and the humerus is
  laterally rotated (SCOREEvidence Level A)
• Overhead pulleys should not be used (Ottawa
  PanelEvidence Level A)
• The upper limb must be handled carefully during
  functional activities (SCORE Evidence Level B)
• Staff should position patients, whether lying or
  sitting, to minimize the risk of complications
  such as shoulder pain (RCPEvidence B)

57
Shoulder Pain Assessment and Treatment

• Shoulder pain and limitations in range of motion
  should be treated through gentle stretching and
  mobilization techniques focusing especially on
  external rotation and abduction (SCOREEvidence
  Level B)

58
Resources

• American Association of Neuroscience Nurses
• www.aann.org
• American Stroke Association
• www.strokeassociation.org
• Brain Attack Coalition
• www.stroke-site.org
• Canadian Hypertension Education Program
• www.hypertension.ca/chep/en/default.asp
• Canadian Stroke Strategy
• www.canadianstrokestrategy.ca
• European Stroke Initiative
• www.eusi-stroke.com

59
Resources

• Heart and Stroke Foundation Prof Ed
• www.heartandstroke.ca/profed
• Heart and Stroke Foundation of Canada
• www.heartandstroke.ca
• Internet Stroke Centre
• www.strokecenter.org
• National Institute of Neurological Disorders and
  Stroke
• www.ninds.nih.gov
• National Stroke Association
• www.stroke.org/site/PageServer?pagenameHOME
• Scottish Intercollegiate Guidelines Network
• www.sign.ac.uk
• StrokeEngine
• www.medicine.mcgill.ca/strokengine

60
(No Transcript)