Care of the Stroke Patient Improving Patient Outcomes

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Care of the Stroke PatientImproving 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
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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

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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)

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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

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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
• Its 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 shouldnt be used

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Significance, Types, and Risk Factors for Stroke
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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 patients 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

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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

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Types of Strokes
Ischemic Stroke
Hemorrhagic stroke
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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
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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.
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Stroke Subtypes and Incidence
Hemorrhagic stroke15
Rare causes of stroke include things like
coagulation disorders, drug abuse, etc.
Other5
Like heart disease atherosclerotic plaque causes
clot or debris to dislodge and occlude brain
arteries.
Cryptogenic30
There is lots we still dont understand about
stroke, and sometimes there are no clear reasons
for one.
Atherosclerotic cerebrovascular disease 20
Small vessel disease lacunes 25
Cardiogenicembolism20
Ischemic stroke85
Chronic injury causes local injury to small
vessels directly in the brain.
Clots from the heart travel to the brain (e.g. in
atrial fibrillation).
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Risk Factors for Stroke
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Risk FactorsModifiable 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 lt 130mg/dl
• HDL gt 45mg/dl
• Diabetes controlling blood sugar may reduce
  stroke risk

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• Smoking smokers have twice the risk of
  non-smokers 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 3-4 times greater stroke risk
• Medications and lifestyle changes can
  dramatically reduce many of these risks

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Risk FactorsNon-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 ones risk

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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

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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!

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Know the Signs of Stroke
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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

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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

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Cincinnati Stroke Scale
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Differential Diagnosis

• Rule out other causes of weakness or altered
  mental status
• Hypoglycemia
• Trauma (recent head injury or fall)
• Tumor (slow onset)
• Seizure disorder (post seizure paralysis)

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Management of Ischemic Stroke
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Management of Ischemic Stroke

• Perform appropriate initial and ongoing
  assessments
• Implement SAEMS Stroke Standing Order
• 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

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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.

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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

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Monitoring Parameters

• Temperature
• Increased temperature causes increased metabolic
  demand
• Cardiac rhythm rate
• Risk of arrhythmia and MI

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Monitoring Parameters

• Neurologic exam
• Level of consciousness
• Cognitive function
• Physical status
• Oxygenation
• Hydration
• Anticipate complications

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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 riskand cardiac riskin the next few days

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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

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Timing of Stroke Management
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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

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Acute Stroke Thrombolysis tPA

• Tissue plasminogen activator (tPA) is a synthetic
  version of one of the bodys 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

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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 lt5 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

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Benefits of tPA are greatest when delivered early
after stroke onset
Marler et al., Neurology 2000 551649
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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.

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Common Complications of Stroke

• 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

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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

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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 hospitals ability to
  deliver comprehensive stroke care

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Time is BrainEMS is a CRUCIAL Component!