Acute ischemic stroke: Not a moment to lose By Julie Miller, RN, CCRN, BSN, & Janice Mink, RN, CCRN,...
Transcript of Acute ischemic stroke: Not a moment to lose By Julie Miller, RN, CCRN, BSN, & Janice Mink, RN, CCRN,...
Acute ischemic stroke: Not a moment to lose
By Julie Miller, RN, CCRN, BSN, &
Janice Mink, RN, CCRN, CNRN
Nursing2009, May 2009
2.1 ANCC contact hours
Online: www.nursingcenter.com
© 2009 by Lippincott Williams & Wilkins. All world rights reserved.
Stroke
87% are ischemic, resulting from impaired blood flow to a localized area of the brain
Impaired circulation due to thrombosis, atherogenic plaque, or embolism
13% of strokes are from hemorrhage, rupture of a blood vessel (intracerebral or subarachnoid)
Major sites and sources of ischemic stroke
Improving response improves outcomes
In 1996, original AHA guidelines for use of rtPA, a fibrinolytic agent, were approved to treat acute ischemic stroke
Since then, transport, community awareness of acute stroke signs and symptoms, and treatment have improved immensely
Improving response improves outcomes
Research shows that most stroke patients now arrive at hospitals within 3 hours of symptom onset; more than half of these patients are transported via emergency medical transport
Treating acute ischemic stroke with I.V. rtPA within 3 hours of stroke onset dramatically reduces deaths and disabilities
Improving response improves outcomes
Recent advances in intra-arterial fibrinolysis and endovascular clot retrieval devices allow for effective intervention in some acute ischemic stroke patients who arrive up to 8 hours after onset of symptoms
Evaluating the patient using the seven D’s
1. Detection: early recognition of signs and symptoms onset, includes public education
2. Dispatch: EMS activation and rapid intervention
3. Delivery: advanced prehospital notification and transport to nearest acute stroke care facility
Evaluating the patient using the seven D’s
4. Door: rapid triage in ED, giving stroke signs and symptoms high priority
5. Data: history, neurologic assessment, diagnostic testing to include CT or MRI done within 25 minutes and read within 45 minutes
Evaluating the patient using the seven D’s
6. Decision: evaluation of inclusion and exclusion criteria for rtPA
7. Drug: initiation of weight-based rtPA within 3 hours of symptom onset
- patient meets all inclusion criteria
- has no exclusion criteria
AHA algorithm for suspected stroke
In first 10 minutes after arrival: Alert stroke team Assess patient’s ABCs and vital signs Establish or confirm venous access Treat abnormal glucose levels Obtain blood specimens for baseline Ensure CT order communicated to radiology to
be done upon patient’s arrival Obtain 12-lead ECG
AHA algorithm for suspected stroke
Within 25 minutes of arrival: Establish or confirm stroke symptom onset
Perform neurologic exam using NIHSS
Ensure CT or MRI has been started
Using a stroke assessment tool
National Institutes of Health Stroke Scale (NIHSS) offers tools for patients with language and motor difficulties
Administer NIHSS in this order:
- level of consciousness
- gaze
- visual fields
- facial movement
Using a stroke assessment tool
- motor function of arms and legs
- limb ataxia
- sensory responses
- language
- articulation
- extinction and inattention
Score greater than 22: patient has high risk of hemorrhage, requiring caution to use rtPA
Using a stroke assessment tool
Recommendation is to administer NIHSS every 12 hours for first 24 hours, then every 24 hours until discharge. Check facility’s stroke protocol for time frames
NIHSS must be administered the same way each time it’s performed, so all NIHSS evaluators should undergo same training to ensure accuracy, reliability, validity
Inclusion criteria that must be met for rtPA administration
18 years of age or older
Clinical diagnosis of acute ischemic stroke with measurable neurologic deficit
Time of symptom onset less than 180 minutes (3 hours) before fibrinolytic therapy would begin
Exclusion criteria for rtPA
History or evidence of intracranial hemorrhage
Multilobar infarction on CT scan
Signs of subarachnoid hemorrhage
Exclusion criteria for rtPA
Known arteriovenous malformation, neoplasm or aneurysm
Systolic BP >185 mmHg or diastolic >110 mmHg despite repeated measurements and treatment
Exclusion criteria for rtPA
Acute bleeding tendencies: - platelet count <100,00/mm3 - prothrombin time (PT) >15 seconds - international normalized ratio (INR) >1.7 - activated partial thromboplastin time (aPTT)
> upper normal limit
Active internal bleeding or acute trauma
Exclusion criteria for rtPA
Serious head trauma, stroke, or surgery in past 3 months
Arterial puncture at noncompressible site in last week
Postmyocardial infarction pericarditis
Minor or rapidly improving stroke symptoms
Exclusion criteria for rtPA
Abnormal blood glucose (<50 or >400 mg/dL)
Major surgery or serious trauma within 14 days
Recent acute MI (within 3 months)
Recent GI or urinary tract hemorrhage
Administering rtPA
Weight-based
Monitor patient’s neurologic status and BP
Risk of hemorrhage is higher if BP >180/105
Lower BP conservatively; 15 to 25% first day
Administering rtPA
Sodium nitroprusside is only drug recommended for treating BP not controlled by labetalol or nicardipine
Assess for signs of internal bleeding
Following rtPA administration, admit patient to ICU or stroke unit for close monitoring
How stroke centers compare
Brain Attack Coalition published recommendations in 2000 advocating for implementation of primary stroke centers and comprehensive stroke centers
Primary stroke centers have essential components to manage uncomplicated strokes: expert personnel, protocols, infrastructure, capacity to admit patients into a stroke unit
How stroke centers compare
Early evidence shows patients with acute ischemic stroke treated at a primary stroke center are more likely to receive fibrinolytic agents
Comprehensive stroke centers fulfill requirements for primary stroke centers, provide diagnostic services (MRI, interventional neuroradiology) for endovascular treatments
How stroke centers compare
Guidelines recommend transporting a patient suspected of having a stroke to closest, most appropriate facility; EMS should bypass facilities that don’t have resources or institutional commitment to treat a patient with stroke if a facility with proper resources is reasonably close
Other treatment options
Catheter-directed intra-arterial fibrinolysis for patients past 3-hour window
- inclusion criteria are same - exclusion criteria vary based on clinical trials
and facility protocols - can be administered up to 6 hours after
stroke - currently no fibrinolytic has FDA approval