Download Acute Ischemic Stroke: Not a moment to loose

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