Download Stroke

ACLS
CVA
What is a stroke?
20%
80%
Signs and Symptoms
The “Suddens”
• Sudden:
– numbness or weakness of face, arm, or leg
– confusion, trouble speaking or understanding
speech
– trouble seeing in one eye or both
– trouble walking, dizziness, loss of balance or
coordination
– severe headache with no known cause
Signs and Symptoms
• Speech Disturbance
– Aphasia: Inability to speak
– Dysphasia: Difficulty speaking
– Dysarthria: Impairment of the tongue muscles
essential to speech
Conditions that may mimic
stroke
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Altered mental status
Electrolyte imbalances (esp. Sodium)
Epidual or subdural hematoma
Brain abscess or tumor
Post-seizure
Migraine
Hypoglycemia
Timeline: Time is Brain
• MD at bedside within 5 min
of patient notification (in ED or inpatient)
• IV: 18 guage
• Labs (see orderset)
• CT within 25 min
• Neurology and Neuroradiology paged
immediately if patient is a t-PA candidate
• Note: Patients are eligible for t=PA up to
4.5 hours from first s/s
MANAGEMENT FOR PATIENTS PRESENTING
WITH NEW ONSET STROKE SYMPTOMS:
• Determine exact time of onset of symptoms and document in
medical record.
 Activate the Acute Stroke Protocol.
 Order STAT non-contrast head CT. CT Scan will be read by a
neurologist or radiologist.
 Obtain blood samples for STAT CBC, Platelets, BMP, PT, PTT,
fingerstick BS at bedside, bHCG (when applicable).
 CALL ext 5154 to notify the lab of a potential stroke patient
eligible for t-PA.
 Obtain ECG
• Insert one or two 18G or 20G peripheral IVs (2 IVs are
preferred)
Door to Needle
• The benefit of intravenous thrombolytic therapy in acute brain
ischemia is strongly time dependent
• Therapeutic yield is maximal in the first minutes after symptom
onset and declines steadily during the first 3 hours
– 1.9 million neurons lost per minute
– Every 10 minute delay in delivery of TPA, 1 fewer patient
has improved outcome
• BAC/AHA/NIH recommendation: door to needle (DTN) time
< 60 minutes
tPA and Ischemic Stroke Management
• tPA is recommended for treatment of ischemic stroke in
selected patients
• However, tPA is only administered to less than 3% of ischemic
stroke patients
• Delay in presentation contributes significantly to
underutilization of tPA for stroke
• Extending time window for tPA administration beyond the
current recommended 3 hrs might be beneficial.
• The European Cooperative Acute Stroke Study (ECASS III),
investigated tPA (alteplase) treatment in the 3.0 - 4.5 hour
window
5/6/2017© 2009, American Heart Association. All rights reserved.
Window for Treatment of Acute
Advisory
Information from the Expansion of the Time
Ischemic Stroke with IV TPA – Science
Recommendations
• tPA should be administered to eligible pts within 3.0-4.5 hours
after stroke (Class I Recommendation, LOE B)
• Eligibility criteria in this time period are similar to those for
persons treated at earlier time periods with the following
additional exclusion criteria:
– Age > 80 years; Oral anticoagulant use with INR ≤ 1.7*; baseline NIH
Stroke Scale score > 25; a history of stroke and diabetes (*For the 3.0 – 4.5
hr window all pts receiving oral anticoagulant are excluded whatever their
INR).
• The efficacy of IV rt-PA within 3.0 – 4.5 hours after stroke in
pts with these exclusion criteria is not well-established &
requires further study.
(Class IIb Recommendation, LOE C)
5/6/2017© 2009, American Heart Association. All rights reserved.
Information from the Expansion of the Time Window for Treatment of Acute
Ischemic Stroke with IV TPA – Science Advisory
AHA Recommendations: IV and IA
Thrombolysis
Intravenous
• Intravenous rtPA is recommended for selected patients who may
be treated within 3 hours of onset of ischemic stroke. (Class I,
LOE A)
• rt-PA should be administered to eligible pts within 3.0-4.5 hours
after stroke (Class I Recommendation, LOE B)
(Adams, Stroke 2007)
AHA Recommendations: IV and IA
Thrombolysis
Intra-Arterial
• Option for treatment of selected patients who have major
stroke of <6 hours’ duration due to occlusions of the MCA
and who are not otherwise candidates for IV rtPA (Class I,
LOE B)
• Reasonable in patients who have contraindications to use
of IV tPA, such as recent surgery (Class IIa, LOE C)
• Should generally not preclude IV tPA in otherwise eligible
patients
(Class III, LOE C)
(Adams, Stroke 2007)
All patients who are treated with TPA should
receive that treatment within 1 hour of arrival
to the hospital/emergency department.
T-PA Exclusions
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Evidence of intracranial hemorrhage on CT scan
Clinical presentation suggestive of subarachnoid hemorrhage
Multilobar infarction
History of intracranial hemorrhage
Uncontrolled HTN (SBP >185)
Known arteriovenous malformation
Witnessed seizure at stroke onset
Active internal bleeding
Acute bleeding diathesis
Within 3 months of intracranial or intraspinal surgery, head
trauma, or stroke
Relative Exclusions
• Within 14 days of major surgery or serious
trauma
• Resent GI or urinary tract hemorrhage
(within previous 21 days)
• Recent MI (within 3 months)
• Postmyocardial infarction pericarditis
• Abnormal blood glucose level
Imaging at MAH
• CT (with and without contrast)
• CTA
– perfusion studies
• MRI
• MRA
• Carotid imaging
Interventions and Treatment
• MAH
– Neuro-radiology Imaging
– Order-sets
• Ischemic stroke
• t-PA orderset
• Medications
– t-PA
– Prothrombin Complex Concentrate