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Stroke

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by

Lauren Meade

on 18 July 2013

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Transcript of Stroke

tPA
DOSING
0.9mg/kg
Give 10% BOLUS over 1 minute
Give remaining 90% over 1 hour
MAX: 90mg
MERCI and PENUMBRA
National Institute of Health Stroke Scale

The NIHSS is a 15-item neurologic examination stroke scale used to evaluate the effect of acute cerebral infarction on the levels of consciousness, language, neglect, visual-field loss, extraocular movement, motor strength, ataxia, dysarthria, and sensory loss and it requires less than 10 min to complete.
Blood Pressure Management
Goal: Fast and effective control of blood pressure
Ana Esteban BSN RN PCCN CCRN
Adrian Sanchez BSN RN
Dave Rose RN
Lauren Meade BSN RN
Naomi James BSN RN BC



St. Joseph's Regional Medical Center
Paterson, NJ

Stroke Care
The First 24 Hours
WHY?
In states of poor flow to the brain, such as in an ischemic or hemorragic stroke, the brain loses it's vasoregulatory capabilities. The brain then relies directly on MAP and cardiac output to maintain cerebral blood flow.

Rapid reduction of blood pressure


Decreased perfusion pressure


Worsening/Prolonging of ischemia
Ischemic vs. Hemorrhagic Stroke
Ischemic
Keep SBP 140-160
USE: Labetalol
1 mcg/min
TITRATE up to 20 mcg/min
DO

NOT
USE: IV Nitroglycerin
venous dilator
increases ICP and decreases CPP
NEVER
USE: IV Nitroprusside
vasodilates
severely decreases CPP
Avoid antihypertensives UNLESS systolic
B/P is >185mmHg or Diastolic >105
Follow recommendations from physicians and neurologist for specific parameters
Pre tPA B/P must be <185/<110
Due to risk of hemorrhage be extra stringent post tPA with B/P control
DO NOT USE:
sublingual nifedipine
nitropaste
cause extreme hypotension
Hemorrhagic
Follow guidelines specified by physician
May consider decreasing B/P by 15% during the first 24 hours of stroke
Preexisting HTN? may start meds 24 hours post stroke
Arterial line may be recommended
Nicardipine
Initiating a drip?
Reassess B/P q5min
Continue to monitor q15min until parameters are reached
Calcium Channel Blocker: prevents vasospasm and selective for cerebral vasculature
TITRATION:
START: 2.5 mg or 5 mg/hour
TITRATE: q15min by 2.5mg/hour
MAX: 15mg/hour
NIHSS
M
echanical
E
mbolus
R
etrieval in
C
erebral
I
schemia
Clot retrieving system
Retriever catheter inserted in the femoral artery and threaded to point of occlusion in brain
Cork screw shaped catheter transverses and ensares thrombus
Thrombus removed by traction
Penumbra
based on aspiration
microcatheters connected to aspiration pump
tear-drop shaped separator is advanced and retracted within the lumen of the reperfusion catheter
debulks the clot for aspiration
Non-pharmalogic methods to remove clots and reperfuse brain
Consider in patients who do not qualify for IV fibrinolysis
tPA may still be administered
Outcomes improved with fewer delays in therapy
Studies are inconclusive for ultimate patient outcomes but find that these interventions are useful in recanalizing the occluded artery
Before
Eligible?
Blood pressure control
Baseline NIHSS score
Prior to administering rt-PA make sure all invasive lines are in place
Pharmacy mixes t-PA
Inclusion Criteria:
Diagnosis of acute ischemic stroke
Ability to begin within 3 hrs of onset
No contraindications
18 years or older
DURING
2 licensed practitioners to verify dose and rate
Bolus administered by neurologist, 3rd year resident, or APN
Neuro assessment and VS q15min
Call physician if B/P >185 or <110/ >105 or <60
Change in neuro status?
STOP
tPA immediately!
AFTER
Continue with VS/Neuro checks follow post tpa flow sheet and requirements
Follow up Brain CT/MRI
Monitor bleeding
Cardiac Monitoring
Strict I+O
No heparin, warfarin, ASA, clopidogrel, dipyridamole for 24 hours
Labs
Basic metabolic panel
PT/PTT/INR
Lipid Panel
CBC
Type and Screen
Blood Glucose (must precede tPA)
CT head
without contrast within
30 minutes
Recognize
symptoms
and
time
of onset
2
antecubital lines
Initiate
stroke scale
Telestroke
What is Telestroke?
Identifying Stroke
Signs by Cerebral Area
Comprehensive Stroke Center

Comprehensive stroke centers are similar to primary stroke centers, but they also have additional capabilities:
Healthcare personnel with specific expertise in many disciplines, including neurosurgery and vascular neurology
Advanced neuroimaging capabilities, such as magnetic resonance imaging (MRI) and cerebral angiography
Surgical and endovascular techniques
An ICU and stroke registry
Left Hemisphere
Left gaze preference
Right visual field deficit
Right hemiparesis
Right hemisensory loss
Right (Nondominant Hemisphere
Left visual field deficit
Left hemiparesis
Left hemisensory loss neglect (left hemi-inattention
Brain Stem
N/V
Diplopia, dysconjugate gaze, gaze palsy
Dysarthria, dysphagia
Vertigo, tinnitus
Hemiparesis or quadriplegia
Sensory loss in hemibody or all 4 limbs
Decreased consciousness
Hiccups, abnormal respirations
Cerebellum
Truncal/gait ataxia
Limb ataxia
Neck stiffness
Risk Factors
Ishemic Stroke:
HTN
Diabetes
Heart Disease
Smoking
High Cholesterol
Male gender
Age
Ethnicity/Race
Hemorrhagic Stroke:
Hypertension
African American race
Vascular malformation
Excessive ETOH use
Hemorrahagic vs Ischemic
Symptoms
Focal neurological deficits as in AIS
Headache
Neck pain
Light intolerance
N/V
Decreased LOC
Symptoms
Weakness in an extremity of one side of body
Sensory changes
Difficulty speaking or understanding speech
Facial droop
Visual changes
Stroke Code
Goals
Speed screening and assessment rapidly by the Stroke Code Team
Facilitate timely delivery of t-PA therapy
Assist in the initiation of interventional procedures
Call 4444
Provide location of Stroke Code
Patients Name
Callback number
Caller's Name
Administer
tPA
within 1 hour if eligible
Cautionary Signs
NIH >22
Recent MI
Left heart thrombus
Recent trauma
Difficult to control HTN
Early signs of acute stroke on CT scan: large middle cerebral artery involvement with hypodensity, blurring of gray-white margins, or sulcal effacement in 1/3 of the middle cerebral distribution
Hemorrhagic ophthalmic conditions
Age >85
Exclusion Criteria
Onset of Stroke is >3 hours
Additional exclusion criteria for IV tPA 3-4.5 hours: >80 years old, NIHSS >25 or history of CVA/DM
CT showing hemorrhage, atrio-ventriculuar malformation, tumor, aneurysm
Stroke or serious head trauma within 3 months
Past history of significant brain hemorrhage
SBP >180 or DBP >105 (on 3 occassions, 10 minutes apart) despite IV anti-HTN
Seizures activity before or during current stroke
Active internal bleeding
GI hemorhage, urinary tract hemorrhage, other significant bleeding within previous 21 days
Coagulopathy with PT>15, INR >1.7, elevated PTT or platelet count <100,000
Admin of heparin within 48 hours with an elevated PTT
Intracranial neoplasm or mass lesion or evidence of cerebral herniation
Glucose concentration <50 or >400
Hypersensitivity to tPA
Major surgery of serious trauma within 14 days
The stroke scale is valid for predicting lesion size and can serve as a measure of stroke severity.
Shown to be a predictor of both short and long term outcome of stroke patients and serves as a data collection tool for planning patient care and providing a common language for information exchanges among healthcare providers.
•Provides a quantitative measure of stroke-related neurologic deficit.
•The scale is widely used as a clinical assessment tool to evaluate acuity of stroke patients, determine appropriate treatment, and predict patient outcome. •The NIHSS can be used as a clinical stroke assessment tool to evaluate and document neurological status in acute stroke patients.
Completed NIHSS Form
Telestroke technology can provide improved stroke care to patients in underserved areas.

Telestroke is the use of telemedicine specifically for stroke care. Telemedicine is the use of electronic communication methods, such as telephone, Internet, and videoconferencing, to exchange medical information from one geographic site to another.
Hub hospital
The hub hospital is a larger institution, such as a comprehensive stroke center or a tertiary care facility, that provides physician call coverage service for remote consultation with facilities that require such coverage
Spoke Hospital
The spoke hospital is an institution that does not have specialists covering their emergency room and require remote consultation for acute medical conditions.
The consulting physician is typically, but not always, affliated with the hub hospital and provides call coverage services to spoke hospital emergency rooms
Acknowledgments
Dana Reiner-Beenstock RN, MSN, APN-C, CNRN, AVNP-BC
Clinical Manager of the Neuroscience Service Line
Nurse Practitioner Neurology Stroke Center
St. Joseph's Regional Medical Center

Rowena Estrera-Portal BSN, CCRN, CLNC
Nurse Manager, Medical Intensive Care Unit
St. Joseph's Regional Medical Center

Hemorrhagic Stroke Management
Aneurysm Clipping
Craniotomy with Evacuation of Hematoma
Goal: To isolate aneuryms from normal circulation without blocking off any small perforating arteries

Procedure:
Opening of skull
Aneuryms located with retractors
Small clip placed at base of aneurysm to block blood flow

Nursing Care:
Neuro Checks
Monitor for signs of vasospasm (arm/leg weakness, confusion, lethargy, restlessness) or seizure
Possible angiogram to ensure that there has not been a growth of the aneurysm

Goal: Remove hematoma and decompress brain

Procedure:
Depends on hematoma size, age, location, and patient medical and neuro status
Craniotomy performed over the thickest portion of the clot to decompress brain
Active bleeding stopped
Suction used to remove blood
ICP monitor may be placed

Nursing Care:
ICP should be <20 and CPP 60-70
Increased ICP? CT to look for new intracranial mass lesion or reaccumulation of the hematoma
Neurochecks
CT within 24 hours to monitor for residual hematoma
Monitor PT/PTT/INR/Platelets to lessen the risk of bleeding
Monitor for seizure activity
NIHSS in Soarian
Jimmy's Story
External Ventricular Drain
External drainage and monitoring is the temporary drainage of cerebrospinal fluid (CSF) from the lateral ventricles of the brain, or the lumbar space of the spine, into an external collection bag. An external ventricular drainage (EVD) system drains CSF by using a combination of gravity and intercerebral pressure. The drainage rate depends on the height at which the EVD system is placed relative to the patient’s anatomy.

Indications
EVDs are used in neuro critical care situations to:

Monitor and relieve elevated intracranial pressure (ICP)
Drain infected CSF
Drain bloody CSF or blood after surgery or hemorrhage
Monitor the flow rate of CSF

Contraindications
Pt's with bleeding disorder or on anticoagulants
Scalp infections
Brain abscess

Complications
Infections:
meningitis, ventriculitis, and wound infections
Overdrainage:
Intracranial hemorrhage and /or permanent neurological deficit
Frequent punctures in order for insertion:
predispose to intracerebral hemorrhage and edema leading to a further rise in Intracranial Pressure (ICP)


Intracranial Pressure Monitoring
Camino Intracranial Pressure Monitor
This type provides ICP data only (commonly referred to as a “bolt”),

Bolts commonly use fiberoptic technology that allows for continuous ICP monitoring without CSF drainage.

Nursing Responsibilities
Patient has a valid and correct completed  EVD treatment order
Reportable limits are noted and adhered to .
EVD drainage point is set at the prescribed level (as set per Neurosurgeon )
EVD transducer is leveled to the patient's external auditory meatus (Tragus)
EVD column is oscillating and patent.
ICP waveform is pulsatile on monitor
Head dressing is dry and intact
Observe and record volume level of CSF in burette
Report any signs of changes in patient's neurological condition to medical staff
Full transcript