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05.04 Stroke (CVA) Management in the ER

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Overview

Time and type are of the essence when it comes to stroke identification and treatment in the emergency department. When the symptoms started and whether the stroke is ischemic or hemorrhagic are the two most important details in determining the plan of care both in the ED and throughout their stay.

Nursing Points

General

  1. Check out the Med-Surg / Neuro lessons on stroke on NRSNG.com
  2. EMS Pre-notification
    1. Presentation
    2. FAST
    3. Baseline
    4. Time of onset
    5. NIH Stroke Scale
    6. Differentials
  3. Timeline Goals
    1. Door-to-doc
    2. Door-to-CT Scan
    3. Door-to-CT read
    4. Door-to-tPA

Assessment

  1. Presentation
    1. EMS Pre-notification
      1. Stroke Note – allows ED to preactivate Stroke Team with proper information
    2. FAST
      1. Facial droop
      2. Arm Drift
      3. Speech Problems
      4. Time – (time is tissue)
        1. When did the symptoms start – needs to be certain
    3. Baseline
      1. What is the patients normal activity and mental status
      2. Comorbities
        1. Diabetes
        2. Active UTI
        3. Other brain disorders (hydroceophalus, tumor, etc)
    4. Time of onset
      1. We mention this twice because its that important
    5. NIH Stroke Scale
      1. National standard
      2. Measurements of:
        1. Level of consciousness
        2. Horizontal eye movement
        3. Visual fields
        4. Facial palsy
        5. Arm and leg motor function
        6. Sensation
        7. Language and speech
        8. Neglect and innatention
          1. Total score of all assessments can range from 0-42
            1. The higher the score – the worse the situation
    6. Differentials 
      1. Finger Stick
        1. Hypoglycemia?
      2. Urine Sample
        1. UTI?
      3. Other Blood Work
        1. Other metabolic disorders?

Therapeutic Management

Treatment
  1. Ischemic
    1. tPA (Tissue Plasminogen Activator / Alteplase) – THE CLOT BUSTER
      1. Can be mixed in ED or by pharmacy
      2. IV infusion – Bolus then drip
    2. Percutaneous Thrombectomy
      1. Go in and get it!
  2. Hemorrhagic
    1. Ventricolostomy / EVD
    2. Craniotomy
  3. Timeline Goals
    1. Door-to-doc
      1. 10 Minutes
    2. Door-to-Stroke team notification
      1. 15 Minutes
    3. Door-to-CT Scan
      1. 25 Minutes
    4. Door-to-CT read
      1. 45 Minutes
    5. Door-to-tPA
      1. 60 minutes
      2. tPa sh9ould be within 3.5-4 hours of onset of symptoms

Nursing Concepts

  1. Intracranial Regulation
    1. Maintaining proper ICP
  2. Perfussion
    1. Reperfuse with tPA or reduce ICP with surgical procedures
  3. Prioritization
    1. All about time in the ED

Patient Education

  1. FAST
    1. Facial droop
    2. Arm Drift
    3. Speech Problems
    4. Time – (time is tissue)
  2. If there is any suspiscion of possibility of a stroke… do not hesitate, call 911!

Reference Links

Video Transcript

Hello everyone and welcome to today’s lesson on stroke code management in the emergency department.

Its really important to know what kind of stroke we are dealing with and that is usually established in the first 30-45 minutes a patient is in the ED. The reason this needs to happen quickly is that the treatment we give to cure one type of stroke can actually kill another type.

The assessment of these patients begins before they even get to you. EMS can be a huge help for these patients. If a stroke is suspected in the field, many EMS agencies can actually call ahead to the ED to let us know what is about to arrive. When we get the call, some hospitals will activate their stroke team prior to arrival so they can receive the patient at the door. Check with your facility about its protocols in relation to stroke response.

Keep in mind, I use the term “Code Stroke” through out this presentation, but the activation of the stroke or neuro team can have different names. I have heard “Code Silver”, “Code Neuro”, just know that the specific term is not important, it’s the fact that we are getting the proper people to the bedside as fast as possible.

When it comes to that early identification of a possible stroke, we like to use the F.A.S.T. mnemonic. F for facial droop. Is one side of the face drooping down, is there asymmetry to the muscles in the face? If they stick their tongue out, does it go to one side? A is for Arm Drift. Have them hold both arms straight out in front of them and watch to see if one slowly lowers. This is indicative of a neurogenic issue identified as contralateral weakness. S is for speech problems. Are they slurring their words? Are they having trouble getting their words out? Are they not making any sense with what they are saying? All of these are red flags. And T is for time. We need to know when the symptoms started. The saying “time is tissue” comes into play as the longer we wait, the less chance of recovery there is. This is vitally important in the cases of ischemic stroke as there is a window in which we can give the clot busting medication.

We need to know the patient’s baseline. What is his normal. If he normally slurs his words, we can’t trust that as a symptom. This may be someone who has had a previous stroke or has some speech impediment. If they are showing that one sided weakness, we need to know if this is new or chronic. We also want to know if the patient has any comorbidities that can be manifesting as stroke symptoms. Things like hypoglycemia, a raging active UTI or things like brain tumors, or hydrocephalus can all mimic the signs of a stroke.

Again…we need to know when the patients symptoms began. Like to the minute if possible. Saying it started this morning isn’t good enough, we need to know what time. That window for tPA closes quickly so there is a big difference if they were seen normal 3 hours ago as opposed to 6 hours ago.

One of the standards of stroke assessment is the NIH Stroke Scale. This is used across America as a tool to determine the severity of symptoms of our stroke patients. It is series of measurements that each have a score. It tests 13 items such as LOC, eyes, facial muscles, motor and sensory function, speech and orientation. Each category is graded and the total score can range from 0-42. The Actual sheets contain a picture to identify specific items such as a glove or a key, another picture that asks the patient to identify what is happening. It also contains a series of phrases for the patient to repeat and a series of words to remember.

You can view the entire NIH Stroke Scale assessment by clicking on the link within the lesson page here.

While we can suspect a stroke from the way the patient is presenting, there are some other conditions that mimic a stroke presentation. Hypoglycemia can cause the disorientation and slurred speech. A UTI absolutely can cause the changes in LOC as well as complete change in mental status. As well, the list of metabolic disorders than can cause changes is too long to list here but things like hyponatremia, hypercalcemia, sepsis, even something like a bad case of the flu, can all manifest symptoms that we could mistake for stroke. After a CT scan, we need to make sure we rule out or treat as many conditions as we can before moving on.

In the treatment of a stroke, there are what is known as “Timeline Goals”. These are specific metrics that every ED is supposed to meet in relation to the treatment of an acute stroke. The door to Doc, meaning the time that a patient arrives until they are evaluated by a physician (and this doesn’t have to be neuro, can be the ED doc) is 10 minutes. The door to stroke team notification is 15 minutes. From Door to CT scan should be no more than 30 minutes and that CT should be read by the 45 minute mark. And finally, the door to tPA administration is 60 minutes. Again…time is tissue. I will say, some facilities adjust these times for their own purposes, sometimes decreasing the times allowed. Always check with your facility on their stroke protocols.

Now…the moment we have all been waiting for….treating our stroke!

If we have determined that the patient is having an ischemic stroke, meaning that the CT scan has shown a blockage that we believe we can clear, it is time to mix up some CLOT BUSTER! This is known as tPA or tissue plasminogen activator. The trade name is commonly Alteplace or Activase. It usually comes in a box with 2 vials, a powder and a liquid for reconstitution as well as a spike to connect the two. Once mixed, the dosage is calculated as 0.9 mg/kg (not to exceed 90mg total  infused over 60 minutes). 10% of the treatment dose is given as a bolus over 1 minute and the remaining dose is infused over 60 minutes. Check with your facility, but every where I have worked, as tPA is infusing, the patient is under 1:1 nursing care.

If the tPA is ineffective, or the neurosurgeons think it will be ineffective, they can do a percutaneous thrombectomy. This is basically threading a catheter through the vessel with a grabby thing on the end (not sure the correct term, but just think of those claw machines at the arcade). They thread this up to the clot, grab it, and pull it out, and everyone gets a teddy bear. OK that last part isn’t true, but they do remove the clot manually. Its actually a really cool thing to watch, google it and you can find some pretty cool videos.

If the stroke is hemorrhagic, the primary concern is preventing the increase of intracranial pressure and stopping the bleeding. If its not too severe, neuro may be able to just do a ventriculostomy (you know, drilling some holes in the skull) and placing an extra ventricular drain to allow for gradual drainage. If its more severe, they may require a craniotomy to remove a piece of the skull to allow for more immediate drainage and decompression.

Some concepts to remember:

We always need to be aware of proper intracranial pressure and maintaining intracranial regulation. A hemorrhagic stroke is going to greatly affect this and increase those pressures.

With our ischemic strokes, perfusion is decreasing by the minute and needs to be corrected in order to save brain tissue.

And as we have said a few times, time is tissue. Follow the metrics on the door – to times in order to treat our patients safely and effectively but quickly.

Code Stroke, Code Silver…whatever you call it, if you see the symptoms, call the stroke team.

We can’t say it enough… time is tissue, try to get that time of onset and document it!

Be aware of your timeline goals. The times are the limits, it doesn’t mean we can’t move faster!

Treatment of course will depend on the type of stroke the patient is having.

And once we determine what type of stroke we are dealing with, be ready to administer the tPA or assist neuro with procedures in the ED or a trip to the OR.

OK guys, that our lesson on StrokeManagement in the ED. Thank you all for watching and as always…

HAPPY NURSING.

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