Stroke Treatments
Name the two stoke treaments we offer.
tPA and thrombectomy
Your patient has received tPA. What tool is available to you to help keep track of timing the serial vitals and NIHSS?
Yellow Brain Board, found in all front rooms, at charge desk and in brain box over by pharmacy.
What percentage of stroke are Ischemic?
Approx. 85%
Name the two types of hemorrhagic strokes. What is the biggest risk factor for each?
ICH = HTN SAH = aneurysm rupture (in patients without head trauma)
Who can call a stroke alert in the ED? How do you call an alert?
RNs, techs, MD, any staff can call a stroke alert.
What is the time frame tPA can be given? Is there an exception to this?
4.5 hours from LKW. Yes, the wake up protrocol.
Post tPA, what is the timing of your assessments of vitals and NIHSS?
Q15 minutes for two hours, Q30 for 6 hours and Q1 for 12 hours
Where can you find resources like the brain board or MRI form during a stroke alert?
In the Brain box over by pharmacy
Your patient in the scanner is discovered to have a large SAH. What assessments should you begin and what is the timing of these assessments?
Vital signs and Neuro check/Basic neuro assessment Q 15 minutes for 1 hour. (This is also an order placed by ED MD)
You have a patient with sudden onset of right leg weakness and aphasia who has arrived in your ED room, you call a stroke alert. The patient has stable ABCs, do you need an IV prior to CT?
No. The goal is to get to CT as quickly as possible. If the patient is stable go direct to CT. If a CTA is needed an IV can be started in the CT scanner.
What is the time frame thrombectomy can be performed?
24 hours from LKW
You notice during your 15 minute checks post tPA your patient is obtunded and their NIHSS has increased by greater than 4 points. What do you do?
Stop the tPA, go immediately to CT for a CTH.
What is the number one mimic for Ischemic strokes?
Hypoglycemia. Each stroke alert should have a FSBS.
What are the initial blood pressure goals for someone with a hemorrhagic stroke?
SBP <140
While in the CT scanner it has been determined your patient is out of the window for tPA, however they found a LVO in the M1 region on CTA. LKW was 9 hours ago. Is the stroke alert over? What else can we offer this patient?
No. They may be able to go for a thrombectomy.
Your patient was brought to the ED for sudden onset of aphasia 10.5 hours ago. During your NIH exam, you also note a visual field cut - the total NIHSS is 8. You suspect this is a large vessel occlusion stroke. Could this patient be eligible for intervention? What alert could we call?
Yes, possibly a thrombectomy candidate. LVO Stroke Alert for LKW >8 hours up to 24, NIHSS >=6, and a cortical sign (aphasia, neglect, field cut)
What are the two major side effects of tPA administration? Name interventions for both.
1. Angioedema. Stop tPA, Benadryl, solumedrol, prepare for possible intubation. 2. Bleeding. Stop tPA. Control BP. Prepare for possible blood product administration. Airway management.
Why do we say time is brain?
Over 1.9 million neurons are lost in one minute of an LVO, can age the brain over 500 hours, and is equivalent to the loss of a football field of neurons.
What lab(s) is important to monitor/check when your patient has a hemorrhagic stroke? What medications should you be aware of?
INR, Platelets, PTT - coags that are out of range. Anticoagulants.
Your patient is a wake-up stroke alert and after CT need to go down for emergent MRI to determine tPA eligibility. What do you need to complete prior to MRI? What if your patient is aphasic and there is no family?
MRI screening form. Then you must be pan x-rays of the head/chest/abd/pelvis to be cleared by rads prior to MRI. You will need x-ray orders, communicate the plan to MRI and help facilitate this happening quickly.
Can you as an ED RN administer tPA? What is the dose? How do we administer?
Yes. 0.9mg/kg. 10% is given as a bolus, the remainder is given over 1 hour, then line is flushed with 50ml of NS over 1 hour.
What is the BP goal before AND after tPA?
185/110 and 180/105
Can you give tPA to a patient with a NIHSS of 0? Why or why not?
Yes, the NIHSS does not completely assess for posterior stroke symptoms like dizziness or gait ataxia, nor does it test for hand weakness or swallowing. These can be disabling if not treated.
Your patient takes warfarin, and now has a head bleed, what should we consider for treatment?
Reverse and treat with procoagulants. Not all can be reversed. We can also give FFP, PLTS and Cryo.
Your patient arrives with stroke-like symptoms that were present upon waking this morning. When they went to bed at 10 pm last night they were normal. They arrived at UCH within 4.5 hours of waking up. Do you call a stroke alert? What kind?
Yes. Wake up stroke alert. This patient may be able to receive tPA.