Stroke Treatments
What are two primary ischemic stroke treatments?
Thrombolytics (TNK) and thrombectomy
Use this to keep track of assessments post TNK
Yellow Brain Board, found in all front rooms, at charge desk and in brain box over by pharmacy.
What is a VAN positive exam?
Arm weakness AND one or more of the following symptoms present: Neglect; Aphasia; vision (field cut or gaze preference)
What are the two types of hemorrhagic strokes?
ICH (intracerebral) = HTN
SAH (subarachnoid) = aneurysm rupture (in patients without head trauma)
What is the criteria to call a stroke alert?
Last known well time <4.5hrs OR arriving to the ED within 4.5hrs of waking up with symptoms
BE FAST exam positive (One or more of the symptoms present)
LVO Criteria = LKW 4.5-24 hours and VAN positive exam
What is the time frame to be eligible for TNK?
4.5 hours from LKW.
What are the BP goals before and after thrombolytic?
Pre - 185/110
Post -180/105
What is the neglect/inattention phenomenon? How can you assess for it?
During a right sided stroke the right parietal lobe, responsible for PERCEPTION of the body and surrounding can be affected, causing the patient to neglect or ignore the left side of the body and environment.
Your patient is found to have a SAH while in CT. What assessments should you begin?
Vital signs and Neuro check/Basic neuro assessment Q 15 minutes for 1 hour. (This is also an order placed by ED MD)
What does the acronym BE FAST stand for?
B - Balance
E - Eyes/vision changes
F - facial drooping
A - arm (or leg) weakness/numbness
S - speech difficulty - dysarthria, aphasia
T- LKW < 4.5 hours? Time to call a stroke alert!
Your patient is out of the window for TNK, BUT they have a LVO in the M1 region on CTA. LKW was 9 hours ago. What else can we offer this patient emergently?
Thrombectomy!
Just because they can't get TNK doesn't mean we can't intervene!
can be performed up to 24 hours from LKW
Your patient is obtunded and their NIHSS has increased by greater than 4 points. What do you do?
Alert MD. Go immediately to CT for a CTH.
Time is Brain, why?
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 are the initial blood pressure goals for a hemorrhagic stroke?
SBP 130-150
Neurosurgery may make changes to BP parameters once they are involved, however initial BP goals until that time are 130-150.
What does VAN stand for?
•Vision - Has forced gaze or preference to one side or lost vision on one side.
•Aphasia - Difficulty understanding or producing language
•Neglect - Ignoring one side of their body, unable to feel both sides at the same time or unable to identify own arm
Can you give thrombolytic to a patient with a NIHSS of 0?
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 permanently disabling if not treated.
What are two possible side effects of thrombolytic administration?
1. Angioedema. Benadryl, solumedrol, famotidine, prepare for possible intubation.
2. Bleeding. Control BP. Prepare for possible blood product administration. Airway management.
A right gaze preference and left sided weakness indicates which side of the brain is being affected by a stroke?
Right side!
Patients will look toward their stroke and have weakness on the opposite side.
Seizures will look away from the area of brain affected and will have weakness on the same side.
What titratable gtt is used to control BP in hemorrhagic stroke? How often can you titrate?
Cardene!
Start at 5mg/hr and can titrate Q5-15 minute for BP goal.
NEVER start pressors to get to BP goal unless patient is hemodynamically unstable and medically necessary.
What is a 'wake up stroke', can we give a wake-up stroke thrombolytic? Can they go for thrombectomy?
Wake up stroke is a patient whose LKW was before bed, and they woke with symptoms - to be eligible for thrombolytic they must arrive to the ED within 4 hours of waking with symptoms.
-MRI, MRI screening form, we use tPA for wake up
- Can go to IR if there is a LVO
Can an ED RN administer TNK?
Yes. 0.25 mg/kg with a max dose of 25mg. 5-10 second IV push followed by NS flush.
What is the max dose for TNK for stroke?
25 mg!
My patient went to bed normal, woke up with symptoms and arrived in the ED less than 4.5 hours from waking up. Is this a stroke alert?
Yes, this is considered a wake-up stroke!
They may be eligible for tPA. A CT and rapid MRI will be completed to determine if their stroke is less than 4.5 hours old.
What is the time goal to get an ICH or SAH blood pressure between 130-150?
60 minutes!
What is a VAN positive exam?
Arm weakness AND one or more of the following symptoms present: Neglect; Aphasia; vision (field cut or gaze preference)