Stroke Core Measures
This screen should be performed on ALL suspected and confirmed TIA/Stroke/Hemmorgahic patients prior to anything PO.
Bedside RN swallow screen. Complete Tier 1 and Tier 2, both tiers must pass to allow any PO.
What percentage of stroke are Ischemic?
Approx. 85%
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.
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)
What is the primary thrombolytic we use at UCH?
TNK!
This assessment MUST be completed PRIOR to any stroke intervention.
NIHSS. Can be completed by MD or RN.
Where can you find resources like the brain board or MRI form during a stroke alert?
In the Brain box over by pharmacy
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.
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)
What is the time frame a thrombolytic can be given?
Post tPA, what is the timing of your assessments of vitals and NIHSS?
4.5 hours from LKW. Yes, the wake-up protocol.
Q15 minutes for two hours, Q30 for 6 hours and Q1 for 12 hours
Use the yellow brain board to keep track!
You are working in the CDU today, you have a stroke patient who was admitted yesterday and is waiting for a bed upstairs. What interventions must this stroke patient have by the end of hospital day 2?
Aspirin (PO/NG/RE), SCDs on and/OR Lovenox or Heparin SQ administered.
What clinical presentation mimics an ischemic strokes?
Hypoglycemia. Each stroke alert should have a FSBS.
While in the CT scanner it has been determined your patient is out of the window for thrombolytic, however they found an LVO in the M1 region on CTA. LKW was 9 hours ago. What else can we offer this patient?
They may be able to go for a thrombectomy!
What are the initial blood pressure goals for someone with a hemorrhagic stroke?
SBP <140
What is the time from LKW that a thrombectomy can be performed?
24 hours from LKW
You have a TIA patient who is ready to DC to home. How do you educate this patient and where do you chart your education?
Educate on stroke risk factors, the signs and symptoms of a stroke, how to call 911, TIA follow up as an outpatient with tests if applicable, any new medications. Document in a blank note.
Why do we say time is brain?
Over 1.9 million neurons are lost in one minute of a LVO, can age the brain over 500 hours and is equivelant to the loss of a football field of neurons.
What is the time frame from LKW that thrombolytic can be given? Also, what is the primary thrombolytic we use here at UCH?
4.5 hours from LKW
We use TNK (Tenecteplase) here. tPA is ONLY used for wake-up strokes.
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 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 internal UCH time goals for thrombolytic administration? I.E. door to needle goal time?
Less than 60 minutes
Can you give thrombolytic 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 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 to UCH within 4.5 hours of waking up. Do you call a stroke alert?
Yes. Wake up stroke alert. This patient may be able to receive tPA.
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.
Can you as an ED RN administer a thrombolytic? What is the dose for TNK? How do we administer? If you are unsure, where can you find this info?
Yes! RNs are the primary administer of TNK or tPA.
0.25 mg/kg - MAX dose is 25mg!
It is a push over 5-10 seconds.
Badge card, the source stroke page, pharmacy, or your charge for information.