Acute ischemic stroke: Not a moment to lose By Julie Miller, RN, CCRN, BSN, & Janice Mink, RN, CCRN, CNRN Nursing2009, May ANCC contact hours Online: © 2009 by Lippincott Williams & Wilkins. All world rights reserved.

Stroke 87% are ischemic, resulting from impaired blood flow to a localized area of the brain Impaired circulation due to thrombosis, atherogenic plaque, or embolism 13% of strokes are from hemorrhage, rupture of a blood vessel (intracerebral or subarachnoid)

Major sites and sources of ischemic stroke

Improving response improves outcomes In 1996, original AHA guidelines for use of rtPA, a fibrinolytic agent, were approved to treat acute ischemic stroke Since then, transport, community awareness of acute stroke signs and symptoms, and treatment have improved immensely

Improving response improves outcomes Research shows that most stroke patients now arrive at hospitals within 3 hours of symptom onset; more than half of these patients are transported via emergency medical transport Treating acute ischemic stroke with I.V. rtPA within 3 hours of stroke onset dramatically reduces deaths and disabilities

Improving response improves outcomes Recent advances in intra-arterial fibrinolysis and endovascular clot retrieval devices allow for effective intervention in some acute ischemic stroke patients who arrive up to 8 hours after onset of symptoms

Evaluating the patient using the seven D’s 1. Detection: early recognition of signs and symptoms onset, includes public education 2. Dispatch: EMS activation and rapid intervention 3. Delivery: advanced prehospital notification and transport to nearest acute stroke care facility

Evaluating the patient using the seven D’s 4. Door: rapid triage in ED, giving stroke signs and symptoms high priority 5. Data: history, neurologic assessment, diagnostic testing to include CT or MRI done within 25 minutes and read within 45 minutes

Evaluating the patient using the seven D’s 6. Decision: evaluation of inclusion and exclusion criteria for rtPA 7. Drug: initiation of weight-based rtPA within 3 hours of symptom onset - patient meets all inclusion criteria - has no exclusion criteria

AHA algorithm for suspected stroke In first 10 minutes after arrival: Alert stroke team Assess patient’s ABCs and vital signs Establish or confirm venous access Treat abnormal glucose levels Obtain blood specimens for baseline Ensure CT order communicated to radiology to be done upon patient’s arrival Obtain 12-lead ECG

AHA algorithm for suspected stroke Within 25 minutes of arrival: Establish or confirm stroke symptom onset Perform neurologic exam using NIHSS Ensure CT or MRI has been started

Using a stroke assessment tool National Institutes of Health Stroke Scale (NIHSS) offers tools for patients with language and motor difficulties Administer NIHSS in this order: - level of consciousness - gaze - visual fields - facial movement

Using a stroke assessment tool - motor function of arms and legs - limb ataxia - sensory responses - language - articulation - extinction and inattention Score greater than 22: patient has high risk of hemorrhage, requiring caution to use rtPA

Using a stroke assessment tool Recommendation is to administer NIHSS every 12 hours for first 24 hours, then every 24 hours until discharge. Check facility’s stroke protocol for time frames NIHSS must be administered the same way each time it’s performed, so all NIHSS evaluators should undergo same training to ensure accuracy, reliability, validity

Inclusion criteria that must be met for rtPA administration 18 years of age or older Clinical diagnosis of acute ischemic stroke with measurable neurologic deficit Time of symptom onset less than 180 minutes (3 hours) before fibrinolytic therapy would begin

Exclusion criteria for rtPA History or evidence of intracranial hemorrhage Multilobar infarction on CT scan Signs of subarachnoid hemorrhage

Exclusion criteria for rtPA Known arteriovenous malformation, neoplasm or aneurysm Systolic BP >185 mmHg or diastolic >110 mmHg despite repeated measurements and treatment

Exclusion criteria for rtPA Acute bleeding tendencies: - platelet count <100,00/mm3 - prothrombin time (PT) >15 seconds - international normalized ratio (INR) >1.7 - activated partial thromboplastin time (aPTT) > upper normal limit Active internal bleeding or acute trauma

Exclusion criteria for rtPA Serious head trauma, stroke, or surgery in past 3 months Arterial puncture at noncompressible site in last week Postmyocardial infarction pericarditis Minor or rapidly improving stroke symptoms

Exclusion criteria for rtPA Abnormal blood glucose ( 400 mg/dL) Major surgery or serious trauma within 14 days Recent acute MI (within 3 months) Recent GI or urinary tract hemorrhage

Administering rtPA Weight-based Monitor patient’s neurologic status and BP Risk of hemorrhage is higher if BP >180/105 Lower BP conservatively; 15 to 25% first day

Administering rtPA Sodium nitroprusside is only drug recommended for treating BP not controlled by labetalol or nicardipine Assess for signs of internal bleeding Following rtPA administration, admit patient to ICU or stroke unit for close monitoring

How stroke centers compare Brain Attack Coalition published recommendations in 2000 advocating for implementation of primary stroke centers and comprehensive stroke centers Primary stroke centers have essential components to manage uncomplicated strokes: expert personnel, protocols, infrastructure, capacity to admit patients into a stroke unit

How stroke centers compare Early evidence shows patients with acute ischemic stroke treated at a primary stroke center are more likely to receive fibrinolytic agents Comprehensive stroke centers fulfill requirements for primary stroke centers, provide diagnostic services (MRI, interventional neuroradiology) for endovascular treatments

How stroke centers compare Guidelines recommend transporting a patient suspected of having a stroke to closest, most appropriate facility; EMS should bypass facilities that don’t have resources or institutional commitment to treat a patient with stroke if a facility with proper resources is reasonably close

Other treatment options Catheter-directed intra-arterial fibrinolysis for patients past 3-hour window - inclusion criteria are same - exclusion criteria vary based on clinical trials and facility protocols - can be administered up to 6 hours after stroke - currently no fibrinolytic has FDA approval