Care of the Stroke Patient Improving Patient Outcomes

1. Care of the Stroke PatientImproving Patient Outcomes University Medical Center Tucson, Arizona Christine Pasquet, RN, MSN Michelle Strand, RN, Leslie Ritter, RN, PhD Jeremy Payne, MD, PhD Mary Ann Matter, RN, MSN

2. Learning Objectives After completion of this Self Learning Module you will be able to: • Describe the significance of stroke, types of stroke and risk factors for stroke • Describe the prehospital assessment and management of stroke patients • Explain how the use of evidence based guidelines improves care of the stroke patient • Discuss stroke prevention strategies

3. What is a Stroke? Stroke is the acute onset of a focal neurologic deficit resulting from decreased perfusion to the brain, causing permanent tissue damage (an infarction) Strokes are usually the result of vascular disease The symptoms of a stroke depend on the part of the brain involved 85% are ischemic (interruption of blood) 15% are hemorrhagic (bleeding)

4. Old TIA Definition • TIA stands for “transient ischemic attack” – stroke symptoms that improve without causing damage to the brain • The old definition was improvement in 24 hours, BUT: • Some patients have brain injury on MRI after less than an hour, even if symptoms improve • Some patients can have symptoms longer than 24 hours without brain injury on MRI • Even brief TIAs predict increased risk of upcoming stroke

5. Updated TIA Definition • “A brief episode of neurological dysfunction caused by focal brain ischemia with clinical symptoms typically lasting less than one hour and without evidence of acute brain infarction” • It’s not always clear if acute neurologic symptoms are a stroke or TIA until the patient is thoroughly evaluated, so we treat these the same at first • Other terms such as “mini-stroke” are confusing and shouldn’t be used

6. Significance, Types, and Risk Factors for Stroke

7. Significance of Stroke • Stroke is the third leading cause of death and the leading cause of disability for adults • Approximately 700,000 strokes occur annually in the US • About 176,000 result in death • About 200,000 are not the patient’s first stroke • About 350,000 are minimally to severely disabled • Of patients still alive at six months, about one third remain dependent on others for help with daily activities • Transient Ischemic Attacks (TIAs) occur even more frequently

8. Types of Strokes • There are two general types of stroke – ischemic and hemorrhagic • Ischemic stroke occurs when blood supply to the brain is reduced or interrupted and accounts for around 85% of all strokes • Hemorrhagic stroke occurs when a blood vessel in the brain ruptures • Sometimes an ischemic stroke can “convert” to a hemorrhagic stroke, since blood vessels are also injured in an area of infarction

9. Types of Strokes Ischemic Stroke Hemorrhagic stroke

11. Ischemic Stroke Large ischemic stroke Plaque in the wall of an artery or clots from the heart or large blood vessels can break loose and travel downstream to occlude blood vessels in the brain, or injured brain arteries can form local clots to interrupt blood supply. Small strokes can also cause major symptoms

12. Hemorrhagic Stroke Bleeding in the brain can occur after injured blood vessels burst. Longstanding hypertension is a common cause, and some patients have congenital blood vessel anomalies such as aneurysms that are prone to rupture. Sometimes ischemic strokes later bleed, as blood vessels themselves are also injured in a stroke.

13. Stroke Subtypes and Incidence Hemorrhagic stroke15% Rare causes of stroke include things like coagulation disorders, drug abuse, etc. Other5% Like heart disease: atherosclerotic plaque causes clot or debris to dislodge and occlude brain arteries. Cryptogenic30% There is lots we still don’t understand about stroke, and sometimes there are no clear reasons for one. Atherosclerotic cerebrovascular disease 20% Small vessel disease “lacunes” 25% Cardiogenicembolism20% Ischemic stroke85% Chronic injury causes local injury to small vessels directly in the brain. Clots from the heart travel to the brain (e.g. in atrial fibrillation).

14. Non-modifiable risk factors Modifiable risk factors • Older age • Male gender • Non-white genetic background • Family history • Prior stroke or TIA • Hypertension • Diabetes mellitus • Atrial fibrillation • Carotid artery disease • Dyslipidemia • Cardiac disease • Cigarette smoking • Obesity • Others… Previous TIA or stroke is the most important risk factor for stroke. Hypertension is the most prevalent. Risk Factors for Stroke

15. Risk Factors:Modifiable Risks • Risk factors such as lifestyle habits and disease processes can be modified or controlled • Hypertension – the higher the blood pressure the higher the risk of stroke • Cholesterol – high cholesterol increases the risk of stroke: eat low fat diet • LDH < 130mg/dl • HDL > 45mg/dl • Diabetes – controlling blood sugar may reduce stroke risk

16. Smoking – smokers have twice the risk of non-smokers: STOP! • Alcohol – excessive alcohol use increases the risk for stroke: more than 2 drinks a day • Sedentary lifestyle– low activity level increases the chances of stroke: workout 30-60 min 3 X week • Obesity and increased abdominal fat – (waist circumference greater than 40” for man and 35” for women) increases the risk for stroke • Atrial fibrillation – this arrhythmia is associated with 3-4 times greater stroke risk Medications and lifestyle changes can dramatically reduce many of these risks

17. Risk Factors:Non-Modifiable Risks • Age – stroke increases with age and doubles for each decade after 55 • Gender – men have an increased risk of stroke but more women die as a result of stroke • Race and Ethnicity – African Americans have the highest risk followed by Hispanic Americans • Family history – having parent, grand-parents or siblings with stroke increases one’s risk

18. Risk of Stroke with TIA • 10% of patients who present to ED and are diagnosed with a TIA will have a stroke in the next 30 days • 50% of those patients have their stroke in the next 48 hours • Risk of major stroke is increased by about 15% for 3 months after a mild stroke or TIA • We treat TIAs like actual strokes in order to prevent a major stroke

19. Know the Signs of Stroke • Sudden numbness or weakness of the face, arm, or leg (especially on one side of the body) • Sudden confusion, trouble speaking or understanding speech • Sudden trouble seeing in one or both eyes • Sudden trouble walking, dizziness, loss of balance or coordination • Sudden severe headache with no known cause • Call 911!

20. Know the Signs of Stroke

21. Medical Priority Dispatch Key 911 caller questions that elicit any of the following will result in an emergency ALS dispatch: • Not alert • Abnormal breathing • Speech problems • Sudden onset of severe pain • Numbness or paralysis • Change in behavior

22. Assessment of Stroke • Chief complaint • Stroke assessment test (Cincinnati Stroke Scale): • Facial droop • Arm drift • Slurred speech • Symptom onset time • Vital signs to include FSBG

23. Cincinnati Stroke Scale

24. Differential Diagnosis • Rule out other causes of weakness or altered mental status: • Hypoglycemia • Trauma (recent head injury or fall) • Tumor (slow onset) • Seizure disorder (post seizure paralysis)

25. Management of Ischemic Stroke

26. Management of Ischemic Stroke • Perform appropriate initial and ongoing assessments • Implement SAEMS Stroke Standing Order • Initiate IV normal saline TKO • Monitor oxygenation • Monitor cardiac rhythm (12-Lead if able) • Consider airway management if GCS less than 8 • Rapid transport to a primary stroke center • Attention to limb deficits • Assist, positioning, slings, safety

28. Blood Pressure in Acute Stroke • Elevated blood pressure is a significant risk factor for stroke. It is often erratic during acute stroke. • Over a wide range of blood pressures the brain can adjust its own perfusion (“autoregulation”), but this can be disrupted in acute stroke. • More than 60% have at least transient SBP greater than 160 • It is not clear if adjusting BP changes outcomes • Consensus is permissive BP to 220/120 before lowering in acute ischemic stroke.

29. Monitoring Parameters • Blood pressure • Generally elevated and labile for first few days • Stability is important • Blood glucose • Elevated glucose may suggest stress response • Glycemic control correlates with much better outcomes

30. Monitoring Parameters • Temperature • Increased temperature causes increased metabolic demand • Cardiac rhythm & rate • Risk of arrhythmia and MI

31. Monitoring Parameters • Neurologic exam • Level of consciousness • Cognitive function • Physical status • Oxygenation • Hydration • Anticipate complications

32. Treatment of Ischemic Stroke • All new strokes and TIAs should be admitted to the hospital despite requests to stay home • Some acute stroke patients may qualify for thrombolytic therapy • Risk factors must be identified and addressed • Treatable causes may be present • Remember that even in a TIA, there is a high stroke risk—and cardiac risk—in the next few days

33. Stroke Management Issues • Even though neurons begin to die after about 4 minutes without blood, there will be billions whose blood supply is tenuous, and dependant on how the patient is managed (the penumbra - area of potential infarct) • Outcome in stroke depends on good acute management • Many patients will need rehab and swallowing support • Most patients will need significant education • Stroke patients are at risk for various acute complications

34. Hospitalization 3 hrs tPA ~6 hrs Other interventions ~24-48 hrs Instability ~3-5 days Peak Edema ~2-3 weeks Bleeding ~1-3 months Recurrence ~3 months Recovery onset day week month Timing of Stroke Management

35. Standards of Care • Rapid recognition • Rapid transport to a Primary Stroke Center • tPA when indicated • DVT prophylaxis • Discharge with anti-thrombotic Rx (eg, aspirin) • Anticoagulation for atrial fibrillation • Dysphagia screening • Stroke education (risk factors, prevention, etc.) • Smoking cessation • Plan for rehab

37. Acute Stroke Thrombolysis: tPA • Tissue plasminogen activator (tPA) is a synthetic version of one of the body’s natural molecules that break down blood clots • tPA is the only FDA approved treatment for acute ischemic stroke proven to improve outcomes: • Judicious use results in excellent outcomes in an additional 11-13% patients • Chances of complete recovery 39% vs 26% • 48% vs 36% chance of discharge to home • Every 8 patients treated prevents 1 case of disability

39. tPA Cautions • tPA can be dangerous too: • Brain hemorrhage rate: 6.4% overall • Hemorrhage and similar bad outcomes correlate with protocol violations • Nationwide estimates are that <5% of stroke patients are able to receive this treatment: • Must be given within 3 hours of stroke onset or bleeding becomes a big risk • Patients often delay seeking care • Concern over bleeding when in inexperienced hands

40. Benefits of tPA are greatest when delivered early after stroke onset Marler et al., Neurology 2000; 55:1649

41. Administration of IV tPA • tPA is administered intravenously by bolus and continuous infusion. • Some rural Arizona hospitals may have the capability of initiating tPA therapy followed by subsequent air transport to a primary stroke center.

42. Common Complications of Stroke • Hyper- and hypotension • Hemorrhage • Edema, increased intracerebral pressure • Recurrent stroke or progression of initial one • Arrhythmia, MI • Infection • Aspiration • Falls, neglect • Decompensation (transient worsening of prior deficit because of other illness) • Seizures

43. Evidence Based Guidelines • Our ability to decrease mortality and morbidity from stroke is limited because: • Patients and families do not recognize signs and symptoms of stroke, and therefore do not seek care at all • Many patients with stroke delay seeking treatment, limiting the possibility of treatment with tPA • Studies indicate that use of evidence-based, clinical practice guidelines for stroke improves outcomes from stroke • One strategy to ensure use of guidelines and improve outcomes after stroke is through the development of Primary Stroke Centers

44. Primary Stroke Center Certification • Primary Stroke Center Certification by the Joint Commission is considered the “gold standard” in the United States and indicates formal, rigorous, independent review of a hospital’s ability to deliver comprehensive stroke care

45. Time is BrainEMS is a CRUCIAL Component!