It's official: More stroke patients must now be given thrombolytics in your ED
October 1, 2009
It's official: More stroke patients must now be given thrombolytics in your ED
ED nurses are using new protocols
The day started out routinely: A 77-year-old man had breakfast with his wife, who left at 8:45 a.m. to run errands and returned at 11 a.m. "She noticed immediately that he had obvious difficulty speaking," says Alexandra Graves, MS, ANP, clinical director of stroke services at University of Colorado Hospital in Aurora. "While she was away, he had a stroke."
The man arrived at the ED at 11:45, exactly three hours after he was last seen normal. The ED staff called a stroke alert, had labs drawn, and saw that a head CT showed a perfusion deficit in the left hemisphere. It was determined that the patient was a candidate for tissue-plasminogen activator (t-PA), which was given in the ED.
"During the administration of thrombolytics, the patient's symptoms improved," says Graves. "The next day, his speech was back to normal!"
If this patient had come to the ED a year earlier, he would not have received treatment because he was outside the three-hour window. However, an advisory from the American Heart Association/American Stroke Association revises 2007 guidelines stating that t-PA should be given only within the first three hours after symptom onset, and now recommends treatment in select patients in the three- to 4½-hour window.1
A previously healthy man in his late 30s came to the ED at the University of Chicago Medical Center with an acute large left hemispheric stroke. He was unable to talk and had a right-sided paralysis of his arm and leg. Cedric McKoy, MSN, APN, stroke center coordinator, says, "He presented in a time window that allowed treatment with IV t-PA between four and 4½ hours after his stroke onset. Prior to the expansion of the time window, our only options for treatment would have been more invasive and less scientifically studied alternatives, such as an intra-arterial injection of t-PA or retrieval of an occlusive clot with a mechanical device."
Right after t-PA was administered, the man was able to lift his right arm and leg. "This improvement was likely due to the t-PA's success in enhancing brain blood flow. It had both a contemporaneous and long-term benefit for this man," says McKoy.
The ED at University of California — San Francisco Medical Center has revised its stroke protocols to reflect the new time frame. "In addition, we evaluate all patients with stroke symptoms within 12 hours for possible interventional radiology procedures," says Tina Quon, RN, BC, MSN, CEN, ED clinical nurse specialist.
Graves says every patient with stroke-like symptoms presenting under 4.5 hours from symptom onset should be a candidate for t-PA unless a reason not to treat is identified. "It was frustrating in the past to see patients arrive just beyond the three-hour window," she says. "By extending the time window to 4.5 hours, we've been able to treat more patients who benefit from IV t-PA. It is a great feeling to be able to give more stroke patients this treatment option."
Additional exclusions are possible
Patients who are not eligible for thrombolytics, regardless of the time frame they present in, include those with:
- evidence of intracranial hemorrhage;
- suspicion of subarachnoid hemorrhage;
- recent intracranial or intraspinal surgery;
- serious head trauma;
- recent previous stroke;
- uncontrolled hypertension at the time of treatment;
- rapidly improving symptoms;
- patients taking anticoagulants who had an elevated prothrombin time (PT) for more than 15 seconds or international normalized ratio (INR) greater than 1.7;
- patients who have had heparin administered within the last 48 hours and have an elevated partial thromboplastin time (PTT);
- patients with a platelet count less than 100,000/mm.
Quon says that in addition to the existing exclusions for thrombolytics, certain patients who would be eligible for treatment within the three-hour window would be excluded in the expanded time frame. "This is determined on a case-by-case basis, depending on other co-morbidities, past medical history, patient presentation, baseline activities of daily living, and patient/family decisions regarding benefits and potential risks," says Quon.
Ross A. Peterson, RN, BSN, CEN, MHA, stroke coordinator and ED clinical supervisor at Valley Baptist Medical Center — Brownsville (TX), says otherwise eligible patients who are excluded from the expanded time frame include patients older than 80, any anticoagulation use regardless of INR, and previous history of prior cerebrovascular accident and diabetes.
According to Graves, "We are not making additional exclusions for treating patients in the expanded time frame. For each patient who presents in the extended time frame, we are considering whether their age, comorbidities, presenting symptoms, and laboratory results would place them at a greater risk." [The order set used by University of Colorado's ED nurses when admitting a patient with a stroke or TIA is included. Also, stroke orders used by Valley Baptist's ED nurses and physicians and guidelines for t-PA are included.]
Reference
- Del Zoppo GJ, Saver JL, Jauch EC, et al. Expansion of the time window for treatment of acute ischemic stroke with intravenous tissue plasminogen activator: A science advisory from the American Heart Association/American Stroke Association. Stroke 2009; 40:2,945-2,948.
For more information on stroke patients in the ED, contact:
- Alexandra Graves, MS, ANP, Clinical Director of Stroke Services, University of Colorado Hospital, Aurora. Phone: (720) 848-7745. Fax: (303) 724-2300. E-mail: [email protected].
- Cedric McKoy, MSN, APN, Stroke Center Coordinator, University of Chicago Medical Center. Phone: (773) 834-7854. Fax: (773) 834-4612. E-mail: [email protected].
- Ross A. Peterson, RN, BSN, CEN, MHA, Clinical Supervisor, Emergency Services, Stroke Coordinator, Valley Baptist Medical Center — Brownsville (TX). Phone: (956) 698-5573. E-mail: [email protected].
- Tina Quon, RN,BC, MSN, CEN, Clinical Nurse Specialist, University of California — San Francisco Medical Center. Phone: (415) 353-1444. Fax: (415) 353-1799. E-mail: [email protected].
Watch for these changes if giving thromobolytics Thirty minutes after an initial bolus of tissue-plasminogen activator (t-PA), a stroke patient's National Institutes of Health (NIH) Stroke Scale score was 3 — a dramatic improvement from the score of 20 when he arrived at Valley Baptist Medical Center — Brownsville (TX). However, 10 minutes later, the ED nurse noticed that the blood pressure had suddenly dropped to 115/64. The patient was beginning to have increased weakness on his left side. The remaining infusion of t-PA was discontinued, and the patient was given a fluid bolus to increase his systolic blood pressure above 150. "A CT was ordered to rule out any cerebral bleeding, which there was not. Over the next four hours the weakness resolved, leaving the patient with just some aphasic issues," says Ross A. Peterson, RN, BSN, CEN, MHA, stroke coordinator and ED clinical supervisor. "The patient was discharged to home without the need for physical therapy, but to follow up with speech therapy five days after admission." If his nurse had not been monitoring the blood pressure and conducting a neurological assessment, the outcome might have been quite different for this patient. [The order set used for post t-PA monitoring by Valley Baptist's ED nurses is included.] Alexandra Graves, MS, ANP, clinical director of stroke services at University of Colorado Hospital in Aurora, says, "If a patient is receiving thrombolytics, watch for a change in vital signs and neurologic status, as well as for major or minor bleeding complications." Look for these changes Any change in mental status could indicate an evolving stroke or possible cerebral hemorrhage, says Peterson. "Also monitor for any improvement or worsening of deficits such as paralysis or weakness, slurred speech, or visual disturbances," he says. However, Peterson adds that the hope is to see improving mental status as the thrombolytics dissolve the clot and restore blood flow to the affected area of the brain. "There are a lot of times where we see dramatic improvement with just the initial bolus," says Peterson. "It still gives me goose bumps, seeing that patient begin talking when they couldn't just two minutes before, or seeing them moving their arm and leg when they were completely flaccid moments before." Close monitoring of blood pressure also is critical, says Peterson. "We usually like the person to be slightly hypertensive, with systolic blood pressure greater than 150 and less than 170, to ensure cerebral perfusion," he says. "Higher blood pressure risks hemorrhage, and low pressures can reduce cerebral blood pressure and lead to further infarction." Watch for blood pressures trending higher or lower, and maintain normal blood glucose levels, Peterson says. Watch for any new bruising or bleeding, decrease in mental status, ability to move extremities, slurred speech, facial droop, and changes in the patient's visual fields, he says. According to Graves, neurologic changes could indicate increased intracranial pressure, brain edema, hemorrhagic transformation of an infarction, recurrent infarction, acute delirium, or seizures. "Changes in cardiovascular assessment could indicate a myocardial infarction, heart failure, hypertension or hypotension," says Graves. "Changes in respiratory assessment could indicate an inability to protect the airway, pneumonia, pulmonary embolism, airway obstruction, or aspiration." |
Save valuable minutes if t-PA is possibility "Almost all successful cases of t-PA [tissue-plasminogen activator] administration have an ER nurse as a critical champion," according to Cedric McKoy, MSN, APN, stroke center coordinator at University of Chicago Medical Center. This success is due to the ED nurse's rapid assessments, expedited laboratory work and intravenous (IV) line insertion, and rapid transport to neuroimaging, McKoy says. At Valley Baptist Medical Center — Harlingen (TX), ED nurses do the following for any patient cleared to receive t-PA, according to Sarah Souffrant, RN, BSN, CEN, CPEN, nurse manager of the ED:
In addition, the following measures are done:
If your patient might receive t-PA, Graves says ED nurses should immediately do these things:
"In doing this, when the decision to treat is made, the t-PA is ready to be infused," says Graves. |
Avoid rapid reduction of BP in this case While tissue-plasminogen activator (t-PA) is infusing, if your patient has high blood pressure, do not give antihypertensives to rapidly reduce blood pressure to a "normal" level. "This may result in significant reduction in cerebral blood flow and should be avoided," says Sarah Souffrant, RN, BSN, CEN, CPEN, nurse manager of the ED at Valley Baptist Medical Center — Harlingen (TX). |
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