Take these steps if you suspect stroke
When paramedics brought a 43-year-old woman to the ED at Norwalk (CT) Hospital, she was awake and able to follow commands, but presented with right-sided weakness, confusion, and slurred speech. The patient was identified as a potential stroke victim, and the hospital’s stroke team was called.
"She was sent emergently to CT scan, and it was determined that she had suffered an ischemic stroke," says Mary Galasinski, RN, the facility’s stroke coordinator.
The woman met the inclusion criteria for tissue plasminogen activator (t-PA), and it was administered in the ED. Within two hours, the woman was able to move her upper and lower extremities. After three days in the intensive care unit, she was sent home.
This case illustrates the importance of immediate intervention for patients with suspected stroke, says Galasinski. She points to studies showing that significant delays exist in ED triage and evaluation of women with stroke.1,2
If you suspect a stroke, notify the ED physician and your facility’s stroke team immediately, urges Galasinski. "Radiology needs to be notified for emergent CT scan, and if there is no stroke team, the neurologist needs to be called," she says.
Advances in the treatment of acute stroke have given patients a better chance at recovery, something that wasn’t possible a decade ago, says John E. Duldner Jr., MD, MS, FACEP, assistant professor of emergency medicine at Northeast Ohio University College of Medicine in Akron.
Unfortunately, treatment protocols are not always followed in the ED, says Duldner. "This is evidenced by two studies that demonstrated protocol violations and higher death rates when patients are considered for, and treated with t-PA," he says.3,4
Duldner says that reported problems included treating patients who should have been excluded for treatment (those having a seizure at the onset of stroke), treating blood pressure outside of the accepted indications, and treating patients outside of the three-hour window. (See chart on blood pressure management, below.)
|
Blood
pressure in Stroke Patients
|
||
| Blood Pressure Level | Fibrinolytic Candidate | Not a Fibrinolytic Candidate |
| >185/>110 mm Hg | Nitropaste or labetalol IV. If blood pressure remains elevated: no fibrinolytics | No acute therapy indicated |
| During/after fibrinolytic treatment, blood pressure may rise | ||
|
DBP>140 M/Hg >230/121-140 mm/Hg 180-230/105-120 mm/Hg |
Nitroprusside infusion Labetalol, then prn nitroprusside Labetalol |
Nitroprusside infusion Labetalol Acute therapy only if hypertensive urgency also present |
| Source: Lauren Brandt, RN, MSN, CNRN, Clinical Director, Neurosciences, Brain & Spine Center, Brackenridge Hospital, Austin, TX. Adapted from Advanced Cardiac Life Support, American Heart Association Stroke Study Group, and Scientific statement. Guidelines for thrombolytic therapy for acute stroke: A supplement to the guidelines for the management of patients with acute ischemic stroke. Circulation 1996; 94:1,167-1,174. | ||
Your practice must be consistent with current guidelines for stroke, he emphasizes.
"If patient care orders deviate from the guidelines, refer to the guidelines to ensure patient safety," Duldner says. "ED nurses can lead the charge to ensure this is done."
Here are ways to improve management of patients with suspected stroke:
• Assess suspected stroke patients rapidly.
The key to evaluation is recognizing a stroke is occurring, says Duldner. Although patients may present atypically, he gives the classic warning signs of a stroke:
— sudden numbness of face, arm, or leg, usually on one side of the body;
— difficulty walking/loss of balance or coordination;
— sudden confusion and/or trouble speaking or understanding speech;
— sudden, severe headache;
— visual problems with one or both eyes.
Any patient with sudden loss of neurological function should be rapidly assessed, regardless if he or she arrives via triage or ambulance, says Duldner. (See Heart Attack, Stroke & Cardiac Arrest Warning Signs.)
• Determine if the patient is eligible for t-PA.
A checklist of inclusion and exclusion criteria for t-PA should be used at the bedside, as is done with thrombolysis for acute myocardial infarction patients, Duldner says.
Other key points to consider include time of symptom onset, the patient’s National Institutes of Health (NIH) Stroke Scale score, and cranial computed tomogram findings, he says. He notes that the time-to-treat window for t-PA is three hours.
"Probe the family and emergency medical services to aid in establishing an estimated time of symptom onset," he says. "The clock is ticking from the time the symptoms started."
The last time the patient was known to be "neurologically normal" is the time of symptom onset, he explains. If the patient’s symptoms are present upon waking in the morning, Duldner says to go by the following guidelines:
— If the patient went to bed at midnight and awoke at 6 a.m. with right-sided weakness and difficulty speaking, then the time of symptom onset is midnight.
— If the patient got up at 5 a.m. to use the bathroom and was normal, then went back to bed and awoke at 6 a.m. with symptoms, then the time of symptom onset was 5 a.m.
An NIH Stroke Scale score of 22 or more suggests a large stroke and a higher likelihood of bleeding after t-PA administration, Duldner notes. A patient should not receive t-PA if they have not undergone cranial computed tomography, as it is necessary to rule out cerebral hemorrhage and evaluate for evidence of a large stroke, he adds.
• Treat with t-PA if appropriate.
The dose is 0.9 mg per kilogram, not to exceed 90 mg, Duldner says. "Give the first 10% as a bolus and the rest over 60 minutes," he says.
Antiplatelet agents and other anticoagulants are contraindicated for 24 hours after receiving t-PA for stroke, says Duldner.
"Monitoring for bleeding and elevated blood pressure is paramount, and both issues should be treated aggressively," he advises.
References
1. Arslanian-Engoren C. Gender and age bias in triage decisions. J Emerg Nurs 2000; 26:117-124.
2. Cannon C. Relationship of symptom onset-to-balloon time and door-to-balloon time with mortality in patients undergoing angioplasty for acute myocardial infarction. JAMA 2000; 283:2,887-3,030.
3. Burgin WS, Staub L, Chan W, et al. Acute Stroke care in Non-urban Emergency Departments. Neurology 2001; 57:2,006-2,012.
4. Katzan I, Furlan AJ, Lloyd LE, et al. Use of tissue-type plasminogen activator for acute ischemic stroke: The Cleveland-area experience. JAMA 2000; 283:1,151-1,158.
Sources
For more information on treatment of acute stroke, contact:
• John E. Duldner Jr., MD, MS, FACEP, Assistant Professor of Emergency Medicine, Department of Emergency Medicine, Northeast Ohio University College of Medicine, 400 Wabash Ave., Akron, OH 44307. Telephone: (330) 344-6326. Fax: (330) 253-8293. E-mail: [email protected].
• Mary Galasinski, RN, CCRN, Stroke Coordinator, Norwalk Hospital, 34 Maple St., Norwalk, CT 06856. E-mail: [email protected].
When paramedics brought a 43-year-old woman to the ED at Norwalk (CT) Hospital, she was awake and able to follow commands, but presented with right-sided weakness, confusion, and slurred speech. The patient was identified as a potential stroke victim, and the hospitals stroke team was called.
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