New time-dependent stroke treatments
Since the first treatment for acute ischemic stroke was approved by the Food and Drug Administration in June 1996, the way stroke patients are treated in the ED has dramatically changed. The clot-dissolving agent rt-PA (recombinant tissue plasminogen activator) can improve chances for recovery with minimal or no disability.
Still, many factors can rule out a patient’s eligibility. (See flow chart to determine patient eligibility for rt-PA, p. 25, and see protocol guidelines for who is eligible, enclosed in this issue.) All patients being considered for rt-PA need to have a CT scan, physical exam, blood tests, neurological assessment, and patient history, all within a time frame that will allow treatment to begin within three hours of symptom onset. Eligible patients must also be over 18.
Less than 5% to 7% of patients meet inclusion criteria for the drug, notes Tim Shephard, MSN, CCRN, CNRN, CS, neurovascular case manager of the Medical College of Virginia in Richmond.
"Because the window of time is so short, it’s imperative that patients are educated to call 911 immediately after they notice symptoms," he notes. "Many patients are excluded because they did not get to the hospital soon enough to be candidates for thrombolytic treatment."
Education on warning signs of stroke needed
The public needs to know that if they notice signs of stroke, they should get to the ED as quickly as possible, says Judith Ann Spilker, RN, BSN, cerebrovascular research coordinator in the department of neurology at University Hospital, University of Cincinnati Medical Center. "The ED should be prenotified by EMS to get the CT warmed up and held, because that is the most important diagnostic test we do on these patients."
Patients over the age of 80 need to be closely evaluated for treatment criteria, but even very elderly patients can benefit from treatment. "It depends on how healthy the patient is. We had a very healthy 91-year-old man who we gave t-PA to," says Teri McClean, RN, CEN, an emergency nurse at the University of California-San Diego. "I’ve seen some pretty miraculous things with t-PA."
More training will be needed
New stroke treatments require education. "EDs which don’t use a lot of thrombolytics will have to be comfortable with using them and become familiar with some of the dos and don’ts that go along with thrombolysis," says Karen Rapp, RN, BSN, CCRN, clinical coordinator of the University of California-San Diego Stroke Center. "You need to become aware that the dose is much lower than what is typically used for MI, which is one of the safety issues for a nurse to consider prior to dosing a stroke patient with t-PA."
Patients should be checked every 15 minutes post-treatment for side effects, says Patti Bratina, RN, BSN, clinical research coordinator for the stroke treatment team at the University of Texas in Houston. "One of the most important things to watch for is a change in level of consciousness," she notes. "If a patient goes from being sleepy to stuporous, or if a weak right arm suddenly can’t be moved at all, you also need to alert the physician."
Bratina recommends carefully watching one condition as a measuring stick of deterioration. "Pick one thing to monitor along with the patient’s level of consciousness," she says. "Instead of doing a full neurological exam every fifteen minutes, pick one area to see if it worsens."
Treatment is not without risks
Patients with blood pressure over 180, hemorrhagic stroke, active internal bleeding, head trauma, or recent previous stroke aren’t eligible for thrombolytics. Although there is about a 30% chance of a complete recovery with t-PA, there is also a risk of bleeding that can lead to death.
Still, most stroke patients are willing to take that risk. "The vast majority say they would rather have a chance of being back to normal vs. knowing they could be permanently disabled," Spilker reports.
Will EDs take the risk?
Still, because of the risks involved, there are ED physicians reluctant to use thrombolytics for stroke patients. "There are still pockets in the country where nobody is willing to take the risk of giving thrombolytics because there is a chance of bleeding, even though it is now an FDA-approved standard, but that is lessening," says Laura R. Sauerbeck, RN, BSN, CEN, clinical research coordinator for the Greater Cincinnati/ Northern Kentucky Stroke Team in Cincinnati.
More acute interventions are on the horizon. "There are some 45 different drugs currently being studied for stroke," says Louise O’Donnell, RN, MS, neuroscience clinical nurse specialist at Butterworth Hospital in Grand Rapids, MI. "T-PA was the first to hit the market, but it has such a small time window for treatment that not many patients are benefiting from it. A couple of different agents are likely to be released in the next couple months. None of them are God’s gift to stroke patients, but we are headed in the right direction, which is really exciting."
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