What are the 2 types of strokes?
Ischemic (80%)
- loss of blood flow to an area of the brain due to a thrombus or embolus
Hemorrhagic (15%)
- bleeding into the brain or surface of the brain due to rupture of a blood vessel supply to the brain
modifiable risk factors
- hypertension
- metabolic syndrome
- smoking and alcohol consumption
- physical inactivity
- poor diet
- sleep apnea
- heart disease
- oral contraceptive use
non-modifiable factors
- age
- gender
- ethnicity and race
- heredity + family Hx
- low birth weight
Subarachnoid vs intracerebral hemorrhage
subarachnoid
- subarachnoid space (between pia matter and subarachnoid membrane) fills with blood
- blood pools and pushes on the brain
intracerebral
- bleeding due to rupture of a vessel supply the brain matter
What is act “FAST”
F - facial drooping
A - arms (cannot lift both up)
S - speech slurred
T - time to call 911
What is a CT used for
- First diagnostic test
- differentiates between ischemic (dark) and hemorrhagic (white)
- confirm that it is a stroke and not a tumor
What is given within 60 mins following assessment and diagnosis of ischemic stroke with a CT scan
Give thrombolytic injection
- ex. tPA
Initial Interventions following diagnosis of stroke
A - AIRWAY
- keep patent
- use head tilt, chin lift
B - BREATHING
- monitor SpO2, RR, rhythm and depth
- intubation if pt cannot maintain adequate O2 levels
- ambu bag
C - CIRCULATION
- establish IV access in case of emergency
- consider fluid and electrolytes related to BP
- monitor BP
D - DISABILITY (NEURO) - CT scan STAT position head midline - HOB at 30 degrees to facilitate venous drainage - Seizure precautions
What is CPP?
CPP = cerebral perfusion pressure CPP = mean arterial P - intracranial P
CPP is also affected by autoregulation
How does autoregulation impact your choice of interventions?
Lots of auto-regulation will occur as a result of an ischemic stroke. One being increased BP to maintain circulation; thus hypertension is normal after a stroke.
We do NOT treat the high BP UNLESS it is really high ( > 220/130), as it risks extending the stroke
Acute care interventions (what to do after recognition of a stroke)
1) ensure patent airway
2) call stroke team
3) remove dentures
4) perform pulse oximetry
5) monitor and maintain adequate oxygenation
6) obtain IV access w/ normal saline
7) maintain BP
8) remove clothing
9) Insert Foley catheter
10) obtain CT scan STAT
11) perform baseline lab tests
12) position head midline
13) HOB > 30 degrees
14) seizure precautions
15) keep pt NPO until swallowing reflex is evaluated
When would you give tPA?
tPA - tissue plasminogen activator
inclusion criteria
- ischemic stroke that has a disabling neurological deficit
- > 18 yrs of age
- time of last stroke < 4.5 hrs
exclusion criteria
- evidence of hemorrhagic stroke or hemorrhage in the brain
Relative exclusion
- look at lab values
- does pt have a blood clotting issue? If so, tPA will be ineffective
What can you give as treatment if tPA is not an option?
anti-platelet drugs
- CHEWABLE Aspirin (ASA) - immediate effect
- Plavix (clopidogrel)
what is EVT?
Endovascular thrombectomy
- removing blood clots with a thin wire and balloon
Clipping and wrapping aneurysms
a small metal clip is used to stop blood flow into the aneurysm
GDC coil
A platinum coil is induced through the femoral artery and is pushed into the aneurysm to prevent bleeding
Other diagnostic studies
- electrocardiogram
- chest x ray
- cardiac markers (troponin)
- echocardiogram
- blood glucose
- CTA
- MRI
- angiography
- transcranial doppler ultrasonography
When would you do a lumbar puncture?
Only done if we suspect a subarachnoid hemorrhage, but we cant see anything on the CT
- Blood in CSF suggests subarachnoid hemorrhage
- Also to rule out infections of the CSF
Assessments for a stabilized patient
comprehensive assessment
- HPI, meds, RF’s, FHx
- comprehensive neurological assessment
Planning
Set goals w/ pt
- maximize communication abilities
- avoid complications
- maintain effective coping
Implementation
- health promotion
- address and intervene regarding system issues identified
- ambulatory and home care (rehab)
Evaluation
Assess goals
- maintain stable or improved LOC
- attain maximum physical functioning
- maximize self-care abilities
- maintain stable body functions
- maximize communication abilities
- avoid complications of stroke
- maintain effective coping
What does the Canadian Neurological Stroke Scale assess?
A common scale used on stroke floors
assess
- cognition
- LOC
- motor abilities
- CN FN
- sensation
- proprioception
- cerebellar FN
- deep tendon reflexes
According to the Canadian neurological scale, what findings should have you notify the MD
- a decrease of > 1 point and/or
- changes in pupil size or reaction to light
- changes in vital signs
