Ischemic Stroke

Hemorrhagic Stroke

https://manual.jointcommission.org/releases/TJC2018B/MIF0391.html

STK-OP-1b Time (in minutes) from ED arrival to transfer of a

hemorrhagic stroke patient to another hospital

STK-OP-1c Time (in minutes) from ED arrival to transfer of an

ischemic stroke patient (drip and ship) to another hospital

STK-OP-1d Time (in minutes) from ED arrival to transfer of an

ischemic stroke patient (no IV t-PA prior to transfer, LVO and

MER eligible) to another hospital

STK-OP-1e Time (in minutes) from ED arrival to transfer of an

ischemic stroke patient (no IV t-PA given prior to transfer, LVO

and not thrombectomy eligible) to another hospital

STK-OP-1f Time (in minutes) from ED arrival to transfer of an

ischemic stroke patient (no IV t-PA given prior to transfer, no

LVO) to another hospital

Nationwide

Measures: 2019

DOOR IN…

...DOOR OUT

(DIDO)

(+) tpa

(-) tpa

(+) CVL

No tpa

(+) LVO

(-) CV

L(-) tpa

(-) LVO

Variables Affecting Transfers

https://asa.apprisor.org/epsView.cfm?yvEZg64FnP0LVS1pdC06%2FWl4aOOg36Zk9a2cqIEDanLA6rmdODORWg%3D%3D Poster Presentation International Stroke Conference 2019

Variables Affecting Transfers

– Hospital capacity/skill/speed

– Code stroke activation

– Comfort level of ED providers calling Stroke MD

– Alteplase administration process

– IV Pumps

– ACLS crews available?

– Staffing

– Turnover/training

– Forgetful people

https://asa.apprisor.org/epsView.cfm?yvEZg64FnP0LVS1pdC06%2FWl4aOOg36Zk9a2cqIEDanLA6rmdODORWg%3D%3D Poster Presentation International Stroke Conference 2019

Why

BP MATTERS

Ischemic

Stroke

Ischemic

Stroke During and After

Alteplase (rt-PA)

Hemorrhagic

Stroke

BP

Parameter

Rationale

Ensure good

blood flow to

ischemic brain.

Is what they did in the

original NINDS trial for

rt-PA.

Minimizes risk of

bleeding

Minimize further bleeding

and size of hematoma in

the brain.

180

105

160

90

220

120

140

90

Why

BP MATTERS

Document any BP meds given

Nicardipine

Labetalol

Nitro

…wait

what?

Nicardipine?

Types of Stroke Centers

• CSC: Comprehensive

• TSC: Thrombectomy-Capable

• PSC: Primary

• ASRH: Acute Stroke Ready

Interventional

Facilities

Types of Patients

• Hemorrhagic stroke

• Ischemic Stroke

• May or may not be destined for

thrombectomy in Cath Lab

• +/- alteplase (rt-PA)

• Decreased LOC

• Severe bleeding

• Neuro changes/deterioration

• New headache

• Orolingual angioedema

Complications

During and Post Alteplase:

* OLMC= On-Line Medical Control

• Occurs in 2 % of patients after IV alteplase

Symptoms– Tongue or lip swelling

– hoarse voice

– tight or swollen throat

– stridor

– breathing problems

– sudden appearance red welts, especially near eyes and lips

Orolingual edema (angioedema)

Complications

During and Post Alteplase:

• ANGIOEDEMA TREATMENT

• Stop alteplase immediately

– Diphenhydramine (Histamine blocker) IV STAT

• Hospital should follow with:– Famotidine (Histamine 2 blocker) IV STAT

– Methylprednisolone (corticosteroid) 125mg IV STAT

If worsens or has impending airway obstruction

– Epinephrine 1:1000 IM STAT

• hold pressure to site after given

– Prepare for intubation

Complications

During and Post Alteplase:

Glucose Management

• Avoid hypoglycemia and hyperglycemia

– Goal 70 -180

• Higher serum glucose is associated with

worse outcome (elicits an inflammatory

response)

• Low serum glucose = neurons can’t

function = cell death

Have to check the sugar to be able to treat it

Care during Transfer

• HOB 30o

• Cardiac Monitor

• SpO2 greater than or equal to 95%– Only add O2 if SpO2 less than 95%

• Document when post

alteplase flush given

– IV set can contain the

7-25 ml of alteplase (rt-PA)!!

https://tenor.com/view/chris-farley-holy-cannoli-gif-5719025

ETA UPDATE?

CALL

PROVIDENCE

TRANSFER LINE

888-777-9599

& PRESS 1

EMS

I HAVE AN

ETA UPDATE!

I’M CALLING

PROVIDENCE

TRANSFER LINE

888-777-9599

& PRESSING 1

ERMAHGERD

I LERF YU!!

• 41 y.o. right handed patient who

had onset of left sided weakness.

• He laid down on his couch around

1930 1/15 and fell asleep, when he

awakened he fell to the ground

trying to get up. He had left sided

weakness and droop.

• EMS was called, he arrived to an

outside hospital was

• evaluated by TeleStroke and was

given IV alteplase at 2353.

• CTA was noted to have a right ICA

dissection with occlusion and a

right MCA occlusion.

• Patient was transferred to PSVMC

for thrombectomy

Transfer Case Study:

STROKE Program

I HAD AN

ETA UPDATE!

I CALLED

PROVIDENCE

TRANSFER LINE

888-777-9599

& PRESSED 1

ERMAHGERD

I LERF YU!!

Transfer Case Study:

Before After

Teaches music, discharged home, planning vacation!

Thank You!

Kailey Cox, BSN, RN, SCRNNurse Coordinator: Comprehensive Stroke Program PSVMC

9205 SW Barnes Rd, Portland, OR 97225

Office: 503-216-4247 |Pager: 503-301-0517

Email: Kailey.Cox@providence.org