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: [email protected]
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