Presentation on theme: "Update on Stroke Management"— Presentation transcript:
1Update on Stroke Management Live from JJ Baumann MS, RN, CNS
2Focus on providing treatment quickly! Ischemic StrokeFocus on providing treatment quickly!Patients get treatment faster if :Stroke severity is highArrive by ambulanceArrival during regular hoursFaster treatment times were associated with:Reduced in-hospital mortalityReduced symptomatic intracranial hemorrhageIncreased independent ambulation at dischargeIncreased discharge to homeSaver et al. Time to Treatment With Intravenous Tissue Plasminogen Activator and Outcome From Acute Ischemic Stroke. JAMA. 2013;309(23):
3Goal door to needle time < 60 minutes Raising the bar…Meet goal door to needle time in 80% of cases
5Alteplase – Extending the Window ECASS 3 extended the time window for tPA… hour windowExclusions:> 80 years oldTaking oral anticoagulants regardless of INRBaseline NIHSS > 25> 1/3 MCA territory has injury on CTHistory of stroke and diabetesNot FDA approved!
6Alteplase and the New Anticoagulants Direct factor Xa inhibitors – do not use tPA unless not used for more than 2 days or sensitivity tests (aPTT, INR, platelet count, and ECT or TT) are normal
7Trevo versus Merci retrievers for thrombectomy revascularisation of large vessel occlusions in acute ischaemic stroke (TREVO 2): a randomised trialRaul G Nogueira, Helmi L Lutsep, Rishi Gupta, Tudor G Jovin, Gregory W Albers, Gary A Walker, David S Liebeskind, Wade S Smith, for theTREVO 2 TrialistsLancet 2012; 380: 1231–40Solitaire flow restoration device versus the Merci Retriever in patients with acute ischaemic stroke (SWIFT): a randomised,parallel-group, non-inferiority trialJeffrey L Saver, Reza Jahan, Elad I Levy, Tudor G Jovin, Blaise Baxter, Raul G Nogueira, Wayne Clark, Ronald Budzik, Osama O Zaidat, for theSWIFT TrialistsLancet 2012; 380: 1241–49
8Stent retrievers are preferred over Neuro Intervention?SWIFTPrimary efficacy outcome recanalisation without ICHSolitaire 61% vs. Merci 24%, p<0.0001TREVO 2Primary efficacy outcome TICI score 2-3Trevo 86% vs. Merci 60%, p<0.0001Stent retrievers are preferred overMERCI or Penumbra
9Ischemic Stroke Blood Pressure Hold BP medications unless SBP > 220 or DBP > 120Lower 15% in the first 24 hours
10Ischemic Stroke - ALIAS ALIAS - High-Dose Albumin Therapy for Neuroprotection in Acute Ischemic Stroke (M Ginsberg, MD)Use albumin to reduce brain swelling and improve neurologic outcomes.Stopped due to frutility.No benefit.
11Ischemic Stroke Prevention RE-LY Trial:Dabigatran versus Warfarin in Patients with Atrial FibrillationConnolly SJ, Ezekowitz MD, et al. NEJM. 2009;361;1-13.ROCKET AF:Rivaroxaban versus Warfarin in Nonvalvular Atrial FibrillationPatel, MR, et al. N Engl J Med 2011; 365:ARISTOTLE Trial:Apixaban non-inferior to warfarin in AF patients.Granger, CB, et al. N Engl J Med 2011; 365:
12Intracranial Hemorrhage Phase 2 trialPromising results:ICH volume smaller35% reduction in mortalityLess disabilitySlightly more clotting events (e.g. PE’s ,DVT, MI’s)Phase 3 trialEffectiveNo change in mortality or morbidityProthrombin Complex Concentrate (PCC) is preferred over rFVIIa.
13Intracranial Hemorrhage Treatment STICH IIearly surgery does not increase the rate of death or disability at 6 monthssmall but clinically relevant survival advantage for patients with spontaneous superficial intracerebral hemorrhage without intraventricular hemorrhage.Mendelow, et al. Early surgery versus initial conservative treatment inpatients with spontaneous supratentorial lobar intracerebralhaematomas (STICH II): a randomised trialLancet. Volume 382, Issue 9890, 3–9 August 2013, Pages 397–408.
14Intracranial Hemorrhage Treatment Minimally Invasive Surgery plus rt-PA for ICH Evacuation (MISTIE)Less peri-hematoma edema than control groupEffective and safe clot removalMould el al. Minimally invasive surgery plus recombinant tissue-type plasminogen activator for intracerebral hemorrhage evacuation decreases perihematomal edema. Stroke Mar ;44(3):
15Intracranial Hemorrhage: Blood Pressure Too much pressure these vessels will burst or bleed moreNeed enough pressure for injured area to get blood from other vessels
16Intracranial Hemorrhage: Current BP Guidelines Class IIa Recommendation “In favor of”SBP 150 – 220 lower SBP to 140Class IIb Recommendation “Less well established”SBP > 200 or MAP > 150 give IV infusionSBP > 180 or MAP > 130 ↑ICP monitor ICP, give intermittent or continuous IV medicationSBP > 180 or MAP > 130 maintain BP 160/90 or MAP 110 with intermittent or continuous IV medication
17Intracranial Hemorrhage: Blood Pressure Trial Antihypertensive Treatment of Acute Cerebral Hemorrhage (ATACH) IIHypothesis: SBP reduction to ≤140 mm Hg reduces the likelihood of death or disability at 3 months after ICHStart IV nicardipine within 3 hours of onset of ICH and continue for 24 hours
18Subarachnoid hemorrhage Early aneurysm repair preferredAmicarEarly, short courseAvoid antifibrinolytic therapy > 48 post ictus or > 3 days, concern with side effectsScreen for DVT while on
19VasospasmMonitor for delayed cerebral ischemia (DCI) in environment with expertise in SAHGive Nimodipine 60mg every 4 hours for 21 daysDetect DCI with TCD, DSA, CTA, EEG, PbtO2
20Comprehensive Stroke Center Primary Stroke Care Center Move to Comprehensive, Multi-disciplinary and Multi-dimensional Stroke CareAdvance Practice NursingCritical Care MedicineSupporting Self ManagementNeuroIR, Physiatry, TherapistVascular, Rehab, Stroke RNsNIREVDs, tx of AVM, aSAHNSurgProgramManagementLeadership,Care LevelDelivering/ Facilitating Clinical CareIV tPANeuro Critical CareComprehensive Stroke CenterAccess to SHCPrimary Stroke Care CenterRadiologyEducation to OSHPatient OutcomesClinical Information ManagementResearchEducation/ info sharingPerformance Improvement/ Measurement8 metrics26 metricsCSC specific resourcesMeaningful Use
22Airway Keep NPO until swallow screen performed Good oral care Frasier Free Water protocolGood oral hygiene to prevent bacteria from going into lungs – silent aspirationThis woman would not get swallow screen – facial droop – needs speech therapy
23Breathing Lung sounds Oxygen saturation Shortness of breath Use supplemental oxygen to keep SaO2> 92%Shortness of breath
24Circulation At least 2 IV sites Use isotonic solution, not dextrose, for maintenance fluidCoumadin / warfarinPradaxa/ Dabigatran1. What is the goal INR for each?2. What if the patient has a feeding tube?
25Disability / DVT Neuro checks Early mobilization OOB Work with rehab Frozen shoulderSitting at edge of bedVerbal cuesSCDslovenoxheparin
26Education Diagnosis Interventions Signs of stroke, calling 911 Risk Factors
27Risk Factors HTN Smoking Heart disease cholesterol xs EtOH Sedentary life styleDMAFPrior stroke or TIAAgeSexRaceHereditary
29Food Oral intake Feeding tub or PEG Constipation Also consider: Malnourished on admission?How long do we take to help feed?Enough calories?
30Glycemic Control Blood sugar monitoring HgA1c How to control? Avoid the lows!
31HypertensionJNC 7 report. Journal of the American Medical Association. 2003;289:
32What to do… Need Higher Need Lower Low perfusion in brain - tight ICA, MCA Stroke not completed ***Does the neuro exam decline with decreased BP?Completed their stroke At risk of bleeding ***Slow and steady!
34Stroke Certification for Nurses Stroke Certified Registered Nurse (SCRN)ANVC Certification Exams (NVRN-BC) & (ANVP-BC)American Board of Neuroscience Nursing (ABNN) examThrough American Association of Neuroscience NursesNeurovascular Registered Nurse - Board Certified Advanced Neurovascular Practitioner - Board Certified Through the Association of Neurovascular Clinicians (ANVC)
35GuidelinesConnolly ES Jr.., Rabinstein AA, Carhuapoma JR, et al. Guidelines for the management of aneurysmal subarachnoid hemorrhage: a guideline for healthcare professionals from the American Heart Association/american Stroke Association. Stroke 2012;43:1711–37.Jauch EC, Saver JL, Adams HP Jr., Bruno A, Connors JJ, Demaerschalk BM, et al.; American Heart Association Stroke Council; Council on Cardiovascular Nursing; Council on Peripheral Vascular Disease; Council on Clinical Cardiology. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2013;44:870–947.Morgenstern LB, Hemphill JC 3rd., Anderson C, et al. Guidelines for the management of spontaneous intracerebral hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2010;41:2108–29Summers D, Leonard A, Wentworth D, Saver JL, Simpson J, Spilker JA, Hock N, Miller E, Mitchell PH. Comprehensive overview of nursing and interdisciplinary care of the acute ischemic stroke patient: a scientific statement from the American Heart Association. Stroke 2009; 40: 2911–44.