Making the Case for CPG’s
Jean Luciano, MSN, RN, CNRN, SCRN, CRNP, FAHA Claranne Mathiesen, MSN, RN, CNRN, SCRN, FAHA
Disclosures
• Jeanie Luciano – Genentech speakers bureau
• Claranne Mathiesen - none
Objective
Discuss research based nursing interventions for the stroke patient.
Case Study #1
• 72 year old woman brought to the Emergency Department by helicopter at 0930. Met by the Stroke Team
• Patient complaint “I had a stroke 45 minutes ago”.
• Time of onset: 0845 Reported by patient and witnessed by daughter who was with her at church.
• PMH: Hypertension
• Medications: Amlodipine, HCTZ, and
Lisinopril
Exam
• Dense Left hemiplegia, slurred speech, & left facial droop. NIHSS: 13
• Other systems within normal limits.
• Laboratory results: normal.
• BP: 128/64 HR 77 Sat: 98% EKG: NSR Weight 70 kg.
• Head CT: Hyperdense right middle cerebral artery suggesting the presence of acute thrombus without CT evidence of acute territorial infarct, Old right parieto-occipital infarct, Mild cerebral atrophy
Time
• 75 minutes from onset of symptoms.
• 30 minutes since
presentation to ED.
Treatment
• t-Pa per protocol
• DTN time: 30 minutes
• Frequent vital signs and monitoring per protocol
• Enrolled in an acute ischemic stroke clinical trial.
Response
• 45 minutes into infusion: facial droop and speech without change, left sided strengths improved. NIHSS now 8
• Left lip swelling noted. Angioedema progresses
to the entire mouth and tongue.
Angioedema
• Reported more frequently in patients treated with ACE inhibitors.
• Treated with Diphenhydramine 25 mg. IV x 2 doses, Zantac 50 mg IV x 1, and Racemic
epinepherine nebulizer. Airway visualized by ENT and improvement noted.
• Intubation averted, admitted to ICU.
Workup & Etiology
• TTE: no evidence of cardioembolic source
• No atrial fibrillation noted on continuous telemetry.
• CTA: Complete right ICA occlusion, 40% stenosis on the
left.
Monitoring
• Continue to monitor neurological status , vital signs, and airway.
• Nursing dysphagia screen was deferred secondary to the angioedema; speech and language pathology was consulted and cleared on day 2.
• Physical and occupational therapy initiated.
Discharge
• Started on Plavix.
• Atorvastatin 80 milligrams daily.
• Restarted antihypertensive therapy
• Discharged to acute rehab facility on
Day 8
Patient Education Highlights
• Blood pressure management.
• Monitoring liver functions with statin use.
• Signs and symptoms of stroke and emergent response in the event of new or recurrent symptoms.
DECISION Support
CPG
Jauch, EC et al. Guidelines for the Early Management of Patients With Acute Ischemic Stroke. 2013.
available at http://stroke.ahajournals.org. DOI: 10.1161/STR.0b013e318284056a.
Clinical Trial
SPARCL (2008) Atorvastatin 80mg vs placebo; primary endpoint fatal and non-fatal strokes.
Case Study #2
• 52 year old woman presents with a
transient episode (lasted about 5 minutes) of right sided numbness.
History
• No history of stroke, TIA, heart disease, hypertension or diabetes.
• History of hypothyroidism.
• Medications: Synthroid
• Vital signs BP-156/88 HR-90
ABCD2 Score for Transient Ischemic Attack (TIA)
A simple score (ABCD2) to identify individuals at high early risk of stroke after transient ischemic attack.
• A (Age); 1 point for age >60 years,
• B (Blood pressure > 140/90 mmHg); 1 point for hypertension at the acute evaluation,
• C (Clinical features); 2 points for unilateral weakness, 1 for speech disturbance without weakness, and
• D (symptom Duration); 1 point for 10–59 minutes, 2 points for >60 minutes.
• D (Diabetes); 1 point
ABCD2 Score
Total scores range from 0 (lowest risk) to 7 (highest risk).
Stroke risk at 2 days, 7 days, and 90 days:
• Scores 0-3: low risk
Evaluation
• Admitted to transitional care unit for 24 hour observation and evaluation.
• Telemetry
• MRI, echocardiogram, and all laboratory studies were within normal limits.
Discharge
• Discharged after 22 hours.
• No findings on any studies.
• Plan to follow up with her primary care provider for blood pressure monitoring and vascular risk factor management.
• Set up for extended ambulatory cardiac
monitoring.
Further Findings
Ambulatory monitoring revealed episodes of atrial fibrillation.
Started on Dabigatran
Dabigatran Education
• Bleeding issues
• Concomitant medications
• Take as ordered, do not stop without consulting
with you provider
Dabigatran Education
• Store at room temperature.
• Keep tightly closed
• Discard after the bottle is opened for 4 months
• MEDICAL ALERT
Education Point
• Resetting the “CLOCK” for TIA patients.
Decision Support
CPG
Jauch, EC et al. Guidelines for the Early Management of Patients With Acute Ischemic Stroke. 2013.
available at http://stroke.ahajournals.org. DOI: 10.1161/STR.0b013e318284056a.
Clinical Trials
Connolly S J. Dabigatran versus Warfarin in Patients with Atrial Fibrillation. N Engl J Med 2009;
361:1139-1151September 17, 2009DOI: 10.1056/NEJMoa0905561
Johnston S C. Validation and refinement of scores to predict very early stroke risk after transient ischemic attack. Lancet, 369:283-292, 2007.
Case Study #3
Patient Presentation
• 57 y/o M on Lovenox who presented to spoke hospital with acute L MCA syndrome.
• Transferred for endovascular thrombectomy
• On arrival at HUP: NIHSS 16; right UE paresis, global aphasia
Imaging
Imaging Findings
•CTA with occluded left M1 (Figure A)
•Angiogram confirmed occluded left M1 (Figure B)
Figure A
Figure B
Intervention
• Successful embolectomy with Trevo stent retriever and Penumbra aspiration
LMCA fully reopened (Figure C)
Figure C
C. Post Thrombectomy: L MCA Reopened, branches now filling
Outcome
• Post procedure CT, no bleed
• Discharged home 2 days later
• Day 30-NIHSS-0
• MRS-0
Decision Support
Powers, W J. 2015 American Heart Association/American Stroke Association Focused Update of the 2013 Guidelines for the Early Management of Patients With Acute Ischemic Stroke Regarding Endovascular Treatment. Stroke is available at http://stroke.ahajournals.org DOI: 10.1161/STR.0000000000000074.
