Introduction[edit | edit source]The team approach to
stroke management starts with Emergency Medical Services and continues at a hospital within a Stroke System of Care capable of delivering Acute Stroke Care in the Emergency Department and in a dedicated Stroke Unit. The goal for the acute medical management of patients with stroke is to stabilize the patient and to complete initial evaluation and assessment, including
imaging and laboratory studies, within a short time frame. Critical decisions focus on the need for intubation, blood pressure control, and determination of risk/benefit for thrombolytic
intervention.[1] Patients presenting with Glasgow Coma Scale scores of 8 or less or rapidly decreasing Glasgow Coma Scale scores, require emergent airway control via
intubation[2]. Show
Goals of Emergency Management [3]
Suspected Stroke Algorithm[edit | edit source]There are a number of Stroke Management Algorithms used both by the EMS Services and Acute Hospitals in order to effectively triage and manage the flow of patients suspected of Stroke to improve access to best possible treatments available. The new Severity-based Stroke Triage Algorithm developed by the American Heart Association/American Stroke Association provides ambulance crews with information and tools to better identify a stroke, assess a patient’s condition and determine the best hospital for specific treatment needs[3].
Imaging[edit | edit source]According to Prasad (2011) brain imaging should be performed immediately for patients with persistent neurological symptoms if any of the following apply[4]:
Patients with acute stroke without the above indications for immediate brain imaging, scanning should be performed within 24 hours after onset of symptoms. Level I Clinical Guideline Recommendations
Ischemic Stroke[edit | edit source]In the case of an Ischemic Stroke, the more rapidly blood flow is restored, the more likely for improved recovery and fewer brain cell deaths. Primary treatment is aimed at breaking down the clot through means of medication (Thrombolysis) or mechanical removal of clot (Thrombectomy). Other treatments aim to minimise the clot becoming larger or prevention of new clot formation by means of anticoagulant type medications such as Aspirin, Clopidogrel or Dipyridamole. In conjunction with this, overall patient medical condition should be managed including monitoring of blood sugars, oxygen levels and hydration and providing adequate treatment for same[5].
Thrombolysis[edit | edit source]Tissue Plasminogen Activator (tPA) is a medication that dissolves blood clots. It is called a thrombolytic agent or more commonly referred to as the “clot buster.” It is an intravenous or IV medication usually given through a catheter inserted into a vein in the arm. Rapid administration of intravenous tPA to appropriate patients remains the mainstay of early treatment of acute ischemic stroke. For patients who meet national and international eligibility guidelines, intravenous tPA administration improves functional outcomes at 3 to 6 months when given within 4.5 hours of Ischemic Stroke Onset and should be administered. Every effort should be made to shorten any delays in initiation of treatment as earlier treatments are associated with increased benefits [2]. The goal of therapy for ischemic stroke is to safely maximize patient functional recovery to pre-stroke baseline by rapidly reperfusing the ischemic penumbra. tPA has optimal use within 3 hours from onset of symptoms but in carefully selected patients there is a longer time window for treatment up to 4.5 hours. Studies continue to support that time from onset to treatment with tPA is directly related to outcomes in Ischemic Stroke. The sooner tPA is given, the greater the benefit (Stroke, 2013). Beyond the approved and recommended time windows for tPA use, risk of complications rises. tPA is no different from other medications in that it has potential adverse effects, which makes it essential that a careful consideration is given to exclusion criteria, risks and benefits for use in each
individual patient. The major complications is symptomatic intracranial hemorrhage which occurs at a rate of roughly 5.2%. Other complications include orolingual angioedema (allergic reaction), acute hypotension, and systemic bleeding [2] [6]. Level I Clinical Guideline Recommendations
You can read more about tPA here: Tissue Plasminogen Activator (tPA) - What You Should Know Endovascular Therapy[edit | edit source]Physical removal of a blood clot can be completed by Endovascular Therapy either through a Catheter Based Drug or Mechanical Thrombectomy to dissolve or remove the clot and is another strongly recommended treatment option in Ischemic Stroke. Recent research has shown positive results for carefully selected patients with severe stroke due to proximal arterial occlusion and in whom recanalisation can be achieved within six hours of symptom onset, and compared to patients treated with standard medical treatment alone those who also had mechanical thrombectomy were more likely to be functionally independent at three to six months[7] [8]. The availability of endovascular treatment raises new opportunities for patients with severe stroke but also poses new challenges for stroke services. Observational and clinical trial data suggest that 7% to 13% of patients with acute stroke are potentially eligible for endovascular treatment but currently availability and access to endovascualr therapy poses new challeges ie not all hospitals have the resources and expertise necessary to provide this treatment option. Stroke Services must develop systems in order to work with Hospitals who have Interventional Radiology available and be able to triage and transport eligible patients within the required timeframes[7]. There are a range of Clot Retrieval Devices currently used for Endovascular Treatments and include [9] [2];
Studies have shown that when clot retrieval
is performed within six hours of symptom onset, 60-68% of patients achieved post-procedure revascularization. Patients eligible for clot retrieval are those with recent ischemic stroke, who can receive treatment within at least preferably 3-6 hours of the onset of stroke signs and symptoms. Those patients with uncontrolled HTN, internal bleeding, seizures, blood clotting problems, or those on anticoagulants are not candidates for this procedure. Complications from clot retrieval
procedures include hemorrhage, internal bleeding, death and recurrence of stroke[2] [7] [8]. Level I Clinical Guideline Recommendations
Haemorrhagic Stroke[edit | edit source]In the case of Haemorrhagic Stroke the main aim is to stop the bleeding as early as possible, often requiring Neurosurgical Intervention. The treatment of a hemorrhagic stroke depends upon the cause of the bleeding (eg, high blood pressure, use of anticoagulant medications, head trauma, blood vessel malformation). Most patients are monitored closely in an intensive care unit during and after a hemorrhagic stroke. The initial care of a person with hemorrhagic stroke includes several components [10] [11] [12]:
Basic life support, control of bleeding, seizures, blood pressure (BP), and intracranial pressure, are critical. Medications used in the treatment of acute stroke include the following[11] [10]:
Neurosurgery[edit | edit source]Once a hemorrhagic stroke is brought under control with emergency care, further treatment measures can be taken. If the rupture is small and produces only a small amount of bleeding and pressure, supportive care may be the only other form of care you need. But in some case surgical procedure may be recommended to repair the ruptured vessel, stop bleeding, or prevent further bleeding, for more serious strokes. Surgery may also be required to relieve the pressure caused by the bleeding and brain swelling [11] [10]. Aneurysm Treatment[edit | edit source]An aneurysm is a blood vessel that has a weak area that balloons out. If the area ruptures and bleeds, a hemorrhagic stroke can occur. A clamp can be placed at the base of the aneurysm to prevent bleeding before a stroke or to prevent re-bleeding. This surgery requires removing a piece of the skull and locating the aneurysm within the brain tissue. Coil embolization is an interventional procedure that is less invasive than clipping. It involves inserting a catheter into an artery in the groin. The catheter is guided along blood vessels in the body into the vessel in the brain where the aneurysm is located. A tiny coil is advanced into the aneurysm, filling the area with the coil. A blood clot forms within the coil, blocking blood flow into the aneurysm and preventing it from rupturing again. Other materials may also be injected to obliterate an aneurysm or AVM[11] [10] [12]. Arteriovenous Malformation Treatment[edit | edit source]If the stroke is caused by an Arteriovenous Malformations (AVMs) surgery may be used to remove it. This is not always possible, however, and depends on the location of the AVM. Some AVMs have a significant risk of further bleeding. The decision to treat an AVM depends on several factors; includin patients age, location and size of AVM, and abnormalities of the veins that drain the AVM and whether or not the AVM has previously bled. Treatment could include surgery, radiosurgery (use of radiation to shrink blood vessels), or embolization techniques[11] [12]. Decompressive Craniotomy[edit | edit source]When a patient’s life appears to be threatened because of the pressure effects of a blood clot in the brain, the physician may consider a procedure to open the skull and/or remove the blood. Considerations include the location and size of the hemorrhage, the patient’s age and medical condition, and the likelihood of making a recovery from the stroke[11] [10] [12]. Emergency Stroke Evaluation Simulation[edit | edit source]
References[edit | edit source]
What is the goal of treatment for ischemic stroke?After an ischemic stroke, the goal of treatment is to restore blood flow to the affected area of the brain as quickly as possible, that is, within the first hours after the onset of stroke symptoms.
What is the treatment for acute ischemic stroke?An IV injection of recombinant tissue plasminogen activator (TPA) — also called alteplase (Activase) or tenecteplase (TNKase) — is the gold standard treatment for ischemic stroke. An injection of TPA is usually given through a vein in the arm within the first three hours.
What is the most common treatment for ischemic stroke?Ischaemic strokes can often be treated using injections of a medicine called alteplase, which dissolves blood clots and restores blood flow to the brain. This use of "clot-busting" medicine is known as thrombolysis.
What are the goals of nursing care during the acute phase of a stroke?Introduction: Generally, nursing interventions during the acute stages following a stroke aim at preventing secondary brain injury (intracranial hypertension), maintaining the airways (due to paralysis of the pharynx muscles), providing general body support (vital signs, fluid and electrolyte balance), and anticipating ...
|