Stroke Management and Assessment

Stroke Recognition and Initial Response

  • Identifying a Stroke

    • Initial recognition is fundamental to the proper management of stroke patients.

    • Symptoms may include impaired speech, weakness or paralysis, and altered consciousness.

  • Airway Management

    • Airway is the number one priority in stroke management.

    • If respiratory failure is suspected, emergency protocols for airway maintenance must be enacted.

    • Actions include:

    • Calling a code: Use the bedside emergency button.

    • Removing dentures: Essential if intubation is needed.

    • Oximeter usage: Attach pulse oximeter to monitor oxygen saturation.

  • Oxygen Administration

    • You are permitted to administer oxygen without prior orders in an emergency setting.

    • There is no maximum limit on oxygen delivery as needed to manage the patient's condition.

  • Intravenous (IV) Access

    • Establish IV access as soon as possible.

    • If you are unable to do so, wait for the code team or a registered nurse (RN) to assist.

  • Positioning the Patient

    • Elevate the head of the bed 30 degrees if there are no signs of shock or serious injury.

    • In the presence of shock, do not elevate the head as it may further reduce blood pressure.

  • Monitoring Blood Pressure

    • Use a Dynamap (automatic blood pressure monitor) to maintain and stabilize blood pressure.

Administration of tPA (Recombinant Tissue Plasminogen Activator)

  • Overview of tPA

    • A powerful clot-busting medication indicated for patients experiencing ischemic strokes (caused by emboli or thrombi).

    • REASON: Helps to restore blood flow through blocked arteries to prevent cell death.

    • Time Sensitivity: Can only be administered within a window of 3 to 4.5 hours from the onset of symptoms.

  • Transport Considerations

    • If a patient lives far from the hospital, transportation time may jeopardize the administration window for tPA.

  • Screening for Candidates

    • Patients must be carefully screened to rule out hemorrhagic strokes to avoid complications from bleeding.

    • Necessary screenings include:

    • Non-contrast CT or MRI.

    • Blood tests for coagulation disorders.

    • Screen for gastrointestinal (GI) bleeding history.

    • Evaluate for recent head trauma (last 3 months) or major surgery (last 2 weeks).

  • Pre-Administration Protocol for tPA

    • Place a Foley catheter.

    • An RN will insert a nasogastric (NG) tube.

    • Establish multiple IV lines as needed before administration of tPA.

  • Other Post-Stroke Medications

    • Aspirin: Administered within 24 to 48 hours post-stroke for its anti-platelet qualities.

    • Additional medications:

    • Platelet inhibitors (e.g., Plavix) and anticoagulants after stabilization.

    • Note: Avoid in hemorrhagic stroke cases.

  • Ongoing Research

    • Studies explore combining aspirin with other agents like Plavix to improve outcomes.

Assessment of Neurological Status

  • Glasgow Coma Scale (GCS)

    • Used to assess consciousness level in patients with neurological impairment.

    • Components:

    • Eye Opening:

      • 4: Spontaneous response.

      • 1: No response.

    • Verbal Response:

      • 5: Orientated and appropriate conversation.

      • 2: Incomprehensible sounds.

    • Motor Response:

      • 6: Follows commands (e.g., squeezing hands).

      • Abnormal flexion/extension indicates severe conditions.

    • Scoring Range:

    • Maximum: 15 (normal); Minimum: 3 (deep coma).

    • Scores of 8 or less indicate life-threatening conditions.

  • Intracranial Pressure (ICP)

    • Definition: ICP is influenced by brain tissue, blood, and cerebrospinal fluid (CSF); normally, these components are balanced.

    • Impact of Volume Changes:

    • An increase in any component (e.g., from trauma, edema) results in altered ICP.

    • Compensation by CSF displacement or altered blood flow occurs, but if compensation fails, ICP rises, potentially causing herniation.

    • Conditions Leading to Elevated ICP:

    • Tumors (neoplasms), contusions, abscesses, hematomas, hemorrhages.

Clinical Manifestations of Increased ICP

  • Early Signs

    • Changes in loc: Disorientation and confusion are notable; monitor mental status closely.

    • Increased respiratory effort: Hyperventilation may occur.

    • Pupil abnormalities: Often unilateral changes.

    • Weakness or paralysis in limbs; may indicate localized neurological impact.

    • Symptoms like headache, nausea, or vomiting are common indicators.

  • Late Signs

    • Deterioration of consciousness: Can progress to coma.

    • Vital Signs Changes:

    • Increase in blood pressure (hypertension).

    • Decrease in heart rate (bradycardia).

    • Decrease in respiratory rate due to brainstem pressure.

    • Abnormal respiratory patterns may manifest (e.g., Cheyne-Stokes breathing).

    • Increased occurrence of vomiting, potentially projectile.

    • Hemiplegia or other unusual posturing (flexion/extension) confirms brain damage.

    • Loss of brainstem reflexes (pupil response, gag reflex, respiration) indicates grave deterioration in condition.