ACLS review: Acute Stroke Part 5

Complications of Fibrinolytics

·         Symptomatic intracranial hemorrhage

·         Orolingual angioedema (1.5%)

·         Acute hypotension

·         Systemic bleeding

Note:  Symptomatic intracranial hemorrhage occurred in 6.4% of the 312 patients treated in the NINDS trials and 4.6% of the 1135 patients treated in 60 Canadian centers

Fibrinolytic Precautions

·         Care dose calculation

·         Removal of excess medication

·         Holding anticoagulants and anitplatelet medications for 24 hours until repeat CT scan shows no hemorrhage

Note:  Removal of excess rtPA help prevent inadvertent administration of excess rtPA

General Stroke Care

·         Prevention of hypoxia

·         Manage hypertension

·         Glycemic Control

·         Temperature Control

·         Nutritional support

·         Prevention complications (Pneumonia, DVT, UTI)

·         Initiation of secondary stroke prevention

·         Transfer to stoke unit or stroke center

Prevention of hypoxia

·         ABCs

·         Oxygen to maintain saturations over 94%

·         Advanced airway placement and ventilation

Manage hypertension

·         Depends on whether or not fibrinolytic or intra-arterial therapies were used

·         In patients who are excluded from further intervention more liberal acceptance of hypertension is recommended

·         Normal saline at 75 to 100 mL/h is used to maintain euvolemia

BP Management During and After Reperfusion Therapy

·         Monitor blood pressure every 15 minutes for 2 hours from the start of rtPA therapy; then every 30 minutes for 6 hours; and then every hour for 16 hours

·         If systolic BP 180–230 mm Hg or diastolic BP 105–120 mm Hg

Labetalol 10 mg IV followed by continuous IV infusion 2–8 mg/min, or

Nicardipine IV 5 mg/h, titrate by 2.5 mg/hr every 5–15 minutes, maximum 15 mg/h

If blood pressure not controlled or diastolic BP >140 mm Hg, consider sodium nitroprusside

BP Management in Patients Ineligible for Reperfusion Therapy

·         Consider lowering blood pressure in patients with acute ischemic stroke if systolic blood pressure >220 mm Hg or diastolic blood pressure >120 mm Hg

·         Consider blood pressure reduction as indicated for other concomitant organ system injury

Acute myocardial infarction

Congestive heart failure

Acute aortic dissection

A reasonable target is to lower blood pressure by 15% to 25% within the first day

Glycemic Control

·         Hyperglycemia is associated with worse clinical outcome

·         SQ or IV Insulin when the serum glucose level is >185 mg/dL (Class IIa, LOE C)

Temperature Control

·         Hyperthermia is associated with increased morbidity and mortality

·         Treat fever >37.5°C (99.5°F)

·         Limited data on the role of hypothermia specific to acute ischemic stroke

Dysphagia Screening

·         NPO until screened for dysphagia

·         Perform simple bedside swallowing evaluation

·         If dysphagia present give medications either through NG/OG tube, IV, or IM routes

Note:  A simple bedside screening evaluation involves asking the patient to sip water from a cup. If the patient can sip and swallow without difficulty, the patient is asked to take a large gulp of water and swallow. If there are no signs of coughing or aspiration after 30 seconds, then it is safe for the patient to have a thickened diet until formally assessed by a speech pathologist.

Nutritional support

·         Patient may have thickened diet until formally assessed by a speech pathologist

·         Enteral feedings for patients with dysphagia

Prevention complications

·         DVT prophylaxsis with medications may begin within 24 hours after fibrinolytics once a repeat CT scan is negative for intracranial hemorrhage

·         Keep HOB up and have suctioning available for those with dysphagia

·         Patients treated with rtPA, with severe stroke, posterior circulation stroke, and in younger patients, observe increased intracranial pressure

·         Seizure prophylaxis is recommended only in patients who experience a seizure

Transfer to stoke unit or stroke center

Consistent improvement in 1-year survival rate, functional outcome, and quality of life when patients hospitalized with acute stroke are cared for in a dedicated stroke unit by a multidisciplinary team experienced in managing stroke

Reference:  Jauch EC, Cucchiara B, Adeoye O, Meurer W, Brice J, Chan Y-F, Gentile N, Hazinski MF. Part 11: adult stroke: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010;122(suppl 3):S818–S828.