- Email: [email protected]
Acute ischemic stroke Emergi-path
Clinical Notebook Acute ischemic stroke Emergi-path Authors: Carol Bonnono RN, CEN, and Laura M. Criddle, RN, MS, CEN, Portland, Ore
I
n response to recent advances in care, stroke is now recognized to be as much of a medical emergency as myocardial infarction. Research has shown that appropriate intervention, when initiated in early acute ischemic stroke (AIS), can improve the chances of patients recovering with minimal or no disability.1 To facilitate management of these patients, an Oregon Health Sciences University (OHSU) multidisciplinary team—in collaboration with the Oregon Stroke Center—developed a Suspected Acute Stroke Emergi-path (Figure 1) and clinical guidelines for drug administration (Figure 2). Initiated upon patient arrival, the stroke Emergi-path provides step-by-step guidelines for the early care of this high-risk population. While other authors have identified the benefits of using a clinical path for stroke patients, the OHSU pathway emphasizes the critical role of the emergency department in the care of this population.2,3 Because the treatment of stroke varies depending on etiology (ischemic versus hemorrhagic), this tool was designed to facilitate rapid evaluation of patients with stroke symptoms to direct interventions. The Suspected Acute Stroke Emergi-path was developed consistent with guidelines published by the American Heart Association in its most recent Advanced Cardiac Life Support manual.4 The pathway outlines in detail a coordinated, time-efficient, team approach to the care of the patient with AIS by defining the roles and responsibility of emergency nurses, emergency physicians, and Stroke Team members.
Carol Bonnono, Oregon ENA, is Staff Nurse, Emergency Department; E-mail: [email protected], and Laura Criddle, Oregon ENA, is Emergency, Trauma, and Neuro Clinical Nurse Specialist, Oregon Health Sciences University, Portland, Ore. For reprints, write: Carol Bonnono, RN, CEN, 12320 SW 127th Ave, Tigard, OR 97223. J Emerg Nurs 2000;26:340-2. Copyright © 2000 by the Emergency Nurses Association. 0099-1767/2000 $12.00 + 0 18/9/108403 doi:10.1067/men.2000.108403
340 Volume 26, Number 4
The OHSU pathway emphasizes the critical role of the emergency department in the care of this population. Acknowledgments We wish to thank OHSU ED staff members, especially Penny Stevens, RN, MS, Robert Norton, MD, Jerris Hedges, MD, MS, and Sandy Huston. Thanks also to the Oregon Stroke Center team members, in particular, Kathy Kearns, RN, BSN, Susie Fisher, RN, BSN, Helmi Lutsep, MD, and Wayne Clark, MD, for their valuable collaboration in the development and implementation of this Suspected Acute Stroke Emergi-path.
References 1. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med 1995;333: 1581-7. 2. Blank F, Keyes M. Thrombolytic therapy for patients with acute stroke in the ED setting. J Emerg Nurs 2000;26:24-30. 3. Rapp K, Bratina P, Barch C, Braimah J, Daley S, Donnarumma R, et al. Code stroke: rapid transport, triage and treatment using rt-PA therapy. J Neurosci Nurs 1997;29: 361-6. 4. American Heart Association. Textbook of advanced life support. Dallas (TX): American Heart Association; 1994. p. 10-1–10-9.
Send descriptions of procedures in emergency care and/or quick-reference charts suitable for placing in reference file or notebook to Gail Pisarcik Lenehan, RN, EdD, c/o Managing Editor; PO Box 489, Downers Grove, IL 60515; phone (630) 6631263; E-mail: [email protected].
Bonnono and Criddle/JOURNAL OF EMERGENCY NURSING
Figure 1 Sample of Suspected Acute Stroke Emergi-path, page 1. aPTT, Activated partial thromboplastin time; AVM, arteriovenous malformation; CT, computed tomography; DBP, diastolic blood pressure; GI, gastrointestinal; GU, genitourinary; INR, international normalized ratio; NGT, nasogastric tube; NIH, National Institutes of Health; PT, prothrombin time; PTT, partial thromboplastin time; q, every; SBP, systolic blood pressure.
August 2000 341
JOURNAL OF EMERGENCY NURSING/Bonnono and Criddle
Oregon Stroke Center Guidelines for Intravenous Administration of t-PA in Acute Ischemic Stroke Eligibility for IV treatment with t-PA (Activase) ___ Clinical diagnosis of ischemic stroke causing a measurable neurological deficit. ___ Time of symptom onset well established to be ≤3 h before treatment starts. ___ Baseline CT: no intracranial hemorrhage or other risk factors per radiologist or neurologist. Patient selection: Contraindications ___ Evidence of intracranial hemorrhage on baseline CT. ___ History of intracranial hemorrhage. ___ Uncontrolled hypertension at time of treatment (SBP >185 or DBP >110). ___ Requires aggressive treatment (IV drip) to reduce blood pressure to specified limits. ___ Suspicion of subarachnoid hemorrhage. ___ Active internal bleeding. ___ Any intracranial surgery, serious head trauma, or previous stroke within past 3 months. ___ History of intracranial neoplasm, AVM, or aneurysm. ___ Known bleeding diathesis, including but not limited to: • current use of oral anticoagulants with PT >15 sec or INR >1.4 • administration of heparin within 48 h and an elevated aPTT at presentation. • platelet count <100,000. Patient selection: Warnings ___ Only minor or rapidly improving stroke symptoms ___ Seizure at onset of stroke ___ CBG or serum glucose <50 or >400 ___ Lumbar puncture within 48 h ___ History of GI or GU hemorrhage within 21 days ___ Major surgery or serious trauma in previous 14 days ___ Recent arterial puncture at noncompressible site
___ Patients with severe neurological deficit (eg, NIH Stroke Scale >22) at presentation. There is an increased risk of intracranial hemorrhage in these patients, although improvement with t-PA is still demonstrated. Treatment ___ t-PA (Activase) 0.9 mg/kg total, or maximum 90 mg. ___ Give 10% of total dose as IV bolus over 1 minute. ___ Remaining 90% infused over 60 minutes (start immediately after bolus) Follow-up: General patient management ___ Admission to ICU for 24 h. ___ No IV heparin or antiplatelet drugs during the infusion or for 24 h. ___ Neuro checks and vital signs Q 30 min for 6 hrs, then Q 1 h for 18 h ___ Appropriate measures to control blood pressure within acceptable limits. ___ Cardiac monitoring. ___ Avoid NGT, blood draws, invasive lines/procedures for 24 h if possible. Follow-up: Intracerebral hemorrhage management guidelines ___ If clinical suspicion of ICH (eg, neurological deterioration, new HA, acute hypertension, nausea and vomiting), discontinue t-PA infusion. ___ STAT CT scan for any neurological deterioration. ___ STAT labs: PT, PTT, platelet count, fibrinogen, type and cross. ___ Prepare for administration of 6-8 units cryoprecipitated fibrinogen and factor VIII. ___ Prepare for administration of 6-8 units platelets. For questions call the Stroke Hotline at (503) 494-7221.
Figure 2 Clinical guidelines for stroke medication administration. CBG, Capillary blood glucose; HA, headache; ICH, intracerebral hemorrhage; SBP, systolic blood pressure; for other abbreviations, see Figure 1.
Receive JEN tables of contents by E-mail To receive Journal of Emergency Nursing tables of contents by E-mail, sign up through our Web site at http://www.mosby.com/jen Choose E-mail Notification. Simply type your E-mail address in the box and click the Subscribe button. Alternatively, you may send an E-mail message to [email protected]. Leave the subject line blank and type the following as the body of your message: subscribe jen_toc You will receive an E-mail to confirm that you have been added to the mailing list. Note that table of contents E-mails will be sent out when a new issue is posted to the Web site.
342 Volume 26, Number 4
I
n response to recent advances in care, stroke is now recognized to be as much of a medical emergency as myocardial infarction. Research has shown that appropriate intervention, when initiated in early acute ischemic stroke (AIS), can improve the chances of patients recovering with minimal or no disability.1 To facilitate management of these patients, an Oregon Health Sciences University (OHSU) multidisciplinary team—in collaboration with the Oregon Stroke Center—developed a Suspected Acute Stroke Emergi-path (Figure 1) and clinical guidelines for drug administration (Figure 2). Initiated upon patient arrival, the stroke Emergi-path provides step-by-step guidelines for the early care of this high-risk population. While other authors have identified the benefits of using a clinical path for stroke patients, the OHSU pathway emphasizes the critical role of the emergency department in the care of this population.2,3 Because the treatment of stroke varies depending on etiology (ischemic versus hemorrhagic), this tool was designed to facilitate rapid evaluation of patients with stroke symptoms to direct interventions. The Suspected Acute Stroke Emergi-path was developed consistent with guidelines published by the American Heart Association in its most recent Advanced Cardiac Life Support manual.4 The pathway outlines in detail a coordinated, time-efficient, team approach to the care of the patient with AIS by defining the roles and responsibility of emergency nurses, emergency physicians, and Stroke Team members.
Carol Bonnono, Oregon ENA, is Staff Nurse, Emergency Department; E-mail: [email protected], and Laura Criddle, Oregon ENA, is Emergency, Trauma, and Neuro Clinical Nurse Specialist, Oregon Health Sciences University, Portland, Ore. For reprints, write: Carol Bonnono, RN, CEN, 12320 SW 127th Ave, Tigard, OR 97223. J Emerg Nurs 2000;26:340-2. Copyright © 2000 by the Emergency Nurses Association. 0099-1767/2000 $12.00 + 0 18/9/108403 doi:10.1067/men.2000.108403
340 Volume 26, Number 4
The OHSU pathway emphasizes the critical role of the emergency department in the care of this population. Acknowledgments We wish to thank OHSU ED staff members, especially Penny Stevens, RN, MS, Robert Norton, MD, Jerris Hedges, MD, MS, and Sandy Huston. Thanks also to the Oregon Stroke Center team members, in particular, Kathy Kearns, RN, BSN, Susie Fisher, RN, BSN, Helmi Lutsep, MD, and Wayne Clark, MD, for their valuable collaboration in the development and implementation of this Suspected Acute Stroke Emergi-path.
References 1. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med 1995;333: 1581-7. 2. Blank F, Keyes M. Thrombolytic therapy for patients with acute stroke in the ED setting. J Emerg Nurs 2000;26:24-30. 3. Rapp K, Bratina P, Barch C, Braimah J, Daley S, Donnarumma R, et al. Code stroke: rapid transport, triage and treatment using rt-PA therapy. J Neurosci Nurs 1997;29: 361-6. 4. American Heart Association. Textbook of advanced life support. Dallas (TX): American Heart Association; 1994. p. 10-1–10-9.
Send descriptions of procedures in emergency care and/or quick-reference charts suitable for placing in reference file or notebook to Gail Pisarcik Lenehan, RN, EdD, c/o Managing Editor; PO Box 489, Downers Grove, IL 60515; phone (630) 6631263; E-mail: [email protected].
Bonnono and Criddle/JOURNAL OF EMERGENCY NURSING
Figure 1 Sample of Suspected Acute Stroke Emergi-path, page 1. aPTT, Activated partial thromboplastin time; AVM, arteriovenous malformation; CT, computed tomography; DBP, diastolic blood pressure; GI, gastrointestinal; GU, genitourinary; INR, international normalized ratio; NGT, nasogastric tube; NIH, National Institutes of Health; PT, prothrombin time; PTT, partial thromboplastin time; q, every; SBP, systolic blood pressure.
August 2000 341
JOURNAL OF EMERGENCY NURSING/Bonnono and Criddle
Oregon Stroke Center Guidelines for Intravenous Administration of t-PA in Acute Ischemic Stroke Eligibility for IV treatment with t-PA (Activase) ___ Clinical diagnosis of ischemic stroke causing a measurable neurological deficit. ___ Time of symptom onset well established to be ≤3 h before treatment starts. ___ Baseline CT: no intracranial hemorrhage or other risk factors per radiologist or neurologist. Patient selection: Contraindications ___ Evidence of intracranial hemorrhage on baseline CT. ___ History of intracranial hemorrhage. ___ Uncontrolled hypertension at time of treatment (SBP >185 or DBP >110). ___ Requires aggressive treatment (IV drip) to reduce blood pressure to specified limits. ___ Suspicion of subarachnoid hemorrhage. ___ Active internal bleeding. ___ Any intracranial surgery, serious head trauma, or previous stroke within past 3 months. ___ History of intracranial neoplasm, AVM, or aneurysm. ___ Known bleeding diathesis, including but not limited to: • current use of oral anticoagulants with PT >15 sec or INR >1.4 • administration of heparin within 48 h and an elevated aPTT at presentation. • platelet count <100,000. Patient selection: Warnings ___ Only minor or rapidly improving stroke symptoms ___ Seizure at onset of stroke ___ CBG or serum glucose <50 or >400 ___ Lumbar puncture within 48 h ___ History of GI or GU hemorrhage within 21 days ___ Major surgery or serious trauma in previous 14 days ___ Recent arterial puncture at noncompressible site
___ Patients with severe neurological deficit (eg, NIH Stroke Scale >22) at presentation. There is an increased risk of intracranial hemorrhage in these patients, although improvement with t-PA is still demonstrated. Treatment ___ t-PA (Activase) 0.9 mg/kg total, or maximum 90 mg. ___ Give 10% of total dose as IV bolus over 1 minute. ___ Remaining 90% infused over 60 minutes (start immediately after bolus) Follow-up: General patient management ___ Admission to ICU for 24 h. ___ No IV heparin or antiplatelet drugs during the infusion or for 24 h. ___ Neuro checks and vital signs Q 30 min for 6 hrs, then Q 1 h for 18 h ___ Appropriate measures to control blood pressure within acceptable limits. ___ Cardiac monitoring. ___ Avoid NGT, blood draws, invasive lines/procedures for 24 h if possible. Follow-up: Intracerebral hemorrhage management guidelines ___ If clinical suspicion of ICH (eg, neurological deterioration, new HA, acute hypertension, nausea and vomiting), discontinue t-PA infusion. ___ STAT CT scan for any neurological deterioration. ___ STAT labs: PT, PTT, platelet count, fibrinogen, type and cross. ___ Prepare for administration of 6-8 units cryoprecipitated fibrinogen and factor VIII. ___ Prepare for administration of 6-8 units platelets. For questions call the Stroke Hotline at (503) 494-7221.
Figure 2 Clinical guidelines for stroke medication administration. CBG, Capillary blood glucose; HA, headache; ICH, intracerebral hemorrhage; SBP, systolic blood pressure; for other abbreviations, see Figure 1.
Receive JEN tables of contents by E-mail To receive Journal of Emergency Nursing tables of contents by E-mail, sign up through our Web site at http://www.mosby.com/jen Choose E-mail Notification. Simply type your E-mail address in the box and click the Subscribe button. Alternatively, you may send an E-mail message to [email protected]. Leave the subject line blank and type the following as the body of your message: subscribe jen_toc You will receive an E-mail to confirm that you have been added to the mailing list. Note that table of contents E-mails will be sent out when a new issue is posted to the Web site.
342 Volume 26, Number 4