NIH Stroke

Scale &

Hospital

Management of

the Stroke

Patient

James Fleming, MD

Department of Neurology,

Erlanger Health System

NIH Stroke Scale

DO NOT NEED THESE!

Stroke CODE 1-2-3

• STROKE TEAM receive patient from EMS:

Accomplish upon arrival:

– Bedside Neuro exam (NIH Stroke Scale)

– Lab: CHEM 8, CBC, Coags, Type & Cross,

Pregnancy test and drug screen if appropriate

– Vital signs-(treat blood pressure if indicated: fever)

– 12 lead EKG (common problems w/ ICH and SAH)

– Evaluate for seizure activity at the scene or in the ED

Stroke Code

• If patient is candidate, then will proceed with

thrombolytic therapy (t-PA).

• Dosing: 0.9 mg/kg; maximum dose less than or

equal to 90mg.

– 10% of the total dose is administered as an IV bolus

over 1 minute.

– Remaining 90% is infused over 60 minutes

– Follow up: admit to ICU or Stroke Unit, monitor Vital

signs, Maintain < 180 mmHg if IV tPA given and < 160

after endovascular therapy or if ICH

– No anticoagulant therapy for 24 hours if received tPA

AFTER tPA - Complications

• Bleeding

– Initial signs may be obtundation,

headache, nausea, and vomiting

– Obtain STAT non-contrasted CT of

the brain

• Angioedema

– Medical emergency

– Treatment: Steroids, Histamine 1

and Histamine 2 blockers

– May require intubation

• At first sign of

complication, stop the

administration & call Neuro

Angioedema

General Stroke RN Management

1. Vital signs and Neuro checks (NIHSS) per protocol.

2. Titrate oxygen for Sat greater than 95%

3. Dysphagia Screen

4. Cardiac monitor

5. DVT prophylaxis (per stroke order set and tPA protocol)

6. GI prophylaxis

7. Euglycemia

8. I&O

9. Pressure Ulcer Prevention

10.Passive R.O.M. to prevent contractures or begin

mobility.

11.Pain management: H/A – tylenol is preferred, but for

SAH, opiates may be needed; antiemetics for N&V.

12.Activity per protocol

13.PT/OT to evaluate for discharge planning

14.GOAL: Prevent Falls and mobilize within 24-48

hours.

General Acute Stroke

Management

• DIAGNOSTIC TESTING – 24 hour needed

– Stroke Labs

– 2D Echo +- bubble study:

– Carotid Doppler not done typically

– 12 lead EKG: atrial fibrillation -

– MRI or MRA (if CTA not done)

– EEG if seizure activity noted

– 30 Day MCOT or LINQ may be ordered

Medical Acute Stroke

Management

• Antihypertensive management after 24 hrs

• Aspirin, if ischemic stroke (after 24 hrs if tPA)

• Anticoagulation if needed – time per Neurology

• Cholesterol lowering agents

• Strategies to control any seizure activity or

brain edema initiated in the ED will

continue: Mannitol-3% or AED.

General Management following

admission to the Hospital

• 10-20 % of all stroke

patients will

experience a

deterioration during

the first 24 hours and

outcomes in these

patients are worse.

• Neurological worsening can be due to:– Brain edema

– Acute hydrocephalus

– Seizures

– Progression of thrombosis

– Early recurrent embolization

– Vasospasm ->brain ischemia

– Continued bleeding

– Recurrent hemorrhage

– Medical Complications

In-House Stroke Alerts

RAPID RESPONSE TEAM

• For sudden changes in Level of Consciousness

or suspected stroke, Fire STROKE Pager (ICU)

or Rapid Response (for floor patients)

• Orders for Imaging (CT or CTA or CTP) will be

given by STROKE TEAM.

Complications of Stroke

• Brain edema

• Hydrocephalus

• Elevated ICP

• Seizures

• Hemorrhagic transformation of infarction

• Recurrent Hemorrhage

• Acute delirium

• Recurrent ischemic stroke

• Depression

• Aspiration

• Atelectasis

• Pneumonia

• AMI

• CHF

• DVT

• Pulmonary Embolism

EDUCATION IS KEY!

• Educate patients and family members

of stroke victims on modifiable risk

factors and lifestyle changes that will

prevent disability or death caused by

a second ischemic stroke.

EDUCATION TOPICS FOR THE PATIENT

• Stop Smoking

• Healthy Diet

• Manage Cholesterol

• Increase physical activity

• Lower blood pressure

• Limit alcohol, no illicit drugs

• Maintain good blood sugar

• Take antiplatelet agents as prescribed