Marie Rusnak Stroke

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Management of CatastrophicManagement of CatastrophicStrokeStroke

Marie Rusnak, RNEC, MSN-NHS-GNG SiteMarie Rusnak, RNEC, MSN-NHS-GNG SiteCami D’Uva ACNP-HHSC-HGH SiteCami D’Uva ACNP-HHSC-HGH Site

Johanne Hayes,Nurse Educator GIM St. Joseph’sJohanne Hayes,Nurse Educator GIM St. Joseph’sLeigh Barr, Speech-Language Pathologist BA M.Sc Leigh Barr, Speech-Language Pathologist BA M.Sc

HHSC-HGH SiteHHSC-HGH Site

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What is Catastrophic Stroke?What is Catastrophic Stroke?

No one definitionNo one definition Can ususally be described in terms of :Can ususally be described in terms of : -radiologic evidence of extent of infarct/-radiologic evidence of extent of infarct/ hemorrhagehemorrhage -physiologic signs-physiologic signs -response to treatment-response to treatment

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Clinical Management Clinical Management ConsiderationsConsiderations

Usual Stroke Care-starting point-ERUsual Stroke Care-starting point-ER -diagnostics-CT, labs-diagnostics-CT, labs - Neurological assessment- Neurological assessment -results that determine territory and extent -results that determine territory and extent -may be the1-may be the1st st point of decision-any directives?point of decision-any directives?

Post admission to unitPost admission to unit -further diagnostics, assessments, treatments-further diagnostics, assessments, treatments -feeding-feeding -comfort, mobility-comfort, mobility -prevention of complications-prevention of complications -may be primary or secondary point of decision-may be primary or secondary point of decision

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Clinical Indicators of Poor Clinical Indicators of Poor OutcomeOutcome

•Ischemic / Thromboembolic Stroke

Radiology Evidence Territory -MCA occlusion (anterior, posterior) -within 6 hours-increases risk of fatal cerebral edema -within 24 hours, highly predictive of clinical deterioration due to cerebral edema Extent -greater than 50% of MCA territory -sulci effacement with MCA sign (within 24 hours of onset)

Correlated with: -fatal brain swelling

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MCA SignMCA Sign

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Normal/EffacementNormal/Effacement

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Additional Diagnostic ImagingAdditional Diagnostic Imaging

Carotid Artery Occlusion Carotid Artery Occlusion -on ultrasound at bifurcation-on ultrasound at bifurcation -increases risk of fatal outcome-development of -increases risk of fatal outcome-development of herniationherniation

Infarct VolumeInfarct Volume - on DWI - on DWI

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Brain SwellingBrain Swelling

Fatal OutcomeFatal Outcome (mortality rate- 50-80%, 10% of all ischemic(mortality rate- 50-80%, 10% of all ischemic))

HemisphericHemispheric --not due to infarct/extent/LOCnot due to infarct/extent/LOC -due to edema, shifting of cerebral contents (specific -due to edema, shifting of cerebral contents (specific areas of), and extent of shiftareas of), and extent of shift AND…AND… -development of nausea and vomitting within 24 hours -development of nausea and vomitting within 24 hours - BP >180 systolic - BP >180 systolic -along with hypodensity MCA>50%-along with hypodensity MCA>50%

ARE….ARE…. predictive of development of predictive of development of fatal fatal brain swellingbrain swelling

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Cerebellar InfarctCerebellar Infarct(posterior-inferior-superior cerebellar artery)(posterior-inferior-superior cerebellar artery)

RadiologicRadiologic features predictive of neurologic deterioration: features predictive of neurologic deterioration: -4-4thth ventrical distorstion/shift ventrical distorstion/shift - basal cistern compression- basal cistern compression -obstructive hydrocephalous,-obstructive hydrocephalous, -brainstem deformity-brainstem deformity

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Physical EvidencePhysical Evidence HemisphericHemispheric -impaired consciousness/coma -impaired consciousness/coma -low Glasgow Coma Score (< 8 ) -low Glasgow Coma Score (< 8 ) -NIHS score -NIHS score > > 20, 20, >> 15 for right hemisphere 15 for right hemisphere -loss of brainstem reflexes (pupillary responses, occular -loss of brainstem reflexes (pupillary responses, occular reflexes)reflexes) -development of bilateral ptosis-development of bilateral ptosis -elevated WBC and temperature, arterial PH-elevated WBC and temperature, arterial PH -associated history of hypertension, heart failure-associated history of hypertension, heart failure

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CerebellarCerebellar

-decreased LOC after clinical deterioration-most -decreased LOC after clinical deterioration-most powerful predictor of poor outcome powerful predictor of poor outcome -2-4 days after onset-2-4 days after onset -physical evidence of swelling in cerebellum/-physical evidence of swelling in cerebellum/ herniation (occular, respiratory, cardiac changes)herniation (occular, respiratory, cardiac changes) -age -age >>6060

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HemorrhageHemorrhage Radiology Radiology EvidenceEvidence TerritoryTerritory SAHSAH -hydrocephalous-hydrocephalous -intraventricular hemorrhage/ventricular dilitation-intraventricular hemorrhage/ventricular dilitation -volume of hemorrhage (inaddition to SAH grading)-volume of hemorrhage (inaddition to SAH grading) -global edema on CT-global edema on CT

LobarLobar --volume most important predictor of death/*dependencevolume most important predictor of death/*dependence -poor outcome with hemorrhage volume over 40 ml-poor outcome with hemorrhage volume over 40 ml -displacement of tissue (measured by septal shift on CT)-displacement of tissue (measured by septal shift on CT) over 6mm-predictive of mortality/vegitative state, other over 6mm-predictive of mortality/vegitative state, other evidence suggests shift of >9mm or pineal shift of >4mm is evidence suggests shift of >9mm or pineal shift of >4mm is indicativeindicative

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Ganglionic/PutnamGanglionic/Putnam -volume >60 ml -volume >60 ml -obstructive hydrocephalous-obstructive hydrocephalous

PontinePontine -<20 mm-<20 mm -extension into midbrain/thalamus (fatal)-extension into midbrain/thalamus (fatal)

CerebellarCerebellar -early hydrocephalous on CT-early hydrocephalous on CT -intraventricular hemorrhage-intraventricular hemorrhage -primary hematoma in vermis/extension into-primary hematoma in vermis/extension into -upward herniation (cistern compression)-upward herniation (cistern compression) -ventricular distortion -ventricular distortion -diameter-diameter > > 3mm 3mm

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Thalamic/Subdural HemorrhageThalamic/Subdural Hemorrhage

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Physical EvidencePhysical Evidence SAHSAH -GCS < 12-GCS < 12 -coma-complications secondary to-coma-complications secondary to -failure to improve after interventions, no improvement in 5 days-failure to improve after interventions, no improvement in 5 days -concurrent pulmonary edema-concurrent pulmonary edema -loss of consciousness at onset-loss of consciousness at onset -age > 65-age > 65

LobarLobar -GCS <8-GCS <8 -neuro deterioration in non-comatose to coma-neuro deterioration in non-comatose to coma -extensor posturing, absent occular reflexes (pupil, occulocephalic-extensor posturing, absent occular reflexes (pupil, occulocephalic corneal)corneal) -pre-event hx of heart disease, age older (<80)-pre-event hx of heart disease, age older (<80)

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Ganglion/PutnamGanglion/Putnam

--hypertension on admissionhypertension on admission

-coma at onset (pred of 30 day mortality)-coma at onset (pred of 30 day mortality) -GCS -GCS << 8 8

PontinePontine -longstanding refractory hypertension-longstanding refractory hypertension

-coma on admission-coma on admission -hyperthermia (>39 C) with hydrocepahlous and midbrain -hyperthermia (>39 C) with hydrocepahlous and midbrain -tachycardia extension, do not survive-tachycardia extension, do not survive

NB coma and hemorrhage > 20mm uniformly associated with deathNB coma and hemorrhage > 20mm uniformly associated with death

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CerebellarCerebellar --admission systolic BP > 200mm Hgadmission systolic BP > 200mm Hg -GCS -GCS << 8 8 -abnormal corneal/occulocephalic responses-abnormal corneal/occulocephalic responses (absent corneal response on admission)(absent corneal response on admission) -motor responses on GCS worse than localization-motor responses on GCS worse than localization -Age over 70-Age over 70

NB hydrocephalous, absent occulocephalic responsesNB hydrocephalous, absent occulocephalic responses--92% poor92% poor

without hydrocephalous, but age > 70 and hematoma >3mm poorwithout hydrocephalous, but age > 70 and hematoma >3mm poor

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Research-Clinical IndicatorsResearch-Clinical Indicators

Current ResearchCurrent Research

How do we quantify Overwhelming Acute How do we quantify Overwhelming Acute Ischemic Stroke?Ischemic Stroke?

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ISSUESISSUESTHINGS TO CONSIDERTHINGS TO CONSIDER…..…..

Life support-ventilationLife support-ventilationFeedingFeeding

MedsMedsLabsLabs

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DecisionsDecisions

Clinical Indicators/Prediction rulesClinical Indicators/Prediction rulesDecision making around withdrawal of Decision making around withdrawal of treatment / continuancetreatment / continuanceWho-family /team /patient….Who-family /team /patient….What are the considerationsWhat are the considerationsHow are decisions often made?How are decisions often made?

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Decision Making BiasDecision Making Bias

Estimate of prognosisEstimate of prognosisMethod of communicationMethod of communicationMisunderstandings-values/expectationsMisunderstandings-values/expectationsFailure to appreciate patient health state/Failure to appreciate patient health state/ adaptabilityadaptability

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SuggestionsSuggestions

Structured interactionsStructured interactions Bias/interferenceBias/interference Conflict-expect it, manage itConflict-expect it, manage it Communicating prognosisCommunicating prognosis Patient life valuesPatient life values Treatment Treatment Alternative treatmentsAlternative treatments TimeTime Know policies re: issues such as feedingKnow policies re: issues such as feeding

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FeedingFeeding

Tube feeds are not a cureTube feeds are not a cureSerious implications associated with long-Serious implications associated with long-

term useterm use*Aspiration pneumonia and the tube*Aspiration pneumonia and the tube*Secretion management and the tube*Secretion management and the tube*Infections*Infections

*Tubes for palliative care*Tubes for palliative care

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Aspiration pneumonia and the tubeAspiration pneumonia and the tube

Gastroesophageal reflux is a significant side effects Gastroesophageal reflux is a significant side effects of tube-feedings when accompanied by a of tube-feedings when accompanied by a disordered swallow and a weakened coughdisordered swallow and a weakened cough

Tube feeding is a strong predictor of aspiration Tube feeding is a strong predictor of aspiration pneumonia in the elderlypneumonia in the elderly

Chronic aspiration of small amounts of reflux leads Chronic aspiration of small amounts of reflux leads to aspiration pneumonia to aspiration pneumonia

(Langmore SE, Terpenning MS, Schork A, Chen Y, Murray JT, Lopatin D & Loesche WJ (Langmore SE, Terpenning MS, Schork A, Chen Y, Murray JT, Lopatin D & Loesche WJ (1968). Predictors of aspiration pneumonia: how important is dysphagia? Dysphagia 13(2): (1968). Predictors of aspiration pneumonia: how important is dysphagia? Dysphagia 13(2): 69-81)69-81)

(Koufman JA, (April, 1991). The otolaryngologic manifestation of gastroesophageal reflux (Koufman JA, (April, 1991). The otolaryngologic manifestation of gastroesophageal reflux disease (GERD): A clinical investigation of 225 patients using ambulatory 24-hour pH disease (GERD): A clinical investigation of 225 patients using ambulatory 24-hour pH monitoring and an experimental investigation of the role of acid and pepsin in the monitoring and an experimental investigation of the role of acid and pepsin in the development of laryngeal injury. Laryngoscope 101: 1-78.)development of laryngeal injury. Laryngoscope 101: 1-78.)

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Secretion management and the Secretion management and the tubetube

Patients with swallowing difficulties tend to swallow Patients with swallowing difficulties tend to swallow less frequently between mealsless frequently between meals

A lack of oral intake produces a decreased A lack of oral intake produces a decreased incentive to swallow, patients who are tube-fed will incentive to swallow, patients who are tube-fed will be at greater risk for secretion build-upbe at greater risk for secretion build-up

A lack of oral intake produces a decreased A lack of oral intake produces a decreased incentive to swallow because of this patients who incentive to swallow because of this patients who are tube fed will be at greater risk for secretion are tube fed will be at greater risk for secretion build-upbuild-up

(Murray J, Langmore S, Ginsberg S & Dosile A (1998). The significance of accumulated (Murray J, Langmore S, Ginsberg S & Dosile A (1998). The significance of accumulated oropharyngeal secretions and swallowing frequency in predicting aspiration. Dysphagia oropharyngeal secretions and swallowing frequency in predicting aspiration. Dysphagia 11: 99-103.)11: 99-103.)

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InfectionsInfections

The insertion site of the G- or J- tube is The insertion site of the G- or J- tube is prone to infectionprone to infection

Prevention requires:Prevention requires:-daily monitoring of the site for redness, -daily monitoring of the site for redness, increased warmth, and purulent increased warmth, and purulent

drainage, and daily cleansing of the sitedrainage, and daily cleansing of the site

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Tubes for Palliative CareTubes for Palliative Care

It is not uncommon for the swallowing mechanisms It is not uncommon for the swallowing mechanisms to fail during the end stages of a diseaseto fail during the end stages of a disease

Therefore, introduction of tube feeds at this time is Therefore, introduction of tube feeds at this time is questionablequestionable

Evidence exists to suggest that although nutrition is Evidence exists to suggest that although nutrition is being introduced via a tube, the body is unable to being introduced via a tube, the body is unable to make use of it.make use of it.

Given such conditions, there is no prolongation of Given such conditions, there is no prolongation of life and food may actually become a burden life and food may actually become a burden (Chouinard J, Lavigne E & Villeneuve C (1998). Weight loss, dysphagia and outcome in (Chouinard J, Lavigne E & Villeneuve C (1998). Weight loss, dysphagia and outcome in advanced dementia. Dysphagia 13: 151-155.)advanced dementia. Dysphagia 13: 151-155.)

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Values clarification: Recognizing our pre-Values clarification: Recognizing our pre-existing comfort with catastrophic events existing comfort with catastrophic events

Understanding and respecting the families Understanding and respecting the families inability to accept bad news inability to accept bad news

Tips for communicating bad newsTips for communicating bad newsStrategies to care for patients and families Strategies to care for patients and families

experiencing life changing eventsexperiencing life changing eventsTaking care of yourselfTaking care of yourself

Working Through It………Working Through It………

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Recognizing your ValuesRecognizing your Values

It is important for health care professionals to It is important for health care professionals to complete a values clarification exercise when complete a values clarification exercise when faced with new challenges or difficult situations faced with new challenges or difficult situations

Knowing our values and beliefs is a good Knowing our values and beliefs is a good beginning to the process of positive changebeginning to the process of positive change

Our beliefs and values influence our behaviours Our beliefs and values influence our behaviours (Manly, K. 2003) (Manly, K. 2003)

We must identify our own beliefs about a patient We must identify our own beliefs about a patient situation to prevent confusing them with those of situation to prevent confusing them with those of the family (White, K. & Hall, J. 1999) the family (White, K. & Hall, J. 1999)

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What are your values?What are your values?

You are caring for a women who has suffered a You are caring for a women who has suffered a catastrophic stroke. She is non-responsive & her catastrophic stroke. She is non-responsive & her prognosis is very poor. prognosis is very poor.

She is currently receiving numerous treatments She is currently receiving numerous treatments such as: NG feeding, oxygen, IV fluids & such as: NG feeding, oxygen, IV fluids & medications, numerous blood draws, daily medications, numerous blood draws, daily diagnostic tests, and more. diagnostic tests, and more.

The specialists have identified, based on her stroke The specialists have identified, based on her stroke etiology and clinical presentation, that these efforts etiology and clinical presentation, that these efforts are futile and she will not recover. are futile and she will not recover.

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But the family values……?But the family values……?

Save her life Save her life Save her lifeSave her lifeSave her lifeSave her lifeThis is my motherThis is my motherThis is my sisterThis is my sisterThis is my wifeThis is my wife In many ways, this is my life too……….In many ways, this is my life too……….

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Why can’t the family understand Why can’t the family understand what we are saying?what we are saying?

Families are experiencing a sudden and distressing Families are experiencing a sudden and distressing change change

We can empathize but we cannot feel the changeWe can empathize but we cannot feel the change The family’s ideas about their future and the way in The family’s ideas about their future and the way in

which they will function are under attack which they will function are under attack Emotional responses to this change can be very Emotional responses to this change can be very

powerful. These emotions can cause memory, powerful. These emotions can cause memory, concentration, and decision making problems (Rich concentration, and decision making problems (Rich Wheeler, S. 1996)Wheeler, S. 1996)

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Delivering bad newsDelivering bad news

Become comfortable waiting for decisions to be Become comfortable waiting for decisions to be made about patient caremade about patient care

Be prepared to repeat yourself Be prepared to repeat yourself After you receive report, try to arrange a time with After you receive report, try to arrange a time with

family to listen to their concerns. family to listen to their concerns. Always use real terms such as ‘dying’ or ‘death’.Always use real terms such as ‘dying’ or ‘death’. When trying to explain why the patient will not When trying to explain why the patient will not

recover, you must reinforce the facts of the recover, you must reinforce the facts of the patient’s diagnosis. patient’s diagnosis.

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The return of primitive reflexes The return of primitive reflexes after neurological damageafter neurological damage

The return of the grasp reflex is difficult for the The return of the grasp reflex is difficult for the family to understand as a sign of deterioration in family to understand as a sign of deterioration in the patient. the patient.

They perceive the patient to be improving and They perceive the patient to be improving and responding to themresponding to them

It takes skill to communicate the truthIt takes skill to communicate the truth If it is done without care, this can cause resentment If it is done without care, this can cause resentment

and mistrust in the teamand mistrust in the team If possible, it is crucial to warn the family ahead of If possible, it is crucial to warn the family ahead of

timetime

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Caring for the Grieving FamilyCaring for the Grieving Family

Tell the family that their feelings are normalTell the family that their feelings are normal Give time to make difficult decisions Give time to make difficult decisions Start the process of decision making by asking the Start the process of decision making by asking the

family to identify a spokesperson so that family to identify a spokesperson so that communication can be streamlined communication can be streamlined

Encourage family to be involved with the patient’s Encourage family to be involved with the patient’s care and to touch the patientcare and to touch the patient

Anger is a form of grief. Don’t become defensive. Anger is a form of grief. Don’t become defensive. Instead, acknowledge the anger and show Instead, acknowledge the anger and show acceptance. Set boundaries early. acceptance. Set boundaries early.

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How do I help them decideHow do I help them decide

If available, ask the family to review advanced If available, ask the family to review advanced directives directives

Be truthful about the prognosis. Use the facts and Be truthful about the prognosis. Use the facts and avoid making statements that only make yourself avoid making statements that only make yourself feel better. (Rich Wheeler, S.)feel better. (Rich Wheeler, S.)

““This is God’s will” “Time heals all wounds”.This is God’s will” “Time heals all wounds”. Include spiritual care or social workInclude spiritual care or social work If there is a large extended family, support the If there is a large extended family, support the

nuclear family in their decision makingnuclear family in their decision making

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Other Points to Help With Other Points to Help With Managing the Situation…. Managing the Situation….

Caregiver Burden is real and we must utilize the team Caregiver Burden is real and we must utilize the team system to prevent it. “Its not my patient” is a destructive system to prevent it. “Its not my patient” is a destructive approach to team integrity. approach to team integrity.

Ad hoc or organized debriefing sessions to share challenges Ad hoc or organized debriefing sessions to share challenges and emotions are valuableand emotions are valuable

Utilize employee assistance programsUtilize employee assistance programs Get sufficient restGet sufficient rest If you are having significant difficulty with the assignment, If you are having significant difficulty with the assignment,

communicate this to the teamcommunicate this to the team Seek out educational opportunities to develop skill inSeek out educational opportunities to develop skill in this area this area

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Developing a Plan of CareDeveloping a Plan of CareInclusions and ConsiderationsInclusions and Considerations

Consults-which are important, what additonalConsults-which are important, what additonal Tests-after the initial testing, then what Tests-after the initial testing, then what

Treatments-vital signs, prevention of Treatments-vital signs, prevention of

complications, treatment for comfortcomplications, treatment for comfort MedsMeds NutritionNutrition EliminationElimination ActivityActivity EducationEducation Expected outcome-severe disability/palliativeExpected outcome-severe disability/palliative Discharge planDischarge plan

Anything else we can think of to include?Anything else we can think of to include?

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FINIFINI

That’s All Folks!!That’s All Folks!!

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ReferencesReferences

See inclusions in packageSee inclusions in package

Health & Medicine

Marie Rusnak Stroke