Making the Case for CPG s Jean Luciano, MSN, RN, CNRN, SCRN, CRNP, FAHA Claranne Mathiesen, MSN, RN, CNRN, SCRN, FAHA

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1 Making the Case for CPG s Jean Luciano, MSN, RN, CNRN, SCRN, CRNP, FAHA Claranne Mathiesen, MSN, RN, CNRN, SCRN, FAHA Disclosures Jeanie Luciano Genentech speakers bureau Claranne Mathiesen - none 1

2 Objective Discuss research based nursing interventions for the stroke patient. Case Study #1 72 year old woman brought to the Emergency Department by helicopter at Met by the Stroke Team Patient complaint I had a stroke 45 minutes ago. Time of onset: 0845 Reported by patient and witnessed by daughter who was with her at church. PMH: Hypertension Medications: Amlodipine, HCTZ, and Lisinopril 2

3 Exam Dense Left hemiplegia, slurred speech, & left facial droop. NIHSS: 13 Other systems within normal limits. Laboratory results: normal. BP: 128/64 HR 77 Sat: 98% EKG: NSR Weight 70 kg. Head CT: Hyperdenseright middle cerebral artery suggesting the presence of acute thrombus without CT evidence of acute territorial infarct, Old right parieto-occipital infarct, Mild cerebral atrophy Time 75 minutes from onset of symptoms. 30 minutes since presentation to ED. 3

4 Treatment t-pa per protocol DTN time: 30 minutes Frequent vital signs and monitoring per protocol Enrolled in an acute ischemic stroke clinical trial. Response 45 minutes into infusion: facial droop and speech without change, left sided strengths improved. NIHSS now 8 Left lip swelling noted. Angioedema progresses to the entire mouth and tongue. 4

5 Angioedema Reported more frequently in patients treated with ACE inhibitors. Treated with Diphenhydramine 25 mg. IV x 2 doses, Zantac 50 mg IV x 1, and Racemic epinepherinenebulizer. Airway visualized by ENT and improvement noted. Intubation averted, admitted to ICU. Workup & Etiology TTE: no evidence of cardioembolic source No atrial fibrillation noted on continuous telemetry. CTA: Complete right ICA occlusion, 40% stenosis on the left. 5

6 Monitoring Continue to monitor neurological status, vital signs, and airway. Nursing dysphagia screen was deferred secondary to the angioedema; speech and language pathology was consulted and cleared on day 2. Physical and occupational therapy initiated. Discharge Started on Plavix. Atorvastatin 80 milligrams daily. Restarted antihypertensive therapy Discharged to acute rehab facility on Day 8 6

7 Patient Education Highlights Blood pressure management. Monitoring liver functions with statin use. Signs and symptoms of stroke and emergent response in the event of new or recurrent symptoms. DECISION Support CPG Jauch, EC et al. Guidelines for the Early Management of Patients With Acute Ischemic Stroke available at DOI: /STR.0b013e a. Clinical Trial SPARCL (2008) Atorvastatin 80mg vs placebo; primary endpoint fatal and non-fatal strokes. MATCH (2004) 7599 pt w/ stroke or TIA in prior 3 mo; ASA/Plavix vs Plavix; primary outcome was composite of ischemic stroke, MI, vascular death, or rehospitalization with ischemia. ASA/Plavix not better than Plavix 7

8 Case Study #2 52 year old woman presents with a transient episode (lasted about 5 minutes) of right sided numbness. History No history of stroke, TIA, heart disease, hypertension or diabetes. History of hypothyroidism. Medications: Synthroid Vital signs BP-156/88 HR-90 ABCD2 Score: 1 8

9 ABCD2 Score for Transient Ischemic Attack (TIA) A simple score (ABCD2) to identify individuals at high early risk of stroke after transient ischemic attack. A (Age); 1 point for age >60 years, B (Blood pressure > 140/90 mmhg);1 point for hypertension at the acute evaluation, C (Clinicalfeatures); 2 points for unilateral weakness, 1 for speech disturbance without weakness, and D (symptom Duration); 1 point for 10 59minutes, 2 points for >60 minutes. D (Diabetes); 1 point ABCD2 Score Total scores range from 0 (lowest risk) to 7 (highest risk). Stroke risk at 2 days, 7 days, and 90 days: Scores 0-3: low risk Scores 4-5: moderate risk Scores 6-7: high risk 9

10 Evaluation Admitted to transitional care unit for 24 hour observation and evaluation. Telemetry MRI, echocardiogram, and all laboratory studies were within normal limits. Discharge Discharged after 22 hours. No findings on any studies. Plan to follow up with her primary care provider for blood pressure monitoring and vascular risk factor management. Set up for extended ambulatory cardiac monitoring. Discharge medications: aspirin 81 mg and Synthroid 10

11 Further Findings Ambulatory monitoring revealed episodes of atrial fibrillation. Started on Dabigatran Dabigatran Education Bleeding issues Concomitant medications Take as ordered, do not stop without consulting with you provider Can be taken with or without food, do not crush, chew, or open capsules. Common side effect: GI distress 11

12 Dabigatran Education Store at room temperature. Keep tightly closed Discard after the bottle is opened for 4 months MEDICAL ALERT Education Point Resetting the CLOCK for TIA patients. 12

13 Decision Support CPG Jauch, EC et al. Guidelines for the Early Management of Patients With Acute Ischemic Stroke available at DOI: /STR.0b013e a. Clinical Trials Connolly S J. Dabigatranversus Warfarin in Patients with Atrial Fibrillation. N Engl J Med 2009; 361: September 17, 2009DOI: /NEJMoa Johnston S C. Validation and refinement of scores to predict very early stroke risk after transient ischemic attack. Lancet, 369: , Case Study #3 Patient Presentation 57 y/o M on Lovenox who presented to spoke hospital with acute L MCA syndrome. Transferred for endovascular thrombectomy On arrival at HUP: NIHSS 16; right UE paresis, global aphasia 13

14 Imaging Imaging Findings CTA with occluded left M1 (Figure A) Angiogram confirmed occluded left M1 (Figure B) Figure A Figure B Intervention Successful embolectomy with Trevostent retriever and Penumbra aspiration LMCA fully reopened (Figure C) Figure C C. Post Thrombectomy: L MCA Reopened, branches now filling 14

15 Outcome Post procedure CT, no bleed Discharged home 2 days later Day 30-NIHSS-0 MRS-0 Decision Support Powers, W J American Heart Association/American Stroke Association Focused Update of the 2013 Guidelines for the Early Management of Patients With Acute Ischemic Stroke Regarding Endovascular Treatment. Stroke is available at DOI: /STR