CEREBROVASCULAR ACCIDENT(STROKE)

Yves-Aime Amougou, BSN RNSouth University

NSG 6420: Family Health-Adults & GerontologyDr. Kelli Miller

August 23rd, 2015

FACTS Every year, about 800,000 people in the United States have a

stroke. Stroke is the fifth leading cause of death in the United States.

Nearly 130,000 Americans die each year, and 25% of stroke patients die within a year of their first stroke!

On average, one American dies from stroke every four minutes. Stroke is number one cause of disability in the United States

(About 70% of stroke survivors regain functional independence. 20% of stroke survivors require institutional care)

Stroke treatment costs an estimated 34 billion a years in the United States, including medications and missed days

Getting early treatment is the crucial to preventing death and disability secondary to stroke

DEFINITION A cerebrovascular

accident (CVA) or stroke is a condition marked by an interruption of blood flow to the brain, and associated with neurologic deficits. A stroke can be ischemic or hemorrhagic (Buttaro, Trybulski, Bailey, & Sandberg-Cook, 2013).

CVA is accompanied by brain tissue death due to lack of oxygen

RISKS FACTORS NON-MODIFIABLE RISKS FACTORS

RACE (STROKE IS MORE PREVLENT AMONG BLACK)FAMILY HISTORYAGE

MODIFIABLE RISKS FACTORSDIET(high in saturated fats, trans fat, and cholesterol)INACTIVITY OR LACK OF PHYSICAL EXERCISESMOKINGALCOHOL AND COCAINE USEHIGH STRESSCONTROL OF MEDICAL CONDITIONS (Hypertension, Diabetes Mellitus,

Hypercholerolemia, Sickle cell diseases)

TYPES OF STROKE

Ischemic Stroke: About 85% of strokes are ischemic in nature. There are different genesis / pathophysiology to ischemic stroke:

1. It may be due to atherosclerotic disease. It is a progressive occlusion of cerebral artery due to deposit of plaque. 2. Ischemic stroke may be secondary a thrombolytic event related to Atrial Fibrillation

TYPES OF STROKE (Continued)

3. Lacunar stroke is another of ischemic stroke. It affects a small single deep vascular artery of the brain, and it is seen in patients with diabetes or hypertension. HEMORRHAGIC STROKE: Not as prevalent as ischemic stroke, but deadlier. It

affects mostly younger people. Hemorrhagic stroke occurs when an artery in the brain is ruptured, causing excess intracranial pressure, which leads to brain tissue death.

There are 2 types of hemorrhagic stroke:Intracerebral hemorrhage is the most common type of hemorrhagic stroke.

It occurs when an artery in the brain bursts, flooding the surrounding tissue with blood.

Subarachnoid hemorrhage is a less common type of hemorrhagic stroke. It refers to bleeding in the area between the brain and the thin tissues that cover it.

TYPES OF STROKE (Continued)

Transient Ischemic Attack (TIA) or Acute Cerebral Vascular Syndrome (ACVS). There are ischemic event that are manifested as neurologic deficits, and that are resolved within 24 hours or less.

It is important to aggressively treat TIAs since they are always precursors of more damaging CVAs.

NOTE : AIRWAYS MANAGEMENT, ABC AND EARLY TRANSPORTATION TO ED / STROKE SPECIALIZED CENTER SHOULD BE A PRIORITY!!!

CLINICAL PRESENTATION Severe headache / Stiff Neck / Hypertension Vertigo Nausea /vomiting Facial sag/Drooping of the face Slurred speech Ataxia Hemiplegia / Hemiparalysis / Hemi-sensorial loss Behavioral changes Irregular respiration.. Including absence of respiration Dilated and fixed pupils Decerebrate rigidity Stupor /Coma / Death Remember the pneumonic FAST(Facial drooping, Arm

weakness/numbness/Slurred speech/Time to call 911)

DIAGNOSTICSEKGPulse OximetryBlood Tests Complete Blood Count with differential Complete Metabolic panel PT/INR Cardiac biomarkers may be drawn due to the link between cardiovascular

disease and CVAImaging CT Scan (Provides faster results than MRI) MRI(Not used on patients with pacemakers)

DIAGNOSTICSAdditional Tests Toxicology (To rule-out patients under the influence of drugs) ABGs (Do this test only if necessary since it may increase risk of hemorrhage Lipid profile Pregnancy Test on all childbearing age women since treatment some medications

(fibrinolytic agents) are Category C for pregnant women BUN/Creatinine Blood culture to rule-out septicemia Lumbar puncture NIH Stroke Scale Neuro-check Chest X-rays for patients with respiratory symptoms

TREATMENT Oxygen therapy as indicated Blood pressure management as well as any other related disease Thrombolytic therapy: Alteplase IV-tPA has been approved by FDA for

confirmed ischemic stroke within 3 hours of onset, (Goldstein, 2014). Antiplatelet agents Surgery (Neurosurgeon would be indicated) Rehabilitation therapy (OT/PT) Dietary consult Speech therapy Palliative therapy

GENERAL GUIDELINES FOR THROBOLYTIC USE

Inclusion and Exclusion Criteria for Thrombolytic in Stroke

Inclusion criteria Exclusion criteria (contraindications) Exclusion criteria (warnings)

•Ischemic stroke with measurable defect on stroke scale•Time of onset less than 3 hours ago•Over 18 years old

•Intracranial hemorrhage on CT•Clinical picture of a subarachnoid hemorrhage (with normal CT)•Known AVM or aneurysm•Prior intracranial bleed•Active internal bleeding•Bleeding diathesis: Plt<10k, PT>15s, INR>1.7, or on blood thinners•BP>185/110•Brain surgery in past 3 m, major surgery within 2 weeks•Pregnant•Post-MI pericarditis

•Rapid improvement of neurologic symptoms•Mild stroke•GI bleeding within 3 weeks•Recent LP•Recent arterial puncture (at no compressible site) •Glucose <50 or >400•Seizure

AJ CASE STUDYChief Complaint: Made by the spouse as informant“My husband’s speech is slurred and he cannot move his right limbs.”

AJ CASE STUDYHistory of Present illnessAJ is a 52 years old black male who came to the emergency room (ER) with report of slurred speech, hemiplegia. According to the informant, The last time AJ was seen alert and asymptomatic was around 1:00 PM. Around 1:30 PM, AJ was found by his spouse, lying on the floor, his speech was slurred and AJ was unable to move his right extremities. Presently, AJ has mild respiratory distress, and AJ does not have any obvious sign of trauma. AJ is lethargic and appears weak. AJ is able answer simple commands, and verbalize his basic needs.

Note: 911 was called immediately, and paramedics brought patient to ER around 1:50 PM.

AJ CASE STUDY

Medical HistoryHypertension since 2000Diabetes Mellitus since 2008Hypothyroidism since 2010Hypercholesterolemia since 2010Current MedicationsLisinopril 40 mg PO daily in the morningMetformin 1000 mg PO twice dailyLovastatin 20 mg PO at bedtimeLevothyroxine 50 mcg PO daily in the morningImmunization: Current Influenza 2014 Pneumococcal 2012

AJ CASE STUDYFamily HistoryAJ father died of MI at 55 years oldAJ mother died of Multiple myeloma complications at 73 years. She also had Hypertension and Type II Diabetes Mellitus.AJ’s younger sister is 42, and she has type II Diabetes Mellitus

No Known Drug Allergies / No food Allergies / No Environmental Allergies

Social HistoryMarried with two adults children. Warehouse worker. Sedentary lifestyle. Diet high fat and high sodium diet, including fast food (Mainstay)

AJ CASE STUDYReview of Systems Informant denies recent hospitalization AJ reports tiredness, and inability to move right extremities AJ reports inability to walk AJ denies headache, reports right eye vision change AJ reports difficulty swallowing AJ reports some degree of shortness of breath AJ denies heat and cold intolerance as well as changes in thirst AJ denies changes in bowel or urination pattern prior to

today’s event

AJ CASE STUDYAssessment/Objective DataInitial pulse oxygen saturation at 95% with oxygen given through rebreathing mask.BP=155/98, P=92, T=98.4, R=22Height=1.80 mWeight=135 kgBMI=41.66

AJ CASE STUDY Assessment/Objective Data AJ appears lethargic Pupils reactive to light with direct response but no consensual

response AJ has a hard time following commands; therefore unable to

assess field of gaze. Right facial drooping No use of assessory muscles for breathing S1 and S2 heard There is a certain degree of tactile extinction noted as evidenced

by inability to feel tactile stimuli in right side of body. Hyporeflexia noted to the right side Initial NIH Stroke Assessment score was 19

LAB TestingCOMPLETE BLOOD COUNT W/ DIFFWBC 7.2 Thous/cu.mm 3.9 - 11.1RBC 4.51   Mil/cu.mm 4.20 - 5.70HGB (HEMOGLOBIN) 14.5 g/dL 13.2 - 16.9HCT (HEMATOCRIT) 44.2 Percent 38.5 - 49.0MCV 87        fl 80 - 97MCH 31.4     pg 27.5 - 33.5MCHC 35.3 Percent 32.0 - 36.0RDW 11.8 Percent 11.0 - 15.0PLATELET COUNT 172  Thous/cu.mm 140 - 390MPV 7.6 fl 7.5 - 11.5DIFFERENTIAL   TOTAL NEUTROPHILS, % 72.1 Percent 38.0 - 80.0  TOTAL LYMPHOCYTES, % 44.1 Percent 15.0 - 49.0   MONOCYTES, % 12.9 Percent 0.0 - 13.0   EOSINOPHILS, % 0.6 Percent 0.0 - 8.0   BASOPHILS, % 0.3 Percent 0.0 - 2.0   TOTAL NEUTROPHILS, ABSOLUTE 8085  Cells/cu.mm 1650 - 8000

   TOTAL LYMPHOCYTES, ABSOLUTE 2997  Cells/cu.mm 1000 - 3500

   MONOCYTES, ABSOLUTE 671  Cells/cu.mm 40 - 900   EOSINOPHILS, ABSOLUTE 31  Cells/cu.mm 30 - 600   BASOPHILS, ABSOLUTE 16  Cells/cu.mm 0 - 125

AJ Lab Report / Drawing date August 20, 2015

Additional lab testingBMP

Na 142 136-145 mEq/L

K 3.7 3.5-5.1 mEq/L

CO2 29 23-29 mEq/L

Cl 101 98-107 mEq/L

Glucose 150 74-100 mg/dL

Ca 9.9 8.6-10.2 mg/dL

BUN 15 8-23 mg/dL

Creatinine 1.0 0.8-1.3 mg/dL

e-GFR 100 138-90 WNL

DIAGNOSTIC STUDIES

Pulse Oximetry EKG / Results show regular sinus rhythms CK/MB and Troponin I are not suggestive of MI Negative drug screening Blood culture and sensitivity shows no bacterial growth PT=33 seconds / INR=1.2 D-Dimer=350 ng/mL suggestive of thrombosis CT scan of brain shows chronic small vessels ischemic changes

suggestive of Left ischemic CVA causing right side weakness with visual and tactile extinction

PROBLEM LIST Shortness of breath Slurred Speech Difficulty swallowing Changes in vision Right side weakness / Right side paralysis

Differential Diagnosis Ischemic Stroke Migraine Seizure Brain Tumor Syncope Cardiac Arrhythmia /MI Hypoglycemia Panic Attack Systemic Infection / Septicemia Drug Overdose

DIAGNOSIS / CODESCURRENT DIAGNOSIS 434.91 Acute Ischemic Cerebrovascular Accident (New Diagnosis) 401.9 Unspecified Hypertension 250.0 Unspecified Type II Diabetes Mellitus 272.4 Unspecified HyperlipidemiaCURRENT TESTS CODES 70460 CT scan of the brain with contrast 85025 CBC with differential/platelets 80053 Complete Metabolic Panel & 84443 TSH withT3 T4 80347 Drug Screening 84484 Troponin I & 82553 CK/MB 3555F PT/INR & 85379 D-Dimer 81015 Urinalysis & 87040 Blood Culture and Sensitivity 82270 Guaiac test

TREATMENT

IV-tPA initiated 2hours and 30 minutes after current onset (RX= 0.9 mg/kg, not to exceed 90 mg total dose) Current dose 90 mgGive 9 mg IV bolus and Give 81 mg Infusion over 1 hour **

Continue the following medications until further notice by MD: Lisinopril 40 mg PO daily in the morning Metformin 1000 mg PO twice daily Lovastatin 20 mg PO at bedtime Levothyroxine 50 mcg PO daily in the morning

TREATMENT PLAN and DISPOSITION

Continue medication therapy to treat underlying cause of CVA Restore maximum function: Physical therapy/Occupational therapy Anticipate Aspirin, Plavix or Coumadin therapy to prevent DVT due to

immobilization. A blood thinner may also be added to daily medication regiment to

prevent future ischemic stroke. Take steps to prevent pressure ulcers Diet Referral Speech therapy Get social worker’s involvement to plan discharge in sub-acute

setting Follow-up with PCP/Neurologist post discharge as indicated

References American Heart Association (2013). Guidelines of early managements of

patients with acute ischemic stroke. American Heart Association Journal. doi: 10.1161/STR.0b013e318284056a

Buttaro, T.M., Trybulski, J., Bailey, P.P & Sandberg-Cook, J. (2013). Primary care: A collaborative practice ( 4th ed.) (pp. 994-999). St. Louis: Elsevier

Boston Medical (2014). Acute stroke protocol. Retrieved from http://www.bmc.org/stroke-cerebrovascular/services/acute-stroke-protocol.htm

Centers for Diseases Control and Prevention (2014). Stroke. Retrieved from http://www.cdc.gov/stroke/index.htm

Goldstein, L. B. (2014). Modern medical management of acute ischemic stroke. Methodist Debakey Cardiovascular Journal, 10(2), 99-104.

Longo, D., Fauci, A. ,Kasper, D., Hauser, S., Jameson, L., Loscalzo, J. (2012). Harrison’s book of internal medicine (18th ed.) (pp 3271). New York: McGraw-Hill Companies, Inc.