Posted in Med Surg

It can be really scary when you suspect your patient has had a stroke. In order for your patient to have the best possible chance for the best possible outcome, time is THE critical factor. You also need to ensure your patient stays safe with an eye toward preventing additional complications. In this article, we’ll be talking through what happens when you call a stroke alert on your patient. 

What is a stroke alert? 

Like a Code Blue, a stroke alert is a way to quickly get your patient the resources he needs for timely stroke intervention. When you push the code blue button, other team members come running and they bring along the equipment you need…namely the crash cart. When you call a stroke alert, it’s the same concept. You get the people you need AND you alert the CT scan technician to clear the scanner and get ready for your arrival. 

When do you call a stroke alert? 

You will call a code stroke anytime you suspect your patient is having a stroke, no matter how minor the symptoms. The evidence shows that rapid intervention is the key factor in keeping neurological deficits to a minimum and improving patient outcomes. So, as soon as you see evidence of potential stroke, you’re going to follow your facility’s procedure for calling a stroke alert.

Signs of a stroke can be summed up with the acronym BE FAST:

  • B: Balance. Is your patient suddenly having trouble with balance, standing or sitting? Are they slumped over to the side? Did they fall? How is their gait? Do they appear to have a lack of coordination?
  • E: Eyes. Has your patient experienced a sudden vision change? Have they lost all or part of a field of vision? Has their vision suddenly blurred? Do you see disparate pupils (a late sign of severe injury). 
  • F: Face. Does the patient have a facial droop? Ask them to smile and assess for symmetry of the nasolabial folds. Have them close their eyes tightly and open their eyes wide while raising the eyebrows as high as they can. Any asymmetry is cause for concern. 
  • A: Arms. Have your patient hold their arms out with palms up and eyes closed. You are assessing for something called pronator drift…the upturned palm will pronate downward as the arm slowly drops. Of course, if your patient can’t hold his arm up, that’s a clear deficit in and of itself!
  • S: Speech. Has the patient developed slurred speech? Is he having trouble finding words, are the words he is using appropriate? Does he appear to not understand spoken language? Any problems with speech recognition or performance are concerning for stroke.
  • T: Time. Again, brain = time. The faster you can intervene, the more brain tissue we can save. 

What happens after you call the stroke alert?

While stroke protocols may vary from hospital to hospital, in general you can expect the following things to occur in rapid succession. 

  • Evaluation by MD or rapid response RN. Many facilities will use the NIHSS to score the severity of stroke symptoms.
  • STAT non-contrast head CT (sometimes called a “dry head” because no contrast dye is used). MD may also order CT angiogram and CT perfusion scan as needed. The goal is to get the patient to the non-contrast CT scan as quickly as possible…often in less than 10 minutes from the time the stroke alert is called.
  • Ensure the patient has IV access (two please!) 
  • Draw labs (coags, CBC, chemistry panel, blood glucose).

The next things that happen will depend on the results of the CT scan. 

Option A: If the CT scan is negative for a bleed

  • The patient will be evaluated for alteplase (Activase), which is a thrombolytic medication that can break up the clot and restore blood flow to the brain tissue. You can learn more about thrombolytics here. The use of alteplase relies on several factors which include the time since last seen normal (LSN), patient’s medical history, blood pressure, presence of active bleeding, and lab results (including blood glucose level). For a long time, alteplase was only used for patients with a LSN of three hours or less. Alteplase is now being used for up to 9 hours of LSN, but can vary based on hospital protocols and procedures. So, don’t be surprised if you see a max time frame of 4.5 hours since LSN in some facilities.
  • The alteplase will be prepared for administration either by a pharmacist or an RN. Alteplase is weight-based, so I hope you have a recent patient weight on record! This medication is always infused with an infusion pump and is administered as a bolus dose followed by an infusion over one hour.
  • Some patients, depending on the time since “last seen normal” (LSN), may require neuro intervention. These procedures are typically conducted in interventional radiology by an MD who specializes in these procedures. Thrombectomies can be conducted on patients up to 24 hours since LSN, which greatly expands the time period for responding to ischemic stroke. 

Option B: If the CT shows a hemorrhagic stroke

If the diagnostics have shown the patient has had a hemorrhagic stroke, the plan of care is completely different and will revolve around blood pressure control and some kind of neurological intervention to address the bleed. 

So what else is happening throughout all this?

I am so glad you asked! Throughout the entire stroke alert event, you want to make sure your patient is safe and you are monitoring for worsening (or improvement) of stroke symptoms. 

Things you can do to ensure patient safety are: 

  • Stay with the patient and stay calm! They are likely very afraid (and you probably are, too!). It is possible to stay calm while also expressing a sense of urgency. Your confidence and competence will go a long way toward making the patient feel they are in good hands.
  • Get the patient back into bed if they weren’t in bed when the event occurred.
  • Monitor VS and supply supplemental oxygen if warranted.
  • Maintain optimal blood pressure and cerebral perfusion pressure. The MD will order a range for the patient’s blood pressure and medications to either raise or lower it as needed. Note that if the patient is on a continuous infusion to manage blood pressure, he will be in the ICU.
  • Maintain airway patency. Some patients will have to be intubated to ensure airway patency (this is in severe stroke cases).
  • Prevent aspiration. Many stroke patients are affected so severely they are unable to manage their secretions. Positioning the patient on their side can help the secretions flow out of the mouth vs down into the lungs. Suction as needed.
  • Monitor for worsening symptoms. Most facilities use a standardized stroke assessment called the NIHSS (National Institute of Health Stroke Scale). It is typically conducted every fifteen minutes during the alteplase infusion, then every fifteen minutes for the first hour, then every thirty minutes for the next six hours, then hourly for the 8th to 24th hour. Needless to say, patients who receive alteplase get very little sleep in that first 24-hour period, which can make it challenging to get an accurate neurological assessment. 

So there you have it! I hope you feel more confident with the idea of calling a stroke alert and doing your part to get timely intervention and keep your patient safe in the process. 

 

Get this on audio in episode 148 of the Straight A Nursing podcast wherever you get your podcast fix, or stream it right here.

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References:

Genentech. (2020). Post-activase care sheet. Genentech. https://www.activase.com/content/dam/gene/activase/PDFs/Activase-Posttreatment-Monitoring/Post-Activase-Care-Sheet.pdf

Hughes, R. E., Tadi, P., & Bollu, P. C. (2020). Tpa therapy. In StatPearls. StatPearls Publishing. http://www.ncbi.nlm.nih.gov/books/NBK482376/

Jauch, E. C. (2020, May 27). What is the role of supplemental oxygen in the treatment of ischemic stroke? Medscape. https://www.medscape.com/answers/1916852-118781/what-is-the-role-of-supplemental-oxygen-in-the-treatment-of-ischemic-stroke

Lou, N. (2019, May 9). Benefits of tpa for stroke extend to 9 hours post-onset. Medpage Today. https://www.medpagetoday.com/neurology/strokes/79734

Maxwell, Y. L. (2018, October 25). New BMJ guidance urges prudence with supplemental oxygen, especially in acute MI, stroke. TCTMD. https://www.tctmd.com/news/new-bmj-guidance-urges-prudence-supplemental-oxygen-especially-acute-mi-stroke