Cerebrovascular Accident

brain stroke (CVA) - causes, types and management. nursing care of stroke patients.

1. Cerebrovascular Accident Dr. Prasenjit Gogoi, MBBS, MEM, PGDHHM Attending Consultant Apollo Hospital, Guwahati

2. Overview A stroke occurs when the blood supply to part of your brain is interrupted or reduced, depriving brain tissue of oxygen and nutrients A stroke is a medical emergency Strokes can be treated and prevented

3. Epidemiology Global Perspective 13.7 million new strokes each year 5.5 million people die of stroke annually 70% acute stroke caused by ischaemic event Indian Perspective Prevelance 90-222 per 100,000 ( Dalal 2007) 102,620 million deaths ( Nongkynrih 2004) 1.44 – 1.64 million new cases every year (WHO 2005)

4. Symptoms Trouble with speaking and understanding Paralysis or numbness of the face, arm or leg Trouble with seeing in one or both eyes Headache Trouble with walking

5. STROKE – SPOT IT

6. Risk Factors

7. Risk Factors Lifestyle Risk Factors Obesity Physical inactivity Heavy drinking Drugs – cocaine etc

8. Risk Factors Medical Risk Factors Hypertension Smoking Diabetes High cholesterol Cardiovascular disease Obstructive Sleep Apnea Family history Other Factors Age > 55 Sex – Men>Women Race – African American Hormones - OCP

9. Types of Stroke Ischaemic – caused by a blocked artery. Hemorrhagic – caused by leaking or bursting of blood vessel. Transient Ischaemic Attack (TIA) – caused by temporary disruption of blood flow to the brain.

10. Ischaemic Stroke

11. CT Scan – Ischaemic Stroke

12. Hemorrhagic Stroke

13. Types of cerebral hemorrhage

14. CT Scan – Hemorrhagic Stroke

15. Diagnosis Physical examination Check all systems – check for bruits in carotid arteries. Stroke Scales – NIHSS Canadian Neurological Scale European Stroke Scale Hemispheric Stroke Scales Blood tests : Complete blood count Electrolytes Renal Function Test Lipid Profile Liver Profile

16. NIH Stroke Scale

17. Glasgow Coma Scale

18. Diagnosis Computerised Tomography Scan (CT) Magnetic Resonance Imaging (MRI) Carotid Ultrasound Cerebral Angiogram Echocardiogram

19. Treatment A B C

20. ED Treatment Treatment Cervical spine Spinal precautions Airway Maintain airway, intubate for GCS<8 or as needed Oxygenation and ventilation Oxygen saturation >90; P CO2 35-45 BP Systolic BP > 90 mmHg, MAP 80 mmHg; give NS, blood products as needed Exam and GCS GCS before paralytics if possible; treat life-threatening injuries and active bleeding Stat head CT and cervical spine Identify mass lesions and signs of increased ICP Repeat exam Check GCS for changes and for signs of impending herniation/deterioration

21. ED Treatment Treatment Check glucose Treat hypoglycemia and hyperglycemia Control temperature Maintain between 36 o F and 38.3 o F Seizure prophylaxis Give antiepileptic drug if GCS < 10, acute seizure with injury, or abnormal head CT scan Identify and treat elevated ICP, herniation Keep head of the bed at 30 degrees; ensure good BP, ventilation and temperature control; give Mannitol 1 gm /kg IV bolus; urgent NS consult Neurosurgery referral/transfer for advanced care ICP monitoring, ventriculostomy for ICP management, emergency surgery

22. Preventive Medication Anti-platelet drugs Aspirin – makes blood less likely to clot Anticoagulants Heparin and Warfarin – reduce blood clotting

23. Treatment Ischaemic Stroke Medications – IV injection of tissue plasminogen activator ( tPA ) - Alteplase Candidate – upto 4.5 hours of onset of stroke symp

24. Thrombolysis Checklist

25. Treatment ( I schaemic Stroke cont.) Emergency Endovascular Procedures Intra-arterial thrombolysis Clot removal with stent retriever Other procedures Carotid Endartectomy Angioplasty and Stents

26. Treatment Hemorrhagic Stroke Surgical clipping Coiling (Endovascular embolization) Surgical AVM removal Stereotactic radiosurgery

27. Complications Paralysis or loss of muscle movement Difficulty in talking or swallowing Memory loss or thinking difficulties Emotional problems Pain or numbness Changes in behavior and sel -care ability

28. Nursing Care in Acute Stroke Patients The emergency or hyperacute phase – prehospital /ED Acute care phase – ICU/Stroke Unit/Medical care unit Two Phases

29. Nursing Care – Acute Phase Bleeding assessment of post thrombolysis patient – check for raised ICH Monitor Blood Pressure Check Temperature Cardiac Monitoring Monitor Oxygen Saturation Identification of Seizures

30. Nursing Goals (Planning Patient Recovery) Improved mobility Avoidance of shoulder pain Achievement of self care Relief of sensory and perceptual deprivation Prevention of aspiration Continence of bowel and bladder Improved thought processes Achievement of a form of communication Maintenance of skin integrity Restoration of family functioning Absence of complications

31. Stroke Recovery and Rehabilitation Neurologist Rehabilitation doctor Nurse Dietitian Physical therapist Occupational therapist Recreational therapist Speech therapist Social worker Psychologist/Psychiatrist Case manager Chaplain

32. Take Home M essage Stroke is treatable Remember FAST – Recognise Stroke Early treatment – better outcome Nursing care – second to none Stroke recovery – Team effort

33. Thank You..!!