Stroke Management

Emergency Stroke Chain of Survival and Nursing Imperatives

1. Topic Overview

Stroke is a time-critical neurological emergency and a leading cause of long-term disability and death in the United States.^[1] For the Certified Emergency Nurse (CEN) exam, understanding the rapid identification, assessment, and management of both ischemic and hemorrhagic strokes is a high-yield priority. The emergency nurse plays a pivotal role in the "Stroke Chain of Survival," where every minute saved reduces permanent brain damage. This section will prepare you to quickly differentiate stroke types, activate protocols, manage thrombolytic therapy, and anticipate life-saving interventions.

The core principle driving all stroke care is "Time is Brain." Neurons die at a rate of approximately 1.9 million per minute during a large vessel ischemic stroke, making efficient workflow and protocol adherence essential.^[1]

2. Key Concepts and Definitions

Mastering the terminology below is essential for both exam success and clinical practice.

• Ischemic Stroke: Caused by a thrombotic or embolic occlusion of a cerebral artery, accounting for approximately 87% of all strokes.^[1]
• Hemorrhagic Stroke: Caused by rupture of a blood vessel (intracerebral or subarachnoid hemorrhage). This carries a higher mortality rate than ischemic stroke.
• Transient Ischemic Attack (TIA): A transient episode of neurological dysfunction caused by focal brain, spinal cord, or retinal ischemia without acute infarction.^[1] Recent TIA is a major risk factor for imminent stroke.
• Last Known Well (LKW): The exact time the patient was last seen at their baseline or known to be symptom-free. This is the most critical time point for determining eligibility for acute therapies.^[1]
• Penumbra: The zone of ischemic tissue surrounding the core infarct. This tissue is hypoperfused but still viable. The primary goal of acute therapy is to salvage the penumbra.^[1]
• Large Vessel Occlusion (LVO): Occlusion of a major cerebral artery (e.g., internal carotid, middle cerebral, basilar). LVOs are often severe and may require mechanical thrombectomy.

3. Core Principles & Processes

The Stroke Chain of Survival

The American Heart Association/American Stroke Association (AHA/ASA) emphasizes a coordinated response.^[1] The ED nurse is critical in the "Door" to "Drug/Device" phases.

1. Detection: Patient or bystander recognizes signs (e.g., BE FAST).
2. Dispatch: EMS is activated; pre-notification is sent to the receiving ED.
3. Delivery: Rapid transport and pre-hospital assessment.
4. Door: Triage, immediate ED bed placement, and alert activation.
5. Data: Simultaneous labs, CT scan, glucose check, and NIHSS.
6. Decision: Neurologist/Stroke team reviews eligibility for tPA or thrombectomy.
7. Drug/Device: Administration of Alteplase/Tenecteplase or transport to the angio suite for thrombectomy.

Stroke Alert Activation

• Pre-notification: EMS communication allows the team to assemble before patient arrival.
• Team Mobilization: Typically includes ED physician, neurologist, RN, CT tech, and lab.
• Goal: Door-to-needle (tPA) time should ideally be < 60 minutes.^[1]

4. Signs, Symptoms, & Clinical Findings

BE FAST Mnemonic

The BE FAST acronym is a validated screening tool used to identify acute stroke symptoms.^[3]

• Balance: Sudden loss of balance or coordination.
• Eyes: Sudden vision loss, double vision, or visual field deficit.
• Face: Facial droop, especially when smiling.
• Arm: Arm drift or weakness when both arms are extended.
• Speech: Slurred speech or difficulty understanding language (aphasia).
• Time: Time is critical; note the LKW.

Stroke Mimics

Be aware that up to 30% of suspected strokes are mimics. The CEN exam will test your ability to consider these differentials:^[7]

• Hypoglycemia (always check血糖 first!)
• Seizure (postictal Todd's paralysis)
• Migraine with aura (complicated migraine)
• Electrolyte disturbances (hyponatremia)
• Conversion disorder

5. Assessment, Diagnosis, & Evaluation

Primary Nursing Assessment

• Airway, Breathing, Circulation (ABCs): Ensure adequate oxygenation and hemodynamic stability.
• Finger-stick Blood Glucose: Hypoglycemia can perfectly mimic a stroke. This is a mandatory, immediate step.^[1]
• Neurological Assessment: Rapid, focused exam looking at level of consciousness, pupils, and motor/Sensory function.

NIH Stroke Scale (NIHSS)

The NIHSS is a standardized, 15-item tool used to objectively quantify the severity of a stroke.^[4]

• Score Range: 0 (no deficit) to 42 (severe stroke).
• Key Components: LOC, gaze, visual fields, facial palsy, motor arms/legs, limb ataxia, sensory, language, dysarthria, extinction/inattention.
• Nursing Role: ED nurses often perform the initial NIHSS to establish a baseline and track changes.

Diagnostic Imaging

• Non-Contrast Head CT (NCCT): The gold-standard first-line imaging. It is rapid and highly sensitive for ruling out intracranial hemorrhage.^[1]
• CT Angiography (CTA): Used to identify LVO and assess for thrombectomy candidacy.
• CT Perfusion (CTP): Helps identify the ischemic penumbra vs. core infarct, particularly useful in the extended time window (6-24 hours).^[6]
• EKG: Atrial fibrillation is a common embolic source.^[8]

6. Treatment, Interventions, & Patient Care

Ischemic Stroke: Thrombolysis (tPA)

• Medication: Alteplase (or Tenecteplase) is the primary thrombolytic.
• Time Window: 3 hours from LKW (or 4.5 hours in eligible patients).^[5]
• Dose (Alteplase): 0.9 mg/kg intravenously, with a maximum dose of 90 mg. Give 10% as a bolus over 1 minute, followed by the remaining 90% as an infusion over 1 hour.^[1]

Critical Inclusion/Exclusion Criteria for tPA (High-Yield)

Post-tPA Nursing Care

• BP Management: Maintain BP < 180/105 mmHg for the first 24 hours.^[1]
• Anti-platelet Therapy: Hold for 24 hours post-tPA (start Aspirin after 24-hour CT confirms no hemorrhage).
• Bleeding Watch: Monitor for intracranial hemorrhage (HA, vomiting, neuro decline), mucosal bleeding, and angioedema (tongue/lip swelling).
• Vital Signs: Frequent neuro checks (q15min x 2h, q30min x 6h, q1h x 16h).

Ischemic Stroke: Mechanical Thrombectomy

• Indication: Confirmed LVO with disabling deficit.
• Time Window: Up to 6 hours from LKW (standard). Extended to 24 hours with favorable CT perfusion imaging (DAWN/DEFUSE-3 criteria).^[6]
• Nursing Role: Prepare patient for the angio suite, assist with groin access site management, and monitor for complications (vasospasm, re-occlusion, groin hematoma).

Hemorrhagic Stroke: Initial Management

• BP Control: Reduce BP aggressively (SBP < 140-160) to reduce hematoma expansion.^[1]
• Reverse Anticoagulation: If on Warfarin, administer Vitamin K and FFP/PCC. If on NOACs, use specific reversal agents (e.g., idarucizumab for dabigatran, andexanet alfa for factor Xa inhibitors).
• Neurosurgery: Consult for possible EVD, craniotomy, or hematoma evacuation.

7. Safety Precautions & Complications

• Hemorrhagic Conversion: The most feared complication of tPA. Symptoms include sudden worsening of neuro status, severe headache, and HTN. Discontinue tPA and obtain a stat CT.^[1]
• Angioedema: Orolingual swelling can occur post-tPA. Treatment includes antihistamines, steroids, and potentially epinephrine or intubation if severe.
• Cerebral Edema & Increased ICP: Peaks 24-72 hours post-stroke. Monitor for Cushing's triad (HTN, bradycardia, irregular respirations).
• Dysphagia: Aspiration risk is high. Keep patient NPO (nothing by mouth) until a formal swallow evaluation is performed by a speech therapist.^[8]
• Fall Risk: Hemiparesis and ataxia significantly increase fall risk. Implement fall precautions.
• DVT Prophylaxis: Immobility puts stroke patients at high risk for DVT. Start prophylactic anticoagulation 24-48 hours post-tPA if no contraindication.

8. Exam Tips & High-Yield Points

Focus on these concepts for the CEN exam:

• Know the BP Numbers Cold:
  • Before tPA: < 185/110
  • After tPA: < 180/105
• Glucose First: Hypoglycemia is the #1 stroke mimic that must be ruled out immediately.
• tPA Contraindications: Recent surgery (14d), recent stroke (3m), head trauma (3m), GI/GU bleed (21d), coagulopathy (INR > 1.7).
• Time Windows:
  • tPA: 3 hours (extended 4.5 hours).
  • Thrombectomy: 6 hours (extended 24 hours with CTP mismatch).
• Memory Aid for tPA Dose: Alteplase is 0.9 mg/kg (max 90 mg). Write it down: "0.9 / 90".
• Hemorrhagic Stroke Management: Control BP, reverse coagulopathy, protect airway.
• NPO Status: Always remember to keep the stroke patient NPO until their swallow is cleared to prevent aspiration pneumonia, a common complication.

9. References & Sources

1. Powers, W. J., et al. (2019). AHA/ASA Guideline for the Early Management of Patients With Acute Ischemic Stroke. Stroke, 50(12), e344-e418. https://doi.org/10.1161/STR.0000000000000211
2. Jauch, E. C., et al. (2013). AHA/ASA Guideline for the Early Management of Patients With Acute Ischemic Stroke. Stroke, 44(3), 870-947. https://doi.org/10.1161/STR.0b013e318284056a
3. Aroor, S., et al. (2017). BE FAST: A Sensitive and Specific Tool for Identifying Patients with Acute Stroke. Journal of Stroke and Cerebrovascular Diseases, 26(6), 1296-1300. https://doi.org/10.1016/j.jstrokecerebrovasdis.2017.02.021
4. National Institute of Neurological Disorders and Stroke. (2021). NIH Stroke Scale. https://www.ninds.nih.gov/health-information/public-education/know-stroke/health-professionals/nih-stroke-scale
5. Hacke, W., et al. (2008). Thrombolysis with Alteplase 3 to 4.5 Hours after Acute Ischemic Stroke. New England Journal of Medicine, 359(13), 1317-1329. https://doi.org/10.1056/NEJMoa0804656 (ECASS III Trial)
6. Nogueira, R. G., et al. (2018). Thrombectomy 6 to 24 Hours after Stroke with a Mismatch between Deficit and Infarct. New England Journal of Medicine, 378(1), 11-21. https://doi.org/10.1056/NEJMoa1706442 (DAWN Trial)
7. Emergency Nurses Association (ENA). (2019). Emergency Nursing Core Curriculum (7th ed.). Elsevier.
8. Lewis, S. M., et al. (2022). Medical-Surgical Nursing: Assessment and Management of Clinical Problems (11th ed.). Elsevier.