Your next TIA patient is at risk for an untreated stroke: Take these steps

Look for 'subtle-but-potentially-deadly' signs

If a patient told you that she was a little dizzy a few hours ago, but she feels absolutely fine now, would you consider this as a life-threatening emergency? If this patient is having a transient ischemic attack (TIA) and leaves your ED, she is at risk of having a full-blown stroke shortly afterward.

About one in 20 TIA patients will have a stroke within 48 hours after they leave the ED, according to a review of research.1 "Multiple studies have found an early high risk of stroke in TIA patients," says Jonathan A. Edlow, MD, the study's author and vice chair of the Department of Emergency Medicine at Beth Israel Deaconess Medical Center in Boston. "This finding is very different from what we believed 10 years ago."

Even though TIA patients often are asymptomatic when they present at triage, they must be treated as a "real emergency," he says.

With increased volume and acuity in EDs, patients with vague complaints and resolved symptoms don't always receive immediate interventions, says Shelley Calder, RN, CEN, MN, clinical nurse specialist for the ED at Beth Israel. "An evolving stroke is usually obvious on presentation, but TIA is considerably more difficult to recognize. Unfortunately, this may only be considered by a nurse with many years of clinical expertise."

Triage nurses tend to focus on the obvious, and TIA patients often have an unclear history and presentation, says Calder. "Often, their symptoms have completely resolved, and their vital signs are stable. However, it is absolutely essential that all care providers recognize the potential risk of TIA and stroke," she says.

To improve care of TIA patients, do the following:

Differentiate between stroke and TIA.

At Beth Israel, the ED's protocol activates the Code Stroke team for patients with acute stroke less than six hours from onset of symptoms, with symptoms still evolving. Patients are considered to have nonacute or possible TIA if onset of symptoms is over six hours and less than 24 hours, with complete symptom resolution, says Calder.

TIA symptoms are transient and last from two to 20 minutes, but a stroke has evolving symptoms that do not resolve, she says. "If patients voice concern about an earlier episode of headaches, visual disturbance, or unilateral weakness, you need to be thinking of TIA," she says.

Don't discharge TIA patients.

At MetroHealth Medical Center in Cleveland, TIA patients are not usually discharged from the ED, says Christina Kirkner, RN-MSN, EMT-P, ED nurse manager. "We admit them, usually just for observation status, to ensure that their symptoms don't change or increase," she says. "If a patient chooses to leave against medical advice, we make sure that the patient is educated about possible outcomes, including the worst-case scenario."

Any patient with acute dysrhythmia, a persistent deficit, or other need for additional inpatient evaluation should definitely not be discharged from the ED, says Amber Egyud, BSN, RN, director of the ED at the University of Pittsburgh Medical Center. "If the nurse feels badly about discharging the patient, they speak with the physician to address concerns and discuss an additional plan for evaluation and action," she says.

Rule out other conditions.

Calder says any of the following could alter your patient's neurological status: hypoglycemia, hypoxia, seizures, migraines, and current medications. "If you take away all those things, what else could this be?" Hopefully, you have thought of TIA," says Calder.

Recognize risk factors.

"All TIA patients are at increased risk for stroke," says Egyud. "Our goal is to prevent the progression to stroke." However, TIA patients with advanced age, hypertension, diabetes, high cholesterol, obesity, heart disease, carotid or peripheral vascular disease, and hypercoagulable states are at increased risk, she says.

Ask these questions at triage, says Kirkner: What time did you first notice symptoms? Do you take blood pressure medication? If so, are you taking it consistently? Do you have headache? Do you have blurred vision? Do you have problems swallowing?

Assess the following in your patient, she recommends:

— whether there are any changes in speech;

— whether hand grasps are symmetrical in strength;

— whether the tongue is midline when you ask the patient to stick it out;

— whether there are any changes in mental status from the time of arrival;

— when you ask the patient to smile, whether the smile looks symmetrical or there is a facial droop on one side;

— when you have the patient close his or her eyes and hold both arms out in front of them, palms up, whether one arm drifts down.

Sometimes symptoms can be fairly subtle, adds Calder. "It all comes down to recognizing that even if the symptoms aren't present at the moment, there can still be a serious underlying issue," she says.

Make sure patients get a complete work-up.

"All TIA patients need an electrocardiogram and some form of brain imaging," says Edlow. Carotid angiography, such as ultrasound or magnetic resonance imaging, is not routinely done in EDs for TIA patients who are not admitted, but this is important to see if there is critical carotid stenosis, he adds.

At University of Pittsburgh, ED nurses take these steps at the bedside during the initial assessment of a TIA patient, says Egyud:

— A neurological assessment is done using the National Institutes of Health Stroke Scale (NIHSS).

— A CT scan is performed. "Our goal is to have the patient in the CT scanner as soon as possible after arrival," says Egyud;

— An electrocardiogram and serial labs are done.

Use examples from your ED as teaching cases.

Beth Israel's ED nurses are educated during orientation and triage training class about the "subtle-yet-potentially-deadly-presentations" that have been seen at the ED, says Calder. For example, one 58-year old man with a history of coronary artery disease and smoking came to the ED with no present complaints, but he reported an earlier event of visual loss for a few minutes and right arm heaviness. He had a negative work-up, but upon discharge the ED nurse noted that the patient was a little unsteady on his feet.

The man insisted it was because he was lying down for so long, but the ED nurse and patient's wife expressed concern about discharge. "The patient was discharged from the ED, only to return 12 hours later with a fully evolving stroke," she recalls. "I use this as a teaching case to stress two points: First, TIA symptoms are subtle and may not always be present on arrival. Also, nurses are essential patient advocates. This patient should have been observed or admitted to rule out a TIA."

Reference

  1. Shah KH, Kleckner K, Edlow JA. Short-term prognosis of stroke among patients diagnosed in the emergency department with a transient ischemic attack. Ann Emerg Med 2008; 51:316-323.

Sources

For more information about patients with transient ischemic attack in the ED, contact:

  • Shelley Calder, RN, CEN, MN, Clinical Nurse Specialist, Emergency Department, Beth Israel Deaconess Medical Center, Boston. Phone: (617) 754-2310. E-mail: scalder@bidmc.harvard.edu.
  • Jonathan A. Edlow, MD, Vice Chair, Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston. Telephone: (617) 754-2329. Fax: (617) 754-2350. E-mail: jedlow@bidmc.harvard.edu.
  • Amber Egyud, RN, BSN, Director, Emergency Department, University of Pittsburgh Medical Center. Phone: (412) 647-9099. E-mail: egyuda@upmc.edu.
  • Christina Kirkner, RN-MSN, EMT-P, Nurse Manager, Emergency Department, Metro Health Medical Center, Cleveland. Phone: (216) 957-6357. E-mail: ckirkner@metrohealth.org.