Misconceptions can harm your next stroke patient

Patient outcomes are at stake

If a patient's only complaint is dizziness, stroke may not be the first thing you think of, but patients with vertebral artery occlusion may present this way, says Karen Bergman, RN, neuroscience coordinator at Bronson Methodist Hospital in Kalamazoo, MI.

"While some stroke syndromes produce symptoms that are easily identified as stroke, such as hemiplegia and facial droop, other stroke syndromes produce more vague symptoms," she notes.

Dizziness is a common ED complaint, adds Bergman, and this kind of presentation is sometimes not recognized as stroke-related. "By the time it is acknowledged as stroke, the patient may be outside of the treatment window," she says.

Understanding the symptom patterns associated with different arterial occlusions can increase the accuracy of differential diagnosis of stroke versus other illness, says Bergman.

"As we are all aware, time lost is brain lost," says Bergman. "Diagnosing stroke quickly is imperative to initiating stroke treatment options and improving outcomes." Here are other misconceptions about stroke:

Nurses may wrongly believe that the stroke treatment window always ends at three hours from onset of symptoms.

In fact, says Bergman, hospitals that specialize in stroke management are able to provide stroke treatment options well beyond the three hours that was approved by the Food and Drug Administration for intravenous (IV) tissue plasminogen activator (t-PA).

Most patients are eligible for IV t-PA in a three-to four-and-a-half-hour time window, she adds, with a few more exclusion criteria applying to this time frame.

Hospitals with neurological interventional radiology can offer treatment options such as intra-arterial t-PA and mechanical clot retrieval within an eight-hour time window, says Bergman. "When persons with stroke present to the ED outside of the three-hour IV t-PA time window, it is important that other treatment options are considered," she says.

Nurses may mistakenly assume elder patients aren't candidates for treatment with thrombolytics.

After determining that a 95-year-old woman's left-sided weakness and inability to speak started 45 minutes earlier, and that she did not meet any exclusion criteria, ED nurses at Ronald Reagan University of California Los Angeles (UCLA) Medical Center administered IV t-PA per the ED's protocol.

"Within six hours, this patient had notable improvement in her speech and left lower extremity strength," reports Jennifer Zanotti, MS, RN, CEN, CCRN, ED clinical nurse specialist who cared for the patient.

Advanced age alone is not a contraindication for t-PA for the treatment of acute stroke, says Zanotti. "We activate our stroke team based upon clinical and time criteria, and do not exclude those with advanced age," she says.

If the patient meets inclusion criteria and there are not other absolute contraindications, Zanotti says that t-PA should be offered to the patient. "The goal with any patient receiving treatment for acute stroke is to improve not only mortality, but also their morbidity and functional status upon discharge," she says.

Sources

For more information on improving care of stroke patients in the ED, contact:

  • Karen Bergman, RN, Neuroscience Coordinator, Bronson Methodist Hospital, Kalamazoo, MI. Phone: (269) 341-7587. E-mail: BergmanK@bronsonhg.org.
  • Jennifer Zanotti, MS, RN, CEN, CCRN, Clinical Nurse Specialist, Emergency Department, Ronald Reagan University of California Los Angeles Medical Center. Phone: (310) 267-8482. E-mail: JZanotti@mednet.ucla.edu.