New stroke treatments coming soon to your ED

When a young woman came to the ED at University of California-Los Angeles after suffering a severe stroke, she presented with aphasia and right-side paralysis. "We were called by the ED radio room nurse while the patient was still en route to the ED, allowing us to be there within minutes of her arrival," says Judy Guzy, RN, research coordinator for the University of California-Los Angeles Stroke Network.

ED nurses rushed the patient directly to magnetic resonance imaging (MRI), she explains. "They grabbed a blood pressure and drew blood while still on the paramedic gurney, then pushed her out the door," says Guzy. After the MRI, the woman went directly to the angio suite, where the clot was removed with a concentric retrieval device inserted through a femoral artery. As a result of this cutting-edge intervention, the woman’s motor skills returned immediately, and she was talking within five hours of stroke onset, says Guzy.

While waiting for an intensive care unit bed, the woman was brought back to the ED, she recalls. "The same nurses were still on duty and were thrilled to see her moving normally and communicating," says Guzy. "All too often, the ED nurses do not get to see the results of their efforts."

When a stroke patient presents, you need to respond with a rapid assessment, continuous monitoring, laboratory draws, transport to computed tomography (CT)/ MRI, and rapid mobilization of the patient, says Guzy. New mechanical interventions, coupled with these actions, soon will result in dramatic success stories at your ED, she and others predict.

"New developments in technology and pharmaceuticals will greatly change the way we treat stroke in the upcoming years," predicts Lauren Brandt, RN, MSN, CNRN, clinical director of the Neurosciences, Brain, and Spine Center at Brackenridge Hospital. The new technologies include laser emulsification of the clot, clot retrieval devices that remove the clot, and obliteration devices that draw in the clot, fragment it, and aspirate the surrounding thrombus, says Brandt. Although none are currently approved by the Food and Drug Administration, experts in stroke care predict they soon will be used in EDs.

To prepare to update your stroke protocols, consider the following:

Know indications for the new interventions.

Cerebral vessels are smaller and more fragile than cardiac vessels, notes Brandt. "This limits what can be done to open up that vessel," she explains. In addition, the composition of the clot or source of ischemia has to be taken into account for the right treatment to be identified, says Brandt. For example, although angioplasty is the mainstay of cardiac intervention, this is not as effective in cerebral disease because of the high incidence of embolic disease, she notes. "Angioplasty works much better on the plaque developed in thrombotic disease," explains Brandt.

Understand how combination therapies work.

Combination therapies, using mechanical and pharmaceutical interventions, show great promise, according to Brandt. These include therapies such as ultrasonification of the clot, followed by the use of thrombolytics to destroy the remaining residual, she explains. Another example of a combination therapy would be using either angioplasty or cerebral stenting in order to open a vessel so that intra-arterial thrombolysis can be utilized, says Brandt.

Update protocols to add new approaches.

You’ll need to update your protocols significantly to reflect new technologies and approaches, advises Brandt. Here are changes to expect:

  • Perfusion imaging will identify the extent of viable tissue vs. infarcted tissue.
  • CT or MRI angiography will identify the individual location of the clot.
  • Blood pressure stabilization, strict blood glucose control, and temperature regulation will be incorporated into ED stroke protocols. "This will make this a very intense patient population for the ED nursing staff," says Brandt.

Expect the number of stroke patients to increase.

With the use of new technologies, the time window for treatment will expand to eight to 12 hours for anterior circulation and up to 24 hours for posterior circulation, says Brandt. "However, this does not make it a less emergent situation," she cautions. "Time is still brain." What it does mean is that every stroke patient who arrives within a longer time window will need to be started on an aggressive stroke protocol, as compared with the small number of stroke patients who are eligible for treatment currently, she says. "The ED clinical nurse is the starting point of successful treatment and implementation of the appropriate protocol," says Brandt. "This will have a huge impact on the patient’s outcome."

Sources

For more information about new interventions for stroke patients, contact:

Lauren Brandt, RN, MSN, CNRN, Clinical Director, Neurosciences, Brain, and Spine Center, Brackenridge Hospital, 601 E. 15th St., Austin, TX 78701. Telephone: (512) 324-7782. Fax: (512) 324-7051. E-mail: lbrandt@seton.org.

Judy Guzy, RN, University of California-Los Angeles Stroke Network, 924 Westwood Blvd., No. 300, Los Angeles, CA 90024-1777. Telephone: (310) 794-0600. Fax: (310) 794-0599. E-mail: JGuzy@mednet.ucla.edu.