9.3 Medical Emergencies: Stroke (CVA)

Stroke, also called cerebrovascular accident (CVA), is a medical emergency requiring immediate intervention. "Time is brain" - every minute without treatment results in the death of approximately 1.9 million neurons.

Types of Stroke

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FAST: Rapid Stroke Assessment

The FAST mnemonic enables anyone to quickly identify stroke symptoms:

F - Face Drooping

• Ask the person to smile
• Is one side of the face drooping or numb?
• Look for uneven smile

A - Arm Weakness

• Ask the person to raise both arms
• Does one arm drift downward?
• Is there weakness or numbness on one side?

S - Speech Difficulty

• Ask the person to repeat a simple phrase
• Is speech slurred or strange?
• Is the person unable to speak or hard to understand?

T - Time to Call 911

• If ANY of these symptoms are present, call 911 immediately
• Note the time symptoms started (critical for treatment decisions)
• "Last known well" time determines tPA eligibility

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Additional Stroke Signs and Symptoms

Beyond FAST, watch for:

• Sudden severe headache ("worst headache of my life" suggests hemorrhagic)
• Sudden confusion
• Trouble seeing in one or both eyes
• Sudden trouble walking, dizziness, loss of balance
• Sudden numbness on one side of body

Ischemic vs. Hemorrhagic Stroke Signs

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Diagnostic Workup

Immediate Imaging:

• CT scan without contrast - First-line to rule out hemorrhage
• Must be completed within 25 minutes of arrival
• Hemorrhagic stroke appears bright white on CT
• Ischemic stroke may not show changes initially

Additional Tests:

• Blood glucose (hypoglycemia can mimic stroke)
• CBC, coagulation studies (PT/INR, aPTT)
• Basic metabolic panel
• ECG (atrial fibrillation is a stroke risk factor)
• MRI (more sensitive for ischemic stroke)

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Treatment of Ischemic Stroke

Thrombolytic Therapy (tPA/Alteplase)

Tissue Plasminogen Activator (tPA) dissolves clots and restores blood flow.

Eligibility Criteria:

• Symptom onset within 3-4.5 hours (some protocols extend to 4.5 hours)
• CT confirms no hemorrhage
• Measurable neurological deficit
• Age 18 or older

Contraindications (Do NOT give tPA if):

Nursing Considerations During tPA:

• Strict blood pressure monitoring (every 15 min for 2 hours, then every 30 min for 6 hours)
• Neuro checks every 15 minutes during infusion
• NO anticoagulants or antiplatelets for 24 hours
• Watch for bleeding (intracranial, GI, from puncture sites)
• Do NOT place Foley, NG tube, or arterial lines during/immediately after infusion

Mechanical Thrombectomy

• Catheter-based clot removal
• For large vessel occlusions
• Can extend treatment window to 24 hours in select patients
• Used alone or with tPA

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Treatment of Hemorrhagic Stroke

tPA is CONTRAINDICATED in hemorrhagic stroke - it would worsen bleeding.

Treatment Goals:

1. Blood pressure management - Lower gradually to prevent rebleeding
   • Target varies by type and severity
   • Typically maintain SBP < 140-160 mmHg
2. Reverse anticoagulation if applicable
   • Vitamin K for warfarin
   • Protamine for heparin
3. Surgical intervention for large bleeds
   • Craniotomy for hematoma evacuation
   • Ventriculostomy for hydrocephalus

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Nursing Care for Stroke Patients

Positioning

• Elevate HOB 30 degrees to reduce intracranial pressure
• When turning, affected side up (protects weakened side)
• Avoid neck flexion (impedes venous drainage)

Neurological Monitoring

• Use NIH Stroke Scale for standardized assessment
• Document baseline and compare frequently
• Report any deterioration immediately

Swallowing Assessment

• NPO until swallow evaluation (dysphagia is common)
• Bedside swallow screen before any oral intake
• Speech therapy consult for formal evaluation
• Aspiration precautions if dysphagia present

Preventing Complications

• DVT prophylaxis (SCDs, anticoagulation when safe)
• Early mobilization when stable
• Skin integrity monitoring
• Fall precautions

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Time Windows in Stroke Care

Exam Tip: For NCLEX, remember "Last known well" not "symptom discovery time" determines tPA eligibility. If a patient wakes with symptoms, the last known well time is when they went to sleep.

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Key Points for the NCLEX

• FAST is the rapid assessment tool for stroke
• Ischemic stroke = clot = may receive tPA (if within window and no contraindications)
• Hemorrhagic stroke = bleed = NO tPA (would worsen bleeding)
• CT scan without contrast is first-line imaging to differentiate types
• NPO until swallow evaluation is complete
• Elevated HOB 30 degrees reduces intracranial pressure
• "Time is brain" - rapid intervention improves outcomes