Quick action ensures timely therapy.

Takeaways:

• The FAST acronym (Face, Arm, Speech, Time to call 911) are critical to recognizing signs of stroke and ensuring quick treatment.
• The National Institutes of Health (NIH) stroke scale, which provides a numeric score based on assessment results.
• The time window for antithrombolytic therapy with alteplase is 4.5 hours after stroke symptoms start.

Vivian Martin,* a 72-year-old woman, arrives in the emergency department (ED) saying she has a headache, feels light-headed, and that her heart is “pounding.” Ms. Martin has mild arthritis but is otherwise healthy. She’s afebrile with a heart rate (HR) of 122 beats per minute (bpm), respiratory rate (RR) 26 breaths per minute, and blood pressure (BP) 188/118 mmHg. The ED provider diagnoses Ms. Martin with uncontrolled hypertension and starts her on an I.V. infusion of clevidipine. An hour later, her BP is 125/80 mmHg. Ms. Martin is started on lisinopril, the clevidipine is discontinued, and she’s transferred to the progressive care unit.

Assessment

An hour after Ms. Martin is admitted to the unit, you start your shift and conduct a neurologic exam. Your exam reveals a droopy right eye, uneven smile, right arm drift, and slurred speech. You realize your findings align with the acronym FAST (Face, Arm, Speech, Time to call 911), which details the most common signs of stroke. You activate the stroke protocol, start 2 liters of oxygen via nasal cannula, and obtain Ms. Martin’s vital signs: BP 210/120 mmHg, HR 95 bpm, and RR 20 breaths per minute. Ms. Martin’s oxygen saturation is 92%, and she remains afebrile. You realize that she’s in a hypertensive crisis and is likely having a stroke. You complete the National Institutes of Health (NIH) stroke scale, which provides a numeric score based on assessment results. Ms. Martin’s score is 6, indicating a moderate stroke. (Access the scale here.)

Taking action

Ms. Martin’s provider restarts the clevidipine infusion, with a goal of lowering the BP to 185/110 mmHg. As part of the stroke alert, you ensure Ms. Martin has two patent I.V.s and arrange for transport to radiology for a computed tomography (CT) scan. You also notify the neurologist of her condition and the pending scan.

The CT scan shows no evidence of bleeding or head trauma, and Ms. Martin is diagnosed with stroke. The time from Ms. Martin’s initial signs of stoke when you evaluated her to diagnosis is 2.5 hours, well within the time window for antithrombolytic therapy with alteplase—4.5 hours after stroke symptoms start. She meets other inclusion criteria as well. Her BP is now 176/108 mmHg. Although her initial uncontrolled hypertension would have excluded her from alteplase, now that it’s controlled with clevidipine, she can receive this therapy as ordered by the provider.

The nurse who admitted Ms. Martin to the unit had obtained her weight, so you can verify that the alteplase dosage is correct. After administering the drug, you transfer her to the intensive care unit (ICU) for close monitoring.

Outcome

In the ICU, the goal is to keep Ms. Martin’s BP at 180/105 mmHg or lower for 24 hours after alteplase administration. Excessively lowering the BP can reduce cerebral perfusion pressure and exacerbate stroke symptoms. ICU staff monitor Ms. Martin for any signs of bleeding, such as change in level of consciousness, and use the NIH stroke scale for assessments. She doesn’t experience any complications and is transferred to a medical/surgical unit 24 hours after alteplase administration. She has minimal right arm weakness and some speech slurring, but her BP is controlled and she’s looking forward to returning home.

Follow up

Ms. Martin will need long-term BP control, with a goal of 140/90 mmHg. She’ll also need evaluation for deficits related to her stroke; physical therapy, occupational therapy, or speech therapy may be required after discharge. Fortunately, your quick action ensured that her deficits aren’t more serious.

References

Broderick JP, Jauch EC, Derdeyn CP. American Stroke Association Stroke Council Update: Sea change for stroke and the American Stroke Association. Stroke. 2015;46(6):e145-6.

Davis SM, Donnan GA. 4.5 hours: The new time window for tissue plasminogen activator in stroke. Stroke. 2009;40(6):2266-7.

Powers WJ, Rabinstein AA, Ackerson T, et al. Guidelines for the early management of patients with acute ischemic stroke: 2019 update to the 2018 guidelines for the early management of acute ischemic stroke: A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke. 2019;50(12):e344-418.

*Name is fictitious.

Alysia D. Adams is the director of emergency and trauma services at Owensboro Health in Owensboro, Kentucky.