1. Code Brain AttackCode Brain Attack
Good Samaritan HospitalGood Samaritan Hospital
Written by:Written by:
Diane King, Staff Nurse IVDiane King, Staff Nurse IV
RN, MS, PHN, CENRN, MS, PHN, CEN

2. Goals andGoals and Objectives
GoalsGoals
By the end of this presentation will be able toBy the end of this presentation will be able to
describe:describe:
1.1. Basic stroke facts.Basic stroke facts.
2.2. Types of stroke.Types of stroke.
3.3. How staff members affect patient outcomes.How staff members affect patient outcomes.
4.4. Roles and responsibilities of primary nurseRoles and responsibilities of primary nurse
during. patient management.during. patient management.

3. Goals and ObjectivesGoals and Objectives
ObjectivesObjectives
What will learn and skills aught in this training deliver significantWhat will learn and skills aught in this training deliver significant
improvement in areas such as:improvement in areas such as:
1.1. Performance-Clinical implications of relevance.Performance-Clinical implications of relevance.
2.2. Productivity-Time lost is brain lost.Productivity-Time lost is brain lost.
3.3. Teamwork-Calling a brain attack, EKG, CT, Lab work, etc.Teamwork-Calling a brain attack, EKG, CT, Lab work, etc.
4.4. Change Management-Agreement with other team membersChange Management-Agreement with other team members
when patient situations change or resolve.when patient situations change or resolve.
5.5. Quality-Productive processes that are eagerlyQuality-Productive processes that are eagerly
implemented, such as door to t-PA time <1 hr.implemented, such as door to t-PA time <1 hr.

4. Goals and ObjectivesGoals and Objectives
Objectives:
6. Relationships-Working together with staff members and other6. Relationships-Working together with staff members and other
departments effectively to improve patient outcomes.departments effectively to improve patient outcomes.
7. Safety-Review of t-PA administration and patient7. Safety-Review of t-PA administration and patient
management.management.
8. Diversity-Review of Inclusion/Exclusion criteria.8. Diversity-Review of Inclusion/Exclusion criteria.
9.Meetings-Stroke coordinators are here to work together with us9.Meetings-Stroke coordinators are here to work together with us
and willing to help solve obstacles and listen to constructiveand willing to help solve obstacles and listen to constructive
feedback.feedback.
10. Technology-Learn what Good Samaritan Hospital is currently10. Technology-Learn what Good Samaritan Hospital is currently
using for treatment options.using for treatment options.

5. Explaining StrokeExplaining Stroke

6. Stroke FactsStroke Facts- Did you know?- Did you know?
 There are more than 700,000 strokes each year in the U.S.There are more than 700,000 strokes each year in the U.S.
 28% of strokes occur in people under age 6528% of strokes occur in people under age 65
 Over the age of 55, stroke risk doubles every 10 yearsOver the age of 55, stroke risk doubles every 10 years
 There are more than 4 million stroke survivors alive today inThere are more than 4 million stroke survivors alive today in
the U.S.the U.S.
 Stroke is the leading cause of long-term disability in the U.S.Stroke is the leading cause of long-term disability in the U.S.
 Stroke is the 3rd largest cause of death in the U.S., rankingStroke is the 3rd largest cause of death in the U.S., ranking
behind diseases of the heart and cancerbehind diseases of the heart and cancer
 Stroke kills more women than breast cancerStroke kills more women than breast cancer
Source:Source:
http://www.uwmedicine.org/Facilities/Harborview/CentersOfEhttp://www.uwmedicine.org/Facilities/Harborview/CentersOfE
mphasis/Neuro/StrokeCentermphasis/Neuro/StrokeCenter

7. Types of StrokeTypes of Stroke
 Ischemic-83%Ischemic-83%
(Thrombosis 52%, Embolism 31%)(Thrombosis 52%, Embolism 31%)
 Hemorrhagic-17%Hemorrhagic-17%
(Intracerebral Hemorrhage 10%, Subarachnoid(Intracerebral Hemorrhage 10%, Subarachnoid
hemorrhage 7%)hemorrhage 7%)
Source: National Stroke AssociationSource: National Stroke Association

8. Clinical Implications ofClinical Implications of
RelevanceRelevance
NIHSS CertificationNIHSS Certification
(National Institute of Health Stroke Scale)(National Institute of Health Stroke Scale)
Emergency DepartmentEmergency Department
Medical Surgical Intensive CareMedical Surgical Intensive Care
Mandatory EducationMandatory Education

9. How ED Staff MembersHow ED Staff Members
affect Patient Outcomesaffect Patient Outcomes
Sequence of EventsSequence of Events
 AssessmentAssessment
 NIHSSNIHSS
 Stat Lab DrawStat Lab Draw
 CTCT
 EKG (rule out A Fib)EKG (rule out A Fib)
 Possible CT-Angiogram (EDRN mustPossible CT-Angiogram (EDRN must
accompany the patient)accompany the patient)

10. Source: http://www.strokeassociation.org/presenter

11. Cell and Nerve DeathCell and Nerve Death
That Occurs During aThat Occurs During a
StrokeStroke
 During the first second 32,000 brain cellsDuring the first second 32,000 brain cells
diedie
 Next second 1.9 billion cells dieNext second 1.9 billion cells die
 Each minute delay the brain loses 1.9Each minute delay the brain loses 1.9
million neurons, 14 billion synapses and 7.5million neurons, 14 billion synapses and 7.5
miles of myelinated fibersmiles of myelinated fibers
 If a stroke runs it’s full course (10 hours) theIf a stroke runs it’s full course (10 hours) the
brain loses 1.2 billion neurons, 8.3 trillionbrain loses 1.2 billion neurons, 8.3 trillion
synapses, and 4470 miles of myelinatedsynapses, and 4470 miles of myelinated
fibersfibers
Fitzgerald, Ronald. (2007). Good Samaritan Hospital Meditech
Intranet: Retrieved February 27, 2008.

12. Cell and Nerve DeathCell and Nerve Death
That Occurs During aThat Occurs During a
StrokeStroke
 A pea sized piece of brain dies withA pea sized piece of brain dies with
every 12 minute delay.every 12 minute delay.
 Brain tissue the size of a 1.5 pingBrain tissue the size of a 1.5 ping
pong ball are irretrievably lost if apong ball are irretrievably lost if a
typical stroke runs it’s full coursetypical stroke runs it’s full course
without treatment.without treatment.
Fitzgerald, Ronald. (2007). Good Samaritan Hospital Meditech
Intranet: Retrieved February 27, 2008.

13. Cardiovascular disease mortality trends for males andCardiovascular disease mortality trends for males and
femalesfemales (United States: 1979-2004).United States: 1979-2004).
Source: NCHS.Source: NCHS.
380
400
420
440
460
480
500
520
79 80 85 90 95 00 04
Years
Deaths in Thousands
Males Females
0
National Coalition on Health Care

14. Prevalence of stroke by age and sexPrevalence of stroke by age and sex (NHANES: 1999-2004).(NHANES: 1999-2004).
Source: NCHS.Source: NCHS.
0.5
1.2
6.5
0.5
2.3
6.2
12.4
14.8
0
2
4
6
8
10
12
14
16
20-39 40-59 60-79 80+
Percent of Population
Men Women
National Coalition on Health Care

15. Estimated direct and indirect costs of major cardiovascular
diseases and stroke (United States: 2007).
Source: NHLBI.
National Heart Lung and Blood Institute

16. Time is BrainTime is Brain
Time Lost is Brain LostTime Lost is Brain Lost

17. Treatment Options…Treatment Options…
 t-PAt-PA
 CT-AngiogramCT-Angiogram
 RetrievalRetrieval

18. t-PA Inclusion/Exclusiont-PA Inclusion/Exclusion
 Inclusive Criteria (Forms in ED)Inclusive Criteria (Forms in ED)
 Must be 18 years or olderMust be 18 years or older
 Stroke symptoms onset <3 hoursStroke symptoms onset <3 hours
 For IV t-PA within 2.5 hoursFor IV t-PA within 2.5 hours
 For Intra-arterial t-PA/ThrombectomyFor Intra-arterial t-PA/Thrombectomy
(Within 5 hours)(Within 5 hours)

19. t-PA Inclusion/Exclusiont-PA Inclusion/Exclusion
 Awake and alert without significantAwake and alert without significant
reduction of LOCreduction of LOC
 Stroke symptoms ONE OR MOREStroke symptoms ONE OR MORE
of the following: Muscle Weakness,of the following: Muscle Weakness,
speech problems, facial droopspeech problems, facial droop
 12 lead EKG done (rule out A Fib)12 lead EKG done (rule out A Fib)
 Labs: CBC, Chem 7, INR & PTTLabs: CBC, Chem 7, INR & PTT

20. t-PA Inclusion/Exclusiont-PA Inclusion/Exclusion
Absolute Contraindications:Absolute Contraindications:
 Evidence of IC hemorrhage onEvidence of IC hemorrhage on
pretreatment evaluationpretreatment evaluation
 Evidence of SubarachnoidEvidence of Subarachnoid
hemorrhagehemorrhage

21. t-PA Inclusion/Exclusiont-PA Inclusion/Exclusion
Relative Contraindications:Relative Contraindications:
 Minor or rapidly improving signs orMinor or rapidly improving signs or
symptomssymptoms
 Active malignancy, brain or elsewhereActive malignancy, brain or elsewhere
 Recent MI or pericarditis, within theRecent MI or pericarditis, within the
past 2 weekspast 2 weeks
 Recent (30 days) surgery, biopsy, orRecent (30 days) surgery, biopsy, or
arterial puncture (n/a for IA t-PA)arterial puncture (n/a for IA t-PA)

22. t-PA Inclusion/Exclusiont-PA Inclusion/Exclusion
Relative Contraindications:Relative Contraindications:
 Recent (within 30 days) any activeRecent (within 30 days) any active
hemorrhagehemorrhage
 Glucose <50 or >400 mg/dlGlucose <50 or >400 mg/dl
 SBP >185 or DBP >110SBP >185 or DBP >110
(antihypertensive treatment OK)(antihypertensive treatment OK)
 Pregnancy, lactation, or parturitionPregnancy, lactation, or parturition
(childbirth) within previous 30 days(childbirth) within previous 30 days

23. t-PA Inclusion/Exclusiont-PA Inclusion/Exclusion
Relative Contraindications:Relative Contraindications:
 History of intracranial hemorrhageHistory of intracranial hemorrhage
 History of major trauma in the last 2History of major trauma in the last 2
weeksweeks
 Seizure at onset of strokeSeizure at onset of stroke
 Active bacterial endocarditisActive bacterial endocarditis

24. t-PA Administrationt-PA Administration
Goal is door to t-PA time < 1 hourGoal is door to t-PA time < 1 hour

25. t-PA Administrationt-PA Administration
NIH stroke scale upon ER admissionNIH stroke scale upon ER admission
and prior to t-PAand prior to t-PA
 Establish 2 IV linesEstablish 2 IV lines
Primary line for t-PAPrimary line for t-PA
 Connect directly to IV tubing to infuse viaConnect directly to IV tubing to infuse via
pumppump
 Do not use t-PA as piggyback bag withDo not use t-PA as piggyback bag with
.9NS as primary bag. Flush after t-PA is.9NS as primary bag. Flush after t-PA is
complete.complete.

26. t-PA Administrationt-PA Administration
 Make sure that no other solutions orMake sure that no other solutions or
medications are running through t-PAmedications are running through t-PA
line.line.
 Secondary line with .9NSSecondary line with .9NS
 Obtain established or actual bodyObtain established or actual body
weight in kgweight in kg
 Complete Inclusion/Exclusion criteriaComplete Inclusion/Exclusion criteria
for t-PAfor t-PA

27. t-PA Administrationt-PA Administration
 Total dose (weight in _kg x 0.9 mgTotal dose (weight in _kg x 0.9 mg
= total dose.= total dose. Not to exceed 90 mgNot to exceed 90 mg
 t-PA bolus 10% of total calculatedt-PA bolus 10% of total calculated
dose given IV push over 1 minutedose given IV push over 1 minute
 t-PA remainder dose infused viat-PA remainder dose infused via
separate pump/separate channel overseparate pump/separate channel over
60 minutes60 minutes

28. t-PA Administrationt-PA Administration
 Insert catheter tip into port closest toInsert catheter tip into port closest to
IV insertion siteIV insertion site
 Visual confirmation of t-PA infusionVisual confirmation of t-PA infusion
every 15 minutes until infusionevery 15 minutes until infusion
completecomplete
 When t-PA infusion complete, followWhen t-PA infusion complete, follow
with 50 ml .9NS at t-PA infusion ratewith 50 ml .9NS at t-PA infusion rate
through t-PA tubingthrough t-PA tubing

29. t-PA Administrationt-PA Administration
Patient ManagementPatient Management
 Patient to be staffed 1:1 ratio while in ERPatient to be staffed 1:1 ratio while in ER
 Vital signs TPR/BP, neuro checks everyVital signs TPR/BP, neuro checks every
15 minutes for 2 hours, then every 3015 minutes for 2 hours, then every 30
minutesminutes
 No automatic BP’s to be used until 24No automatic BP’s to be used until 24
hours after t-PAhours after t-PA
 NIHSS every shift and STAT for significantNIHSS every shift and STAT for significant
changeschanges

30. Time ClockTime Clock
The time clock should be started whenThe time clock should be started when
the brain attack is called. The goal isthe brain attack is called. The goal is
door to t-PA time <1 hourdoor to t-PA time <1 hour

31. Calling a Brain AttackCalling a Brain Attack
 YES, a Nurse can call a Brain AttackYES, a Nurse can call a Brain Attack
 Call 55 and ask the GSH Operator toCall 55 and ask the GSH Operator to
call a code Brain Attack-EDcall a code Brain Attack-ED
 On Call Neurologist & StrokeOn Call Neurologist & Stroke
Coordinator will call the EDCoordinator will call the ED

32. Stroke CoordinatorsStroke Coordinators
 Automatically paged by GSH Operator and will be calling EDAutomatically paged by GSH Operator and will be calling ED
for information for possible clinical trial study or t-PA.for information for possible clinical trial study or t-PA.
 It is urgent that they speak to EDMD or Primary Nurse ASAP.It is urgent that they speak to EDMD or Primary Nurse ASAP.
 Please don’t place stroke coordinators on hold indefinitely,Please don’t place stroke coordinators on hold indefinitely,
hang up on them, or say “it’s too busy right now…” They arehang up on them, or say “it’s too busy right now…” They are
on call for the hospitalon call for the hospital
 Stroke coordinator’s will ask for: Name, age, symptom onsetStroke coordinator’s will ask for: Name, age, symptom onset
and other relevant data for possible clinical trial studiesand other relevant data for possible clinical trial studies
 Stroke coordinators are on call 24/7 to help us and ourStroke coordinators are on call 24/7 to help us and our
patientspatients

33. What Can Good Samaritan Hospital EDWhat Can Good Samaritan Hospital ED
Nurses Can Do To Increase AwarenessNurses Can Do To Increase Awareness
Regarding Stroke Prevention?Regarding Stroke Prevention?
 Educate our PatientsEducate our Patients
 Attend the annual Stroke SymposiumAttend the annual Stroke Symposium
each May at GSH in the Auditoriumeach May at GSH in the Auditorium
 Become Involved with the StrokeBecome Involved with the Stroke
Health Fair in September ’08Health Fair in September ’08
 Obtain your Mandatory NIH StrokeObtain your Mandatory NIH Stroke
Certification or Re-Certification in aCertification or Re-Certification in a
timely manner for all ED and ICU RN’stimely manner for all ED and ICU RN’s

34. ReferencesReferences
Fitzgerald, Ronald. (2007). Good Samaritan Hospital (personal Interview)
February 27, 2008.
National Center for Health Statistics. Cardiovascular disease mortality trends for mal
and females (United States: 1979-2004). [Power Point Slides]. Retrieved from:
www.cdc.gov/nchs.
National Center for Health Statistics. Prevalence of stroke by age and sex (NHANES
1999-2004). [Power Point Slides]. Retrieved from: www.cdc.gov/nchs.
National Heart, Lung & Blood Institute. Estimated direct and indirect costs of major
cardiovascular diseases and stroke (United States: 2007). [Power Point Slides].
Retrieved from: www.cdc.gov/nchs.
.
National Heart, Lung & Blood Institute. Cardiovascular disease mortality trends for
males and females (United States: 1979-2004). [Power Point Slides]. Retrieved fro
www.nhlbi.nih.gov

35. ReferencesReferences
National Stroke Association. (2007). Explaining Stroke [Brochure].
Retrieved from:
www.stroke.org/pubs/consumer/brochure-brochure.pdf.
Neuro Stroke Center-Harborview. (2007). Stroke Facts- Did you know?
[Power Point Slides]. Retrieved from:
www.uwmedicine.org/Facilities/Harborview/CentersOfEmphasis/Neur
o/StrokeCenter.
Stroke Association (2007). Types of Stroke. [Power Point Slides].
Retrieved from: http://www.strokeassociation.org.
Stroke Association (2007). Types of Stroke. [Power Point Slides].
Retrieved from:
http://www.strokeassociation.org/presenter.

37. The EndThe End