three strikes an your out

Three Strikes and Your Out

HyperglycemiaHyperthermia

HypoxiaRebecca P Campbell RN BS

Outline Statistics Short review Snapshots Symptoms:

differential diagnosis

Three StrikesHyperglycemiaHyperthermiaHypoxia

Five “F’s” Future

Therapies Be the Ball Girl

National Stroke Center Statistics

• 10% survivors recover almost completely

• 25% recover with minor impairment

• 40% experience moderate to severe impairments that require special care

• 10% require care in a nursing home or long term care facility

• 15% dies shortly after the stroke

• 14% of stroke survivors experience a second stroke in the first year following a stroke

Stroke

HemmoragicRuptured Pipe

ThromboticPipe that has blocked

Itself

EmbolicPipe blocked that has been blocked by something else

from somewhere else

LacunarBlockage of a tiny secondary vessel in the brain that

occurs with hypertension

Snapshots• 31 year old male• Hx of CAD• R sided weakness • Facial droop• Small Vessel CVA•Discharged

Snapshots• 27 year old male

• L sided paralysis unresolved from the night before

• R thalamic infarct

•Discharged

Snapshots• 85 year old female• Facial droop• Received t-PA• Right middle cerebral

artery stroke• Atrial fib

•Discharged

Snapshots• 47 year old male

• Slurred speech

• Unable to take foot off gas pedal

• Smoker

•Discharged

Symptoms: Differential Diagnosis

• Ischemic vs Hemmoragic

• Craniocerebral trauma vs Cervical trauma

• Meningitis vs Encephalitis

• Seizure or Migraine with persistent neurological signs

Symptoms: Differential Diagnosis

• Intracranial Mass– Tumor– Subdural hematoma

• Metabolic– Hyperglycemia– Hypoglycemia

• Post Cardiac Event

• Drug or Narcotic Overdose

Goals

Neuro protectionSave the PenumbraPrevent secondary side effectImprove functionImprove life

Penumbra

• The marginal zone outside the infarct zone • The area in which the infarct will expand into

Things to avoid:

Hyperglycemia Hyperthermia Hypoxia

Hyperglycemia• Review of healthy

Endothelial FunctionWhat it should be

doing:– Inflammation

prevention– Coagulation Role– Vascular Tone– Oxidation Inhibition

Hyperglycemia• Role of Nitric Oxide

“Endothelium Derived Relaxing Factor”

Hyperglycemia Effectson the Brain

Increased infarct size because of impairment of vasodilation

Hypometabolic alterations of brain (lactic acidosis)

Inflammation (apoptosis-programmed cell death)

Causes of Hyperglycemia in the CVA Patient

• Non specific reaction to acute stress• Autonomic: cortisol and catecholamine

release in the stress response• Uncovering Latent Diabetes• Secondary to the actual CVA and the

regulatory centers of the brain

Review: Hyperglycemia

• Cannot Vasodilate• Acidosis• Inflammation• Cell Death

Hyperthermia

BIGQuestions!

• What do you consider a fever?

• Does the temperature of the brain match the core temperature of the body?

Surprise!!• In rats and traumatic brain injury:

Brain temp 102 F / Rectal temp

100.7 F Journal of Neuroscience Nursing December 2007

Hyperthermia• Mortality rate when

fever occurs within 24 hours

74% death rate in hyperthermic CVA

2% death rate in normothermic CVA

• Mortality rate when fever occurs within

72 hours

16% death rate at 3 months when patient has been hyperthermic

1% death rate normothermic patient

Journal of Neuroscience December 2007/Stroke 1998

Simple terms: (Timing for Fever Related Brain Damage)

Higher the fever the larger the ischemic lesion.

The earlier the fever the larger the ischemic lesion.

Regardless of fever source, hyperthermia accelerates

cellular necrosis and apoptosis.

Hyperthermia Effectson the Brain

Enhances the release of Neurotransmitters

Exaggerates free radical production

Extensive breakdown of the blood brain barrier

Increases the depolarizations of neural cells in the penumbra

Increases intracellular acidosis

Blood Brain Barrier and Tight Junction

Tight Junction

Etiology of Hyperthermia in the CVA Patient

NON InfectiousInfectious Inflammatory process

Etiology of Hyperthermia in the CVA Patient

InfectiousCMV

Chalmydia pneumoniae

Helicobacter Pylori

Hepatitis A

Etiology of Hyperthermia in the CVA Patient

Inflammatory process

Lupus

Giant Cell Arteritis

Reactive Airway/COPD

Diabetics

Hypoxemia

Immediate Event

Post Event

Hypoxemia

Immediate Events

Sodium ChannelsVasogenic Edema

Calcium ChannelsVasogenic Edema

Hypoxia Effect on Cell Volume and Ion Uptake of Cerebral Microvascular Endothelial Cells

AJP Cell Physiology, October 17, 2007

Hypoxemia

Post Events

Pulmonary Embolism

Always consider the possibility of PE in the presence of cardiorespiratory symptoms post stroke even if an alternative diagnosis is evident.

Pneumonia

Sleep Apnea

Goals

Neuro protectionSave the PenumbraPrevent secondary side effectImprove functionImprove life

The Five “F’s”Flat FluidsFingersticksFever ControlFrequent Neurochecks

The Five “F’s”Flat FluidsFingersticksFever ControlFrequent Neurochecks

• Improves perfusion to the brain

• Prevent Orthostatic blood pressure changes

The Five “F’s”Flat FluidsFingersticksFever ControlFrequent Neurochecks

NSS onlyMaintain blood

pressureabove 100/70below 180/105

Correct rate/perfusion issues

The Five “F’s”Flat FluidsFingersticksFever ControlFrequent Neurochecks

AHA Guidelines:

Keep blood sugar between 80-140

Threshold for insulin use between 140-180

The Five “F’s”Flat FluidsFingersticksFever ControlFrequent Neurochecks

Keep patient NORMOTHERMIC

98.0-98.6 oF

Tylenol and Early Antibiotics

Hypothermia: core temp below 98.0 is NOT recommended by the AHA at this time

The Five “F’s”Flat FluidsFingersticksFever ControlFrequent Neurochecks

NIH stroke scale

Increase of infarct zone into the penumbra

Future Therapies

Cooling TherapyCapsCooling vest

Medication Combination:Control Shivering Sedatives

Future Therapies• Interruption of Apoptosis

Progress in Oncology with

http://www.cellsignal.com/reference/pathway/Apoptosis_Overview.html

Future TherapiesCalcuim Channel Blockers

Nifedipine

• AntibioticsMinocycline

• AlbuminControl vasogenic

edema

Future Therapies

Future Therapies• More aggressive

use of medical devicesStents

Penumbra sucking vacuum

Future Therapies• More aggressive

use of medical devicesNeuroflo catheter

ReferencesAllen, S. McColl, B., Rothwell, N. (2007) Systemic Inflammation and Stroke: Etiology, Pathology and Targets for

Therapy. Biochemical Society Transactions. Vol 35, part 5, 1163-1165

Alonso, O., Busto, R., Dietrich, D., (1993) Moderated Hyperglycemia Worsens Acute Blood Brain Barrier Injury After Fore Brain Ischemia in Rats. Stroke. 24, 111-116.

Bae, H.J., et al. (2005) In Hospital Medical Complications and Long Term Mortality After Ischemic Stroke. Stroke. 36, 2241-2245.

Brillault, J., Foroutan, S., Lam, T., Odonnel, M., Rutkowsky, J. (2008) Hypoxia Effects on cell volume and Ion Uptake of Cerebral Microvascular Endothelial Cells. AJP-Cell Physiol. 294, 88-96.

Brown, R., David, T., Egleton,R., Mark, k. (2004) Protecting Against Hypoxia-Induced Blood Brain Barrier Disruption: Changes in Intracellular Calcium. APJ-Cell Physiol. 286, 1045-1052.

Busto, R., Ginsberg, M. (1998) Combating Hyperthermia in Acute Stroke a Significant Clinical Concern. Stroke. 29, 529-534.

Campbell, L., Grayson, T., Kuo, C. (1998) Chlamydia Pneumoniae and Cardiovascular Disease. Emerging Infectious Disease. Vol. 4, No. 4, Electronically retrieved July 16, 2008. http://www.cdc.gov/ncidod/EiD/vo14no4/campbell.htm

Chaudhuri, A., Dandona, P., Garg, R., Munschauer, F. (2006) Hyperglycemia, Insulin and Acute Ischemic Stroke, A Mechanistic Justification for Trial of Insulin Infusion Therapy. Stroke. 37, 267-273.

ReferencesCooling Therapy for Stroke. John Hopkins Medicine Health Alerts. Retrieved June 26, 2008.

http://www.johnshopkinshealthalerts.com/reports/hypertension_stroke.

Fisher, J., Heller, R., Levi, C. Lim, L., Maths, B., Wang, Y. (2000) Influence of Admission Body Temperature on Stroke Mortality. Stroke, 31, 404-409.

Ginsburg, M. (2003) Adventures in the Pathophysiology of Brain Ischemia: Penumbra, Gene Expression, Neuroprotection. Stroke, 34, 214-223

Guanci, M., Hinkle, J. (2007) Acute Ischemic Stroke Review. Journal of Neuroscience Nursing. 39, 5, 285-293.Initial Success of Intracranial Stents New Devices Bring Hope for Those at Highest Risk. Stroke Connection, JulAugust, p.6.

Kelly, J., Hunt, B., Lewis, R., Rudd, A. (2002) Pulmonary Embolism and Pneumonia May Be Confounded After Acute Stroke May Co Exist. British Geriatric Society Age and Aging. 31, 235-239.

McIlvoy, Laura. (2007) The Impact of Brain Temperature and Core Temperature on Intracranial and Cerebral Perfussion Pressure. Journal of Neuroscience Nursing, 39, 6, 324-331.

Obstructive Sleep Apnea Causes Early Death in Stroke Patients. Science Daily, May 20, 2008. Electronically retrieved July 16, 2008. http://www.sciencedaily.com/releases/2008/05/080518182655.htm.

Viral Infection Linked to Heart Attack and Stroke. Science Daily, December 24, 2002. Electronically retrieved July 11, 2008. http://www.sciencedaily.com/releases/2002/12/021224091204.htm.

Vojdani, A. The Role of Chlamydia Pneumoniae in Athersclerosis is Cardiology Ready for a Revolution? Electronically retrieved July 11, 2008. http://www.immuno-science-lab.com/html/chlamydia_pneumoniae.html