three strikes an your out
TRANSCRIPT
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