Management of Catastrophic Stroke

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What is Catastrophic Stroke?. No one definitionCan ususally be described in terms of : -radiologic evidence of extent of infarct/ hemorrhage -physiologic signs -response to treatment . Clinical Management Considerations. Usual Stroke Care-starting point-ER -diagnos

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Management of Catastrophic Stroke

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1. Management of Catastrophic Stroke Marie Rusnak, RNEC, MSN-NHS-GNG Site Cami D’Uva ACNP-HHSC-HGH Site Johanne Hayes,Nurse Educator GIM St. Joseph’s Leigh Barr, Speech-Language Pathologist BA M.Sc HHSC-HGH Site

2. What is Catastrophic Stroke? No one definition Can ususally be described in terms of : -radiologic evidence of extent of infarct/ hemorrhage -physiologic signs -response to treatment

3. Clinical Management Considerations Usual Stroke Care-starting point-ER -diagnostics-CT, labs - Neurological assessment -results that determine territory and extent -may be the1st point of decision-any directives? Post admission to unit -further diagnostics, assessments, treatments -feeding -comfort, mobility -prevention of complications -may be primary or secondary point of decision

4. Clinical Indicators of Poor Outcome

5. MCA Sign

6. Normal/Effacement A slice indicates hypodense areas in the right frontal lobe and the temporal lobe with effacement of the gyri and blurring of the left insula B indicates the rather extensive change on the left side at 3 months – patient was dependent. Clinically a right hemiparesisA slice indicates hypodense areas in the right frontal lobe and the temporal lobe with effacement of the gyri and blurring of the left insula B indicates the rather extensive change on the left side at 3 months – patient was dependent. Clinically a right hemiparesis

7. Clinical Indicators of Poor Outcome Additional Diagnostic Imaging Carotid Artery Occlusion -on ultrasound at bifurcation -increases risk of fatal outcome-development of herniation Infarct Volume - on DWI

8. Brain Swelling Fatal Outcome (mortality rate- 50-80%, 10% of all ischemic) Hemispheric -not due to infarct/extent/LOC -due to edema, shifting of cerebral contents (specific areas of), and extent of shift AND… -development of nausea and vomitting within 24 hours - BP >180 systolic -along with hypodensity MCA>50% ARE…. predictive of development of fatal brain swelling

9. Clinical Indicators of Poor Outcome Cerebellar Infarct (posterior-inferior-superior cerebellar artery) Radiologic features predictive of neurologic deterioration: -4th ventrical distorstion/shift - basal cistern compression -obstructive hydrocephalous, -brainstem deformity

10. Clinical Indicators of Poor Outcome Physical Evidence Hemispheric -impaired consciousness/coma -low Glasgow Coma Score (< 8 ) -NIHS score > 20, > 15 for right hemisphere -loss of brainstem reflexes (pupillary responses, occular reflexes) -development of bilateral ptosis -elevated WBC and temperature, arterial PH -associated history of hypertension, heart failure

11. Clinical Indicators of Poor Outcome Cerebellar -decreased LOC after clinical deterioration-most powerful predictor of poor outcome -2-4 days after onset -physical evidence of swelling in cerebellum/ herniation (occular, respiratory, cardiac changes) -age >60

12. Clinical Indicators of Poor Outcome Hemorrhage Radiology Evidence Territory SAH -hydrocephalous -intraventricular hemorrhage/ventricular dilitation -volume of hemorrhage (inaddition to SAH grading) -global edema on CT Lobar -volume most important predictor of death/*dependence -poor outcome with hemorrhage volume over 40 ml -displacement of tissue (measured by septal shift on CT) over 6mm-predictive of mortality/vegitative state, other evidence suggests shift of >9mm or pineal shift of >4mm is indicative

13. Clinical Indicators of Poor Outcome Ganglionic/Putnam -volume >60 ml -obstructive hydrocephalous Pontine -<20 mm -extension into midbrain/thalamus (fatal) Cerebellar -early hydrocephalous on CT -intraventricular hemorrhage -primary hematoma in vermis/extension into -upward herniation (cistern compression) -ventricular distortion -diameter > 3mm

14. Thalamic/Subdural Hemorrhage

15. Clinical Indicators of Poor Outcome Physical Evidence SAH -GCS < 12 -coma-complications secondary to -failure to improve after interventions, no improvement in 5 days -concurrent pulmonary edema -loss of consciousness at onset -age > 65 Lobar -GCS <8 -neuro deterioration in non-comatose to coma -extensor posturing, absent occular reflexes (pupil, occulocephalic corneal) -pre-event hx of heart disease, age older (<80)

16. Clinical Indicators of Poor Outcome Ganglion/Putnam -hypertension on admission -coma at onset (pred of 30 day mortality) -GCS < 8 Pontine -longstanding refractory hypertension -coma on admission -hyperthermia (>39 C) with hydrocepahlous and midbrain -tachycardia extension, do not survive NB coma and hemorrhage > 20mm uniformly associated with death

17. Clinical Indicators of Poor Outcome Cerebellar -admission systolic BP > 200mm Hg -GCS < 8 -abnormal corneal/occulocephalic responses (absent corneal response on admission) -motor responses on GCS worse than localization -Age over 70 NB hydrocephalous, absent occulocephalic responses-92% poor without hydrocephalous, but age > 70 and hematoma >3mm poor

18. Research-Clinical Indicators Current Research How do we quantify Overwhelming Acute Ischemic Stroke?

19. ISSUES THINGS TO CONSIDER….. Life support-ventilation Feeding Meds Labs

20. Decisions Clinical Indicators/Prediction rules Decision making around withdrawal of treatment / continuance Who-family /team /patient…. What are the considerations How are decisions often made?

21. Decision Making Bias Estimate of prognosis Method of communication Misunderstandings-values/expectations Failure to appreciate patient health state/ adaptability

22. Suggestions Structured interactions Bias/interference Conflict-expect it, manage it Communicating prognosis Patient life values Treatment Alternative treatments Time Know policies re: issues such as feeding

23. Feeding Tube feeds are not a cure Serious implications associated with long-term use *Aspiration pneumonia and the tube *Secretion management and the tube *Infections *Tubes for palliative care

24. Aspiration pneumonia and the tube Gastroesophageal reflux is a significant side effects of tube-feedings when accompanied by a disordered swallow and a weakened cough Tube feeding is a strong predictor of aspiration pneumonia in the elderly Chronic aspiration of small amounts of reflux leads to aspiration pneumonia (Langmore SE, Terpenning MS, Schork A, Chen Y, Murray JT, Lopatin D & Loesche WJ (1968). Predictors of aspiration pneumonia: how important is dysphagia? Dysphagia 13(2): 69-81) (Koufman JA, (April, 1991). The otolaryngologic manifestation of gastroesophageal reflux disease (GERD): A clinical investigation of 225 patients using ambulatory 24-hour pH monitoring and an experimental investigation of the role of acid and pepsin in the development of laryngeal injury. Laryngoscope 101: 1-78.)

25. Secretion management and the tube Patients with swallowing difficulties tend to swallow less frequently between meals A lack of oral intake produces a decreased incentive to swallow, patients who are tube-fed will be at greater risk for secretion build-up A lack of oral intake produces a decreased incentive to swallow because of this patients who are tube fed will be at greater risk for secretion build-up (Murray J, Langmore S, Ginsberg S & Dosile A (1998). The significance of accumulated oropharyngeal secretions and swallowing frequency in predicting aspiration. Dysphagia 11: 99-103.)

26. Infections The insertion site of the G- or J- tube is prone to infection Prevention requires: -daily monitoring of the site for redness, increased warmth, and purulent drainage, and daily cleansing of the site

27. Tubes for Palliative Care It is not uncommon for the swallowing mechanisms to fail during the end stages of a disease Therefore, introduction of tube feeds at this time is questionable Evidence exists to suggest that although nutrition is being introduced via a tube, the body is unable to make use of it. Given such conditions, there is no prolongation of life and food may actually become a burden (Chouinard J, Lavigne E & Villeneuve C (1998). Weight loss, dysphagia and outcome in advanced dementia. Dysphagia 13: 151-155.)

28. Values clarification: Recognizing our pre-existing comfort with catastrophic events Understanding and respecting the families inability to accept bad news Tips for communicating bad news Strategies to care for patients and families experiencing life changing events Taking care of yourself Working Through It………

29. Recognizing your Values It is important for health care professionals to complete a values clarification exercise when faced with new challenges or difficult situations Knowing our values and beliefs is a good beginning to the process of positive change Our beliefs and values influence our behaviours (Manly, K. 2003) We must identify our own beliefs about a patient situation to prevent confusing them with those of the family (White, K. & Hall, J. 1999)

30. What are your values? You are caring for a women who has suffered a catastrophic stroke. She is non-responsive & her prognosis is very poor. She is currently receiving numerous treatments such as: NG feeding, oxygen, IV fluids & medications, numerous blood draws, daily diagnostic tests, and more. The specialists have identified, based on her stroke etiology and clinical presentation, that these efforts are futile and she will not recover.

31. But the family values……? Save her life Save her life Save her life This is my mother This is my sister This is my wife In many ways, this is my life too……….

32. Why can’t the family understand what we are saying? Families are experiencing a sudden and distressing change We can empathize but we cannot feel the change The family’s ideas about their future and the way in which they will function are under attack Emotional responses to this change can be very powerful. These emotions can cause memory, concentration, and decision making problems (Rich Wheeler, S. 1996)

33. Delivering bad news Become comfortable waiting for decisions to be made about patient care Be prepared to repeat yourself After you receive report, try to arrange a time with family to listen to their concerns. Always use real terms such as ‘dying’ or ‘death’. When trying to explain why the patient will not recover, you must reinforce the facts of the patient’s diagnosis.

34. The return of primitive reflexes after neurological damage The return of the grasp reflex is difficult for the family to understand as a sign of deterioration in the patient. They perceive the patient to be improving and responding to them It takes skill to communicate the truth If it is done without care, this can cause resentment and mistrust in the team If possible, it is crucial to warn the family ahead of time

35. Caring for the Grieving Family Tell the family that their feelings are normal Give time to make difficult decisions Start the process of decision making by asking the family to identify a spokesperson so that communication can be streamlined Encourage family to be involved with the patient’s care and to touch the patient Anger is a form of grief. Don’t become defensive. Instead, acknowledge the anger and show acceptance. Set boundaries early.

36. How do I help them decide If available, ask the family to review advanced directives Be truthful about the prognosis. Use the facts and avoid making statements that only make yourself feel better. (Rich Wheeler, S.) “This is God’s will” “Time heals all wounds”. Include spiritual care or social work If there is a large extended family, support the nuclear family in their decision making

37. Other Points to Help With Managing the Situation…. Caregiver Burden is real and we must utilize the team system to prevent it. “Its not my patient” is a destructive approach to team integrity. Ad hoc or organized debriefing sessions to share challenges and emotions are valuable Utilize employee assistance programs Get sufficient rest If you are having significant difficulty with the assignment, communicate this to the team Seek out educational opportunities to develop skill in this area

38. Developing a Plan of Care Inclusions and Considerations Consults-which are important, what additonal Tests-after the initial testing, then what Treatments-vital signs, prevention of complications, treatment for comfort Meds Nutrition Elimination Activity Education Expected outcome-severe disability/palliative Discharge plan Anything else we can think of to include?

39. FINI That’s All Folks!!

40. References See inclusions in package

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