Management of Catastrophic Stroke

1
Management of CatastrophicStroke

• Marie Rusnak, RNEC, MSN-NHS-GNG Site
• Cami DUva ACNP-HHSC-HGH Site
• Johanne Hayes,Nurse Educator GIM St. Josephs
• 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

• Ischemic / Thromboembolic Stroke
• Radiology Evidence
• Territory
• -MCA occlusion (anterior, posterior)
• -within 6 hours-increases risk of fatal
  cerebral edema
• -within 24 hours, highly predictive of
  clinical
• deterioration due to cerebral edema
• Extent
• -greater than 50 of MCA territory
• -sulci effacement with MCA sign (within 24
  hours of onset)
• Correlated with
• -fatal brain swelling

5
MCA Sign
6
Normal/Effacement
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 gt180 systolic
• -along with hypodensity MCAgt50
• 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 (lt 8 )
• -NIHS score gt 20, gt 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 gt60

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 gt9mm or
  pineal shift of gt4mm is
• indicative

13
Clinical Indicators of Poor Outcome

• Ganglionic/Putnam
• -volume gt60 ml
• -obstructive hydrocephalous
• Pontine
• -lt20 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 gt 3mm

14
Thalamic/Subdural Hemorrhage
15
Clinical Indicators of Poor Outcome

• Physical Evidence
• SAH
• -GCS lt 12
• -coma-complications secondary to
• -failure to improve after interventions,
  no improvement in 5 days
• -concurrent pulmonary edema
• -loss of consciousness at onset
• -age gt 65
• Lobar
• -GCS lt8
• -neuro deterioration in non-comatose to
  coma
• -extensor posturing, absent occular
  reflexes (pupil, occulocephalic
• 
  corneal)
• -pre-event hx of heart disease, age older
  (lt80)

16
Clinical Indicators of Poor Outcome

• Ganglion/Putnam
• -hypertension on admission
• -coma at onset (pred of 30 day mortality)
• -GCS lt 8
• Pontine
• -longstanding refractory hypertension
• -coma on admission
• -hyperthermia (gt39 C) with
  hydrocepahlous and midbrain
• -tachycardia
  extension, do not survive
• 
  
• NB coma and hemorrhage gt 20mm uniformly
  associated with death

17
Clinical Indicators of Poor Outcome

• Cerebellar
• -admission systolic BP gt 200mm Hg
• -GCS lt 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 gt 70 and
  hematoma gt3mm poor

18
Research-Clinical Indicators

• Current Research
• How do we quantify Overwhelming Acute Ischemic
  Stroke?

19
ISSUESTHINGS 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
Working Through It

• 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

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 cant 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 familys 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
  patients 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
  patients care and to touch the patient
• Anger is a form of grief. Dont 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 Gods 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 CareInclusions 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

• Thats All Folks!!

40
References

• See inclusions in package