Cấp cứu & xử trí đột quỵ cấp - Hoàng Bùi Hải

CẤP CỨU & XỬ TRÍ ĐỘT QUỴ CẤP 
FOR ADVANCED NURSING CARE 
TS.BS. Hoàng Bùi Hải 
Khoa Cấp cứu & HSTC, BV Đại học Y Hà Nội 
Bộ môn Hồi sức Cấp cứu, Đại học Y Hà Nội 
Thanh Hoá, 06/10/2017 
 Stroke: 5th leading cause of death in the United States, 
with 1 person dying every 4 min. Approximately 800,000 
people have a stroke each year; 1 every 40 seconds. 
There are three main kinds of stroke: 
1. Ischemic strokes 
2. Hemorrhagic strokes 
3. Transient ischemic attacks (TIAs), also referred to as 
mini-strokes 
https://www.medicalnewstoday.com/articles/7624.php 
Time is brain 
• 1.9 million neurons are lost 
each minute after a stroke 
• Protect ischaemic penumbra 
Stroke 2006 
MỤC TIÊU & THỜI GIAN 
1. NIHSS 
2. Scored 0-42, 
11 Items 
Evaluation and Diagnosis of AIS 
 Immediate diagnostic studies 
ECG, Glucose, O2 sat, Chem 7, CBC, Troponin, PT, INR, 
aPTT (Class I, LOE B); 
Only blood glucose must precede IV rtPA 
administration, unless there is suspicion of a bleeding 
abnormality or coagulation abnormality (e.g, use of 
warfarin) 
Emergency Evaluation 
and Diagnosis of AIS 
Jauch EC, et al. Stroke. 2013;44(3):870-947 
‘Time is Brain’ - Stroke Pathway 
Triage, FAST test 
Speedy call to Stroke Team (whatever severity) 
Rapid admission to ASU 
Cerebral infarct - onset 
Onset 
Infarct 
Ischaemic 
penumbra 
Cerebral infarct – 6 hours 
6 Hours 
Infarct 
Ischaemic 
penumbra 
Cerebral infarct – 24 hours 
24 Hours 
Infarct 
Ischaemic 
penumbra 
Without thrombolysis 
2hrs 
ACUTE STROKE MANAGEMENT 
ABC 
Airway 
Breathing 
Circulation 
After ABC 
GCS 
 ECG 
 Blood glucose 
 Fluid access 
 Hydration 
 Bloods 
 Nil by Mouth 
 Transfer to CT, MRI-continue ABC 
Thrombolysis 
• Must be given within 4.5 hours of stroke 
• Strict inclusion criteria 
• Licensed for IV use in under 80’s 
• Dramatic increase in post-stroke 
 quality of life 
Thrombolysis 
Alteplase rTPA 
 0.6mg /Kg 
15% of total dose –Bolus 2-3 
mins 
90% of total dose –Infuse over 60 
mins 
rTPA Alteplase 
Do not mix t-PA with any other medications. 
Do not use IV tubing with infusion filters. 
All patients must be on a cardiac monitor 
When infusion is complete, saline flush with Normal 
saline 
t-PA must be used within 8 hours of mixing when 
stored at room temperature or within 24 hours if 
refrigerated 
Complications of Thrombolysis 
 Intra -cerebral haemorrhage-1.7% 
(1 in 77 patients) 0.28% fatal 
Bleeding-minor bleeding is 
common (IV site) 
Anaphylaxis- 1% 
Angiodoema 1.3% 
Major Heamorrhage 0.4% 
Angioedema 
Can thiệp lấy huyết khối 
• Can thiệp lấy huyết khối qua đường động 
mạch bằng dụng cụ cơ học (tại phòng can 
thiệp) 
• Cân nhắc chỉ định can thiệp nội mạch lấy 
huyết khối ngay sau khi khởi động quá 
trìnhdùng thuốc tiêu sợi huyết (nếu bệnh nhân 
có chỉ định dùng thuốc tiêu sợi huyết). 
Can thiệp nội mạch lấy huyết khối 
 Tắc các động mạch lớn đoạn ngoài hoặc trong sọ: ĐM cảnh 
trong, não giữa đoạn M1; thân nền; não sau đoạn P1. 
 >18 tuổi 
Modified RANKIN trước đột quỵ: 0 hoặc 1 
 Khởi phát ≤ 6 giờ. Mở rộng hơn, đối với động mạch thân nền 
và não sau, đến 8 giờ. 
 NIHSS ≥ 6 điểm 
 Điểm ASPECTS ≥ 6 điểm (đối với DWI-MRI ), ASPECTS ≥ 7 
điểm (đối với CTScanner không tiêm cản quang). 
MONITORING 
First 24 hours 
30% of all stroke patients will deteriorate in the 
first 24hours 
Stroke 2009 
Monitor GCS 
 Ability to engage with 
immediate surroundings 
 Standardised stimuli 
 E1-E4 
 V1-V5 
 M1-M6 
Best and Worst Score 
 GCS 15- E4 V5 M6 
 Awake, alert and fully responsive 
 GCS 3-E1 V1 M1 
 No cerebrally mediated response 
to stimulus 
NIHSS - A Research Tool 
 Fifteen item impairment 
scale 
• Neurological outcome 
• Degree of recovery 
Physiological Monitoring 
1. Hypoxia 
Respirations 
Saturations <92% 
Associated with neurological 
deterioration 
2. Temperature 
 >38C must be treated. 
-associated with infarct volume 
3. Arrhythmias 
Continuous ECG 
Early detection and treatment of AF 
Right hemisphere /insular lesions 
Physiological Monitoring contd 
4.Blood pressure 
Non thrombolysed patients 
BP Not treated unless: 
 Systolic >220mmHg or 
 Diastolic >120mmHg with 2 consecutive 
readings 
Thrombolysed patients 
BP is treated if: 
 Systolic >185mmHg or 
 Diastolic >110mmHg with 2 consecutive 
readings 
Abrupt fall in BP may affect cerebral 
perfusion pressure 
Physiological Monitoring contd 
 5.Blood Sugar 
• Hyperglycaemia BM>10 treat & 
monitor 
• Hypoglycaemia –immediate 
treatment with glucose 
Hyperglycaemia is associated with 
poor clinical outcome 
Physiological Monitoring Contd 
6. Hydration 
 Glucose 
 Cerebral perfusion 
7. Anuria 
 Polyuria 
 Circulatory failure 
Complications of Stroke 
 Aspiration Pneumonia 
 Urinary infection 
 DVT 
 Pulmonary Embolus 
 Shoulder subluxation 
 Depression 
 Malnourishment 
 Pressure sores 
 Falls 
 Seizures 
Swallow Complications 
(Dysphagia) 
 Chest Infection 
 Aspiration Pneumonias 
 50% are silent 
• Swallow screen 
• Nil by mouth first 24hours 
• Guided eating & drinking regime 
• Encourage to cough 
• Sitting out of bed 
• Mobilisation 
Mouth Care 
 Increased risk of infection 
 Pain and discomfort 
 Effects swallow 
• Gentle mouth care 
• Adequate hydration 
• Gentle tooth brushing 
Head Position 
 Controversial 
• Head in a neutral position 
• Flat if tolerated. 
• Or 30 –40 degrees 
• Aids venous drainage & 
improves cerebral perfusion 
Bladder &Bowels 
 Urinary incontinence 
 Urinary infection 
• Avoid catheters 
• Early plan of care 
• Adequate hydration 
• Bowels 
• Privacy & dignity 
Psychological Support 
• Assess mood 
• Recognise grief/loss 
• Talk 
• Engage with family 
• Interests 
• Timely realistic goals 
• Refer 
Pressure Sores 
• Air mattress 
• Two hourly turns 
• Nutrition 
• Hydration 
• Personal hygiene 
Deep Vein Thrombosis 
• Early mobilisation 
• Low molecular weight heparin 
• Compression devices 
• TED stockings not beneficial in 
stroke patients 
 Clots Trial 2009 
Positioning 
 Loss of sensation 
 Loss of power 
 Subluxation 
 Supportive 
 IV lines and BP cuffs avoided on 
affected limb 
 Assess moving and handling 
 Good technique 
Nutrition 
 Malnourishment associated 
with poor outcome 
• Weight 
• MUST assessment 
• Naso gastric tube 
• History of patients eating 
habits 
 Controversial 
• When to commence invasive 
feeding regime 
TAKE HOME MESSAGES 
Đột quỵ nhồi máu não là chính 
Tme is brain 
NIHSS (0-42 pts, 11 items) 
Tiêu sợi huyết cho đột quỵ NMN < 4.5 giờ 
Tiêu sợi huyết + lấy huyết khối qua catheter: 
Tắc ĐM cảnh, M1, não sau và thân nền 
Theo dõi các biến chứng: 24h đầu, thường 
gặp nhất. 
Dự phòng các biến chứng. 
XIN CHÂN THÀNH CẢM ƠN!