I am going to take this time to explain how strokes are treated in the hospital. I am going to make this understandable to the layman, so there will be some things that get simplified, or even omitted to make this easier to understand.
Strokes are the fifth leading cause of death in the US, so treating them is an absolute must. When people have signs of a stroke in the Emergency Department, the rules say that we have to get them a head CT within 10 minutes. The CT is looking for bleeding in the brain, which is called a hemorrhagic stroke. About one in eight strokes is caused by bleeding in the brain. The other seven are called ischemic strokes and are caused by blood clots.
Immediately after the CT scan is done (the patient is still in the CT imaging room), they are interviewed by a neurologist to see if they are showing signs of an ischemic stroke, meaning one caused by a blood clot cutting off oxygen to the brain. The nurse does the evaluation at the same time, and each of them come up with what is called an NIH score. They then compare scores and, if different, they discuss why. The idea is to give the score that is most advantageous to the patient. An NIH score measures the likelihood and severity of a stroke through a score that ranges from 0 to 42. The higher the score, the more severe is the stroke. A score of eight or higher means that the patient gets screened to see if they are a candidate for TPA administration.
TPA is a miracle drug. It breaks up blood clots, and allows blood to again flow, saving brain tissue from death. If administered within the first 4.5 hours of a stroke first beginning, the patient frequently leaves the hospital with no permanent disability. Sadly, many people with stroke symptoms wait too long to come in and are not candidates for this therapy.
If they are having a stroke, but are outside of that 4.5 hour window, they are admitted and we see just how much brain function they have lost. Then they are discharged to be rehabilitated and taught to live with their new disability.
In 84% of cases, patients who have just had a stroke will see their blood pressures greatly increase as the body tries to use this pressure to force blood past the clot that is cutting off blood to the brain. This process actually reduces the amount of damaged brain tissue in an ischemic stroke, reduces the amount of permanent disability, and decreases patient mortality due to ischemic brain tissue.
The risk of this is that the large increase in blood pressure greatly increases the chances that a blood vessel will rupture, causing a second, hemorrhagic stroke, and that second one is often fatal. I believe that a hemorrhagic stroke is what killed my mother last year.
Since 2019, the American Stroke Association and the American Heart Association both recommend that a patient with an ischemic stroke that isn’t a candidate for TPA administration be permitted to have high blood pressure for the first 24-72 hours after the stroke while being closely monitored. The only high blood pressure to be treated in these cases is a blood pressure higher than 220/120. In those cases, the patient should be medicated to reduce blood pressure by 15%. This is called permissive hypertension and is the current way that hypertension in stroke patients is being treated.
The problem is that this is not received well by older medical professionals, who have spent their lives thinking that “high blood pressure is bad” and want to reduce blood pressure no matter what. They just haven’t remained current in their clinical knowledge, and secure in their ignorance, will violently defend what they have always done, even when that has been shown to be the wrong thing to do.
I recently had a stroke patient with a BP of 263/152 and had formed a plan in conjunction with the doctor to lower her BP slightly to 220/110 using medication. Another nurse (who used to be a charge nurse) came over and started a loud shouting match, telling me that I was being dangerously lazy in not controlling the patient’s blood pressure. She accused me of being a shitty nurse and reported me for poor patient care.
I produced all sorts of studies showing that I was right, so I won’t be getting in trouble, even though the QA department agreed with her, trying to tell me that blood pressures of over 200 are too dangerous. They pointed out that the units on the floor have a policy of not accepting patients with a blood pressure that high. I told them that maybe the policy should be revisited in light of current literature.
Why? Because medicine is evidence based, and the evidence and current literature is on my side. I presented my nursing plan and the current literature to my department head, and she agreed that my treatment was in keeping with current AHA and ASA guidelines.
That required me writing a long dissertation to support my position. It wound up being a 460 word essay, complete with references to the AHA and ASA guidelines, as well as referencing multiple studies carried out since 2020, showing that patient outcomes are better under these guidelines.
It’s cases like this that show why good nurses make a lot of money for the level of education that they have. I’m probably going to present my case to the hospital’s clinical standards council (one of whom already spoke with me and thinks its a great idea) and try to get the policy changed. It’s a stupid policy that is likely killing people. The bonus is that, if I am successful in forcing the change, I get a raise and I also get published.
