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.
22 Comments
Mark · October 28, 2024 at 5:53 am
Nice work. Keep us posted on the promotion to hospital director. At 59, my bp has risen over time to to 140s/90s. My daughter the NP has been after me to get it reduced. She is recommending Benicar in addition to lifestyle changes. I see my primary tomorrow to discuss. I’m not looking forward to what some of the side-effects might be. Lethargy primarily. We shall see.
Divemedic · October 28, 2024 at 8:12 am
I have no desire to be in management. It’s all political apple polishing and brown nosing. Not interested. Plus, I am loud, outspoken, and completely not politically correct. I am not afraid to (nicely) tell someone that they are an asshole or when they couldn’t tell the difference between their ass and third base. For those reasons, I wouldn’t be good at it, anyhow.
Scott Norris · October 28, 2024 at 11:44 am
But that is EXACTLY the kind of people we NEED in management !!!
oldvet50 · October 28, 2024 at 6:17 am
Thanks for the informative article. I had wondered how they determined which medicine to give. Obviously administering a clot buster for a hemorrhagic stroke would be fatal. Good luck on getting the changes implemented. It’s been my experience (in a previous corporate life) that getting any change implemented is more difficult than suspending gravity. It’s very hard to overcome “..because that’s the way we’ve always done it”. Corporate politics sucks to the extreme.
TRX · October 28, 2024 at 6:39 am
So a sudden spike in blood pressure would be a sign of a stroke?
Divemedic · October 28, 2024 at 8:00 am
Not necessarily. There are numerous things that can cause sudden increases in blood pressure. The following are signs of a stroke, and should you or someone you know have these, call 911 immediately. As the above post illustrates, time is of the essence if you want to be in the window for TPA:
Sudden balance difficulty or dizziness, vision changes, facial drooping, severe headache, the sensation of heaviness, weakness, or numbness in the arms or legs (especially on one side of the body), trouble speaking, or confusion.
ModernDayJeremiah · October 31, 2024 at 1:34 pm
BE FAST
Balance
Eyesight changes
Face drooping
Arm weakness
Speech slurred/impaired
Time. TIME is BRAIN.
Dan D. · October 28, 2024 at 6:40 am
This reminds me of the institutional inertia that had to be overcome to move toward replacing blood volume with actual blood products (when possible) and away from using crystalloids.
I’m glad you took the time to write that 460 word essay; it is because you are a true medical professional that prefers, as you wrote, evidence based medicine above CYA-based medicine. I’ll send you something to personally thank you for also being an upstanding patient advocate.
Mel · October 28, 2024 at 7:28 am
Good information
And I may add, it behooves the family members of a potential stroke victim to get person to medical care as soon as possible.
A few years back, I got a call about my mother, she had fallen and had called for help. They had put her in a chair where she had weakness in her right side. I told them to get her to ER quickly and tell them that she potentially had a stroke. Unfortunately at the ER they treated her for a concussion based on the information given. It was later that day(3 hours away) before when I was with her and talking to the doctor doing a follow-up exam on concussion protocol that I saw Babinski sign when he stroked the sole of her foot. As soon as I saw it, I asked ‘are sure it’s a concussion and not a stroke?’ He agreed and off to CT again (did one earlier and whether there was no indication or if they were confirmation bias on concussion, we will never know). By then it was too late(12 hours since her fall) for TPA and I do believe they were keeping her BP below normal.
Anyway recovery was long and vascular dementia set in within 3 months, a sad way to go.
Probably would have been different if we had a nurse like you.
No One · October 28, 2024 at 7:44 am
Had one back in 2018 when I was 150lbs. heavier. The EMS saved my wretched ass by getting there within minutes.
Blood sugar level and BP was the issue with mine and I should have known with swollen ankles and no thirst quench after a six pack of water the night before.
Lost track of two weeks time and left with an astronomical medical bill.
All kinds of procedures and exams as the health coverage was good back then.
Escaped with mild cognitive impairment. (H/T-G) {Doctors & Nurses}
When the Pajeet doctor tried to take credit afterwards, I said the ICU doctors did all the heavy lifting as the air went out of the room. Not gonna give credit where it is not due.
Off all meds now and wearing jeans from HS and sold leftover meds on CL after they skyrocketed under Brandon.
SoRuss · October 28, 2024 at 10:49 am
Very informative, thanks. Will save for future reference. I never heard of BP that high. As a aside, since you are discussing BP as a part in this. Could you do a post on BP in your view and how every doctor seems to believe different things on what BP should be for folks in general. BP measures years ago that were considered normal are now considered high. Some doctors seem to have a vendetta on a patient not having their version of proper blood pressure. Its like how freaking low do you want me to be since previous doctors said my BP was fine and appeared to be normal for me or wife? Do I have to pass out every day due to low BP??
As a example,I and my wife have gone to multiple DR visits in a day and every office measured my and wife BP at different levels and in some places the way they did the check was different in each office? So how can they know what the BP is if its different in each office?
Divemedic · October 28, 2024 at 11:07 am
Doctors are a profession that follows evidence based practices. Those practices change from time to time as more studies and evidence come to light. When I first went to school, a normal blood pressure for a man was considered to be a systolic of 100 plus his age. We now know that this is far too high.
Some doctors are more up to date than others. Once you are a doctor, you don’t HAVE to stay current, and many don’t. That’s one reason for the disparity between doctors.
Higher blood pressure damages kidneys, eyes, and other structures with thin walled blood vessels. It also causes structural changes to the heart that can cause heart failure. It is a large factor in things like hemorrhagic strokes.
The higher your blood pressure, the higher your risk. The ideal blood pressure is a systolic between 100 and 120, and diastolic between 60 and 80. Anything higher than that needs to be monitored, and anything higher than 140/90 should be treated, but even then a target below 130/80 is sometimes followed with the presence of certain comorbidities such as diabetes or chronic kidney disease.
Unknownsailor · October 28, 2024 at 7:57 pm
I used to get talked to a lot about borderline high BP in the Navy, but what it really was is that the machines being used to take my BP did not have cuffs bug enough for my 19″ arms. When the nurse would get out the extra large manual cuff and their stethoscope, I had normal BP. I had to tell this to everyone who wanted to chirp at me about my BP ever since.
As I’m sure you know, Navy medicine is one size fits all, and like all things military, it doesn’t deal with edge cases well.
Silverfox · October 28, 2024 at 12:42 pm
So why not administer TPA, as a preventative, prophylaxis measure, for those that are at risk for a stroke?
Divemedic · October 28, 2024 at 1:24 pm
Great question, and anticoagulants are used prophylactically, just not TPA. The reason is that TPA doesn’t prevent clots, it breaks them down. There are significant risks for bleeding to administering TPA to a patient, to include risk of hemorrhagic stroke, internal bleeding, etc..
For preventing clots, other drugs are used. There are five classes of anticoagulation medications, and each of them attack or inhibit different parts of the body’s clotting mechanism.
There is warfarin, which works by inhibiting the synthesis of vitamin K dependent clotting factors.
Xarelto and Eliquis, called Direct Oral Anticoagulants (DOAC) work by inhibiting factor Xa.
There are antiplatelet medications like aspirin and Plavix.
Then there is Heparin.
Low molecular weight heparins like enoxaparin are also used.
Each of these classes has a different use because they attack the body’s ability to clot in a different way, but all of them work to prevent blood clots in some way. There are benefits and risks associated with each of them, and healthcare providers have to balance those risks and benefits for each patient.
For example, people with Atrial Fibrillation are at significant risk of developing blood clots that can cause heart attacks, pulmonary emboli, or strokes. For that reason, most of them are put on some form of anticoagulation therapy, and nowadays, that usually means Eliquis. It used to be warfarin, but that drug is no longer recommended for A Fib.
However, most people who have had clots form in their leg veins after knee surgery get warfarin.
The science is constantly evolving. As new and better drugs are developed, things change.
Silverfox · October 28, 2024 at 5:30 pm
Thanks for the info.
Greg · October 29, 2024 at 12:53 pm
A great post and comment DM. I have a younger brother who had a stroke two weeks ago. He was very fortunate to get to an ER soon enough. He still has some residual paraplegia, but no other neurological deficits. I’ve sent your column to my family.
As you well know, the coagulation mechanism is hideously complex. We meddle with it at our peril. An especially dangerous combination is Plavix and Aspirin, and needs to be monitored very closely.
Aesop · October 28, 2024 at 1:58 pm
Feeding stupid charge nurses a shitburger is its own reward.
I can count the number of charge nurses I have held any respect for on my thumbs, but I’ve only been doing this 30 years, so there may be a few more I’ve yet to see.
The personality type that hospital manglement thinks makes a good manager is antithetical to what makes a good nurse, so invariably, as in all political systems, and septic tanks, the biggest pieces of shit tend to rise to the top.
Good on you for doing some uncompensated staff education. This is why medical texts aren’t written on stone tablets.
Vlad the Non-Impaler · October 28, 2024 at 9:26 pm
Shows how long I’ve been retired from EMS. The last TPA timeframe I heard was 3 hrs. Good on you for being a thinking, knowledgeable pt advocate. 👍🏻
As Aesop noted, break it off in a bitch’s ass brings that warm fuzzy feeling.
Trailer For Sale Or Rent · October 28, 2024 at 10:34 pm
I had a surprise hemorrhagic stroke, caused by an arteriovenous malformation, in 2017. I noticed it because I twice stumbled getting out of a chair, which was unheard of for me, and I had learned as a child to look for “the claw”, which I saw in my right hand.
You never hear about the claw anymore, but I seem to remember that 50 years or so ago, it was a commonly taught warning sign for stroke. By claw, I mean a relaxed hand that is unable to extend the fingers straight out, when you could the day or hour before, rather than the rigid examples I saw when I googled “claw hand as an indication of stroke”
ColdSoldier · October 30, 2024 at 7:42 pm
As someone with high blood pressure I appreciate you writing this.
The Timing is Beautiful – Area Ocho · October 30, 2024 at 7:13 am
[…] this week’s post where a fellow nurse reported my so-called (in her opinion) poor patient care, I got a surprise email telling me that I am being promoted, effective Saturday. This was a huge […]
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