Chest X-Ray - Initial Interpretation

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Radiographic Findings

• Dense, homogeneous opacity occupying the lower 2/3 of the left hemithorax
• Classic meniscus sign visible along the lateral chest wall
• Positive silhouette sign - left hemidiaphragm, left costophrenic angle, and left heart border are all obliterated
• Lower left lobe is compressed / passive atelectasis

• Subtle rightward shift of the trachea and heart, consistent with a large space-occupying left pleural collection
• Raises concern for a tension effusion given the degree of mass effect

• Clear and well-aerated
• No focal consolidation, mass, or nodule
• Right costophrenic and cardiophrenic angles are sharp

• Left border obscured by effusion; overall cardiac size difficult to assess
• Right border visible and displaced rightward

• No acute fractures, lytic lesions, or soft tissue abnormality appreciated

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Impression

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Recommended Next Steps

1. Clinical correlation - symptoms, vitals, O2 sat, duration
2. Thoracentesis - both diagnostic (LDH, protein, cell count, culture, cytology, ADA) and therapeutic
3. CT chest - to evaluate for underlying lung pathology, loculations, or pleural masses once fluid is drained
4. Labs - CBC, CMP, LDH, protein (to apply Light's criteria for exudate vs. transudate)

BAT Patients in the Stroke Unit

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What is a Brain Attack Team (BAT)?

Who is on the BAT?

• Neurologist / Stroke physician (team leader)
• Emergency physician
• Radiologist (for urgent CT/MRI)
• Neurosurgeon (on standby)
• Nursing (stroke-trained RN)
• Pharmacist (for tPA preparation)
• Interventional neuroradiologist (for thrombectomy cases)

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What Happens During a BAT Activation?

Key Actions When BAT is Called:

1. Check blood glucose (to rule out hypoglycemia mimicking stroke)
2. Secure 2 IV lines
3. Obtain NIHSS score (stroke severity)
4. Urgent CT head (non-contrast) - rule out hemorrhage
5. CT angiography - identify large vessel occlusion (LVO)
6. Decision for IV tPA (alteplase or tenecteplase) if eligible, within 4.5 hours of last known well
7. Decision for mechanical thrombectomy if LVO confirmed

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BAT vs. Other Related Acronyms in Stroke

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Phase 1: Immediate Assessment (0-10 minutes)

On Arrival / At Bedside:

• ABC assessment - Airway, Breathing, Circulation
• Vital signs - BP, HR, RR, O2 sat, Temperature
• Blood glucose - FIRST thing to check (hypoglycemia mimics stroke)
• NIHSS (NIH Stroke Scale) - score the neurological deficits:
  • Level of consciousness
  • Eye movements
  • Facial droop
  • Arm/leg motor strength
  • Sensory, language, speech, neglect
• Last Known Well (LKW) time - most critical piece of history
• IV access - 2 large bore IVs
• 12-lead ECG - detect atrial fibrillation (common stroke cause)
• Connect to cardiac monitor + pulse oximetry

Immediate Labs (drawn simultaneously):

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Phase 2: Imaging (10-25 minutes)

CT Head (Non-Contrast) - FIRST

• Rule out hemorrhagic stroke (bleeding = contraindication to tPA)
• Look for early ischemic changes (hyperdense MCA sign, loss of gray-white differentiation)

CT Angiography (CTA) Head + Neck

• Identify Large Vessel Occlusion (LVO) - determines thrombectomy eligibility
• Assess carotid and intracranial vessels

CT Perfusion (CTP) - if indicated

• Shows ischemic core vs. penumbra (salvageable tissue)
• Used for extended time window patients (4.5-24 hours)

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Phase 3: Treatment Decision (25-60 minutes)

A. Ischemic Stroke - Treatment Options:

1. IV Thrombolysis (tPA)

• Alteplase 0.9 mg/kg IV (max 90 mg) - 10% bolus, rest over 60 min
• Tenecteplase - newer, single bolus, preferred if thrombectomy planned
• Window: Within 4.5 hours of LKW
• Absolute contraindications:
  • Hemorrhage on CT
  • Recent surgery (<14 days)
  • Active bleeding
  • Very high BP (>185/110 uncontrolled)
  • INR >1.7 / on direct anticoagulants

2. Mechanical Thrombectomy (MT)

• For LVO confirmed on CTA
• Catheter inserted via femoral/radial artery up to the brain
• Clot retrieved using stent retriever or aspiration
• Window: Up to 24 hours with perfusion imaging guidance
• Door-to-puncture target: ≤90 minutes

B. Hemorrhagic Stroke - Treatment:

• Reverse anticoagulation (Vitamin K, FFP, PCC, idarucizumab/andexanet alfa)
• BP control - target SBP <140 mmHg
• Neurosurgery consult - for hematoma evacuation if indicated
• NO tPA - strictly contraindicated

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Phase 4: Stroke Unit Monitoring (First 24-72 hours)

Vital Sign Monitoring:

Neuro Monitoring:

• Hourly NIHSS for first 24 hours (post-tPA: every 15-30 min)
• Watch for neurological deterioration - may indicate:
  • Hemorrhagic transformation
  • Cerebral edema
  • Re-occlusion

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Phase 5: Acute Stroke Unit Care Bundle

1. Swallowing Assessment

• NPO until swallow screen passed (bedside or formal speech therapy)
• Risk of aspiration pneumonia is high

2. Positioning

• Head of bed flat (0°) in first 24 hours for ischemic stroke (maximizes cerebral perfusion)
• Elevated if raised ICP or aspiration risk

3. DVT Prophylaxis

• Early mobilization as soon as stable
• Compression stockings / pneumatic compression devices
• Anticoagulation deferred 24-48 hours post-tPA

4. Antiplatelet Therapy

• Aspirin 300 mg loading dose (if no hemorrhage, 24 hours after tPA)
• Dual antiplatelet (aspirin + clopidogrel) for minor stroke / TIA - POINT/CHANCE trial evidence

5. Statin Therapy

• Start high-intensity statin (atorvastatin 40-80 mg) early

6. AF Workup

• If AF detected → anticoagulation (DOAC preferred) after 2-14 days depending on infarct size

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Phase 6: Rehabilitation (Starts within 24-48 hours)

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Summary Flow

Symptoms onset / discovered
        ↓
Code BAT activated
        ↓
Vitals + NIHSS + Glucose + ECG + Labs
        ↓
CT Head (non-contrast) → CTA Head/Neck
        ↓
Ischemic?          Hemorrhagic?
    ↓                   ↓
tPA ± Thrombectomy   BP control + Reverse anticoag
        ↓
Stroke Unit - Monitor BP/Glucose/Temp/Neuro
        ↓
Swallow screen → Diet / NG tube
        ↓
Aspirin + Statin + AF workup
        ↓
Early Rehab (PT/OT/SLP)
        ↓
Discharge planning + Secondary prevention

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🔴 Most Feared: Symptomatic Intracranial Hemorrhage (sICH)

• Incidence: ~6% with alteplase
• Time frame: Usually within 24-36 hours of tPA
• Warning signs:
  • Sudden neurological deterioration (NIHSS increase ≥4 points)
  • New severe headache
  • Sudden rise in BP
  • Vomiting
  • Decreased level of consciousness
  • New focal deficits

If sICH suspected - STOP tPA infusion immediately and:

1. STAT non-contrast CT head
2. Call neurosurgery
3. Cryoprecipitate 10 units IV (replaces fibrinogen consumed by tPA)
4. Consider tranexamic acid or aminocaproic acid
5. FFP, platelets if needed
6. Aggressive BP control (target SBP <140)

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🟠 Systemic Bleeding Complications

Key Rule Post-tPA:

Avoid all invasive procedures for 24 hours - no NG tube, no arterial line (non-compressible sites), no Foley (if not already in), no IM injections

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🟡 Orolingual Angioedema

• Incidence: ~1-5%
• Tongue, lip, or oropharynx swelling - can cause airway obstruction
• More common in patients on ACE inhibitors (up to 13x higher risk)
• Time frame: During infusion or within hours after

Management:

1. Stop tPA if still infusing
2. Airway assessment - call anesthesia/ENT immediately if severe
3. Cetirizine (antihistamine) + Ranitidine
4. Methylprednisolone IV
5. Epinephrine 0.3 mg IM if airway compromise
6. Prepare for intubation if progressing rapidly

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🟡 Hemorrhagic Transformation (HT) of Infarct

• PH-2 = classified as sICH
• Detected on 24-hour follow-up CT (routine after tPA)

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🟡 Re-occlusion / Early Neurological Deterioration

• Clot can re-form after tPA dissolves it
• Patient improves then worsens again
• Consider if NIHSS worsens after initial improvement
• May need repeat imaging + escalation to thrombectomy

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🟡 Reperfusion Injury / Cerebral Edema

• When blood flow is restored to a large ischemic area
• Brain swelling peaks at 48-72 hours
• Especially dangerous in large MCA infarcts (malignant MCA syndrome)
• Signs: declining consciousness, pupillary changes, herniation signs
• Management:
  • HOB elevation 30°
  • Osmotherapy (mannitol, hypertonic saline)
  • Neurosurgery consult for decompressive hemicraniectomy if indicated

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🟢 Blood Pressure Emergencies

If BP exceeds limits:

• IV labetalol 10-20 mg bolus (first line)
• IV nicardipine infusion (if labetalol insufficient)
• IV hydralazine as alternative
• Avoid nitroprusside (increases ICP)

Hypertension post-tPA is the #1 modifiable risk factor for hemorrhagic transformation

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🟢 Hypoglycemia / Hyperglycemia

• Hypoglycemia (<3.9 mmol/L) - worsens neuronal death, mimics stroke worsening
• Hyperglycemia (>10 mmol/L) - increases hemorrhagic transformation risk
• Check glucose every 1-2 hours post-tPA
• Target: 7.8-10 mmol/L

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🟢 Cardiac Complications

• Arrhythmias - AF may unmask post-reperfusion
• Neurogenic stunned myocardium - especially with large strokes (insular cortex involvement)
• Troponin elevation, ECG changes (deep T-wave inversions, QTc prolongation)
• Continue continuous cardiac monitoring for at least 24 hours

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Nursing Monitoring Protocol Post-tPA

Each Neuro Check Includes:

• NIHSS or GCS
• Pupil size and reactivity
• Limb strength (grip, leg raise)
• Speech quality
• BP and HR

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Quick Reference - Red Flags to Escalate Immediately

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tPA - Tissue Plasminogen Activator

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What It Is

• Alteplase (Activase) - the standard, most widely used
• Tenecteplase (TNKase) - newer, single-bolus form, gaining preference

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How It Works (Mechanism)

Blood clot blocks brain artery
         ↓
tPA given IV
         ↓
tPA binds to PLASMINOGEN
(a protein sitting on the clot surface)
         ↓
Converts plasminogen → PLASMIN
         ↓
Plasmin breaks down FIBRIN
(the mesh that holds the clot together)
         ↓
Clot dissolves
         ↓
Blood flow restored to brain

In Simple Terms:

tPA "activates" the body's own clot-dissolving system - it turns on plasmin, which chews through the fibrin framework of the clot.

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The Drug: Alteplase

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Why 4.5 Hours?

• The ischemic area becomes irreversibly damaged (infarct core grows)
• Risk of hemorrhagic transformation (bleeding into dead tissue) outweighs benefit
• The brain penumbra (salvageable tissue around the core) is largely lost

"Time is Brain" - every 1 minute without treatment = ~1.9 million neurons lost

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Who Can Get tPA? (Eligibility)

✅ Included:

• Confirmed ischemic stroke (no bleed on CT)
• Within 4.5 hours of last known well
• Age ≥18
• NIHSS ≥4 (significant deficit)
• BP controlled to <185/110 before giving

❌ Contraindicated:

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tPA vs. Mechanical Thrombectomy

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What Nurses Must Know About tPA

1. Never shake the vial - gentle swirling only
2. No IM injections, arterial lines, or invasive procedures for 24 hours after
3. Monitor BP every 15 minutes during infusion
4. Watch for orolingual angioedema (tongue/lip swelling) - rare but life-threatening
5. If patient worsens neurologically - STOP infusion, call doctor, get CT immediately
6. No antiplatelets or anticoagulants for 24 hours after tPA
7. Soft toothbrush, no unnecessary needle sticks - patient bleeds easily

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Bottom Line

tPA is the only proven medical treatment for acute ischemic stroke. It works by dissolving the clot blocking blood flow to the brain. Given early enough, it can mean the difference between full recovery and permanent disability - which is why the entire BAT protocol exists to get it given as fast as possible.

NIHSS - NIH Stroke Scale

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Score Interpretation

Score ≥16 predicts high probability of death or severe disability Score ≤6 predicts good recovery in most patients

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The 11 Items - How to Assess Each One

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Item 1a - Level of Consciousness (LOC)

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Item 1b - LOC Questions

1. "What month is it?"
2. "How old are you?"

If intubated or has severe dysarthria - score 1

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Item 1c - LOC Commands

1. "Open and close your eyes"
2. "Grip and release my hand"

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Item 2 - Best Gaze (Horizontal Eye Movement)

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Item 3 - Visual Fields

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Item 4 - Facial Palsy

NLF = nasolabial fold

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Item 5 - Motor Arm (done separately: 5a = Left, 5b = Right)

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Item 6 - Motor Leg (done separately: 6a = Left, 6b = Right)

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Item 7 - Limb Ataxia

• Tests cerebellar coordination
• Only scored if out of proportion to weakness

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Item 8 - Sensory

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Item 9 - Best Language (Aphasia)

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Item 10 - Dysarthria

Dysarthria = slurred speech (motor) Aphasia = language disorder (cognitive)

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Item 11 - Extinction and Inattention (Neglect)

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NIHSS Score Sheet Summary

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Important Rules When Scoring

1. Score what you SEE - not what you think the patient can do
2. Do not coach or help the patient during testing
3. First response counts - do not average multiple attempts
4. Untestable items (UN) must be clearly documented with reason
5. Always do items in order - 1 through 11
6. Assess both sides separately for arms and legs
7. If patient has prior deficits (old stroke) - still score current presentation

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When to Reassess NIHSS Post-tPA

A worsening of ≥4 points from baseline = neurological deterioration → STOP tPA, call doctor, urgent CT head immediately

Hypertensive Urgency vs. Hypertensive Emergency

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The Core Difference

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Hypertensive URGENCY

Definition:

Severely elevated BP (>180/120) WITHOUT acute target organ damage

Symptoms (if any):

• Severe headache (without neurological signs)
• Nausea
• Anxiety
• Nosebleed (epistaxis)
• Palpitations
• No focal neurology, no chest pain, no pulmonary edema

Management:

• Oral medications - no need for IV
• Resume or increase existing antihypertensives
• First-line oral agents:

BP Reduction Goal:

• Reduce by no more than 25% in 24 hours
• Then gradually to <160/100 over next 24-48 hours
• Then to <140/90 over days to weeks

⚠️ Do NOT lower BP too fast - risk of watershed infarction, MI, renal failure

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Hypertensive EMERGENCY

Definition:

Severely elevated BP (>180/120) WITH acute end-organ damage

The "End-Organs" That Get Damaged:

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Management of Hypertensive Emergency

Setting:

• ICU admission
• Arterial line for continuous BP monitoring
• IV antihypertensives - titratable infusions

BP Reduction Goals:

⚠️ Exception: Aortic dissection - target SBP <120 within 20 minutes

IV Drug Choices by Condition:

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Drug Reference - Common IV Agents

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Special Scenario: Hypertension in Stroke

Ischemic Stroke (no tPA):

• Do NOT treat unless BP >220/120
• Elevated BP is a compensatory mechanism (maintains perfusion to ischemic penumbra)
• If treating, reduce by only 15% in first 24 hours

Ischemic Stroke (pre-tPA):

• Must bring BP to <185/110 before giving tPA
• Use IV labetalol or nicardipine

Ischemic Stroke (post-tPA):

• Maintain BP <180/105 for 24 hours
• Strict monitoring every 15 min

Hemorrhagic Stroke (ICH):

• Target SBP <140 mmHg within 1 hour (INTERACT2 trial)
• IV nicardipine preferred

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Quick Memory Aid

High BP + NO organ damage = URGENCY
→ Oral meds, slow reduction over 24-48 hours

High BP + YES organ damage = EMERGENCY  
→ ICU, IV meds, reduce MAP 25% in first hour

The danger in BOTH conditions is going too fast - rapid BP drop causes cerebral, cardiac, and renal hypoperfusion, which can be just as deadly as the high BP itself.