Resuscitation After A Stroke: What You Need To Know

A stroke is a life-threatening medical condition that requires immediate attention. In the event of a stroke, timely medical intervention is crucial to increase the chances of survival and reduce the risk of long-term complications. Cardiopulmonary resuscitation (CPR) is an emergency procedure that can be performed on stroke patients to restore blood flow and breathing. However, in some cases, individuals may choose to have a Do-Not-Resuscitate (DNR) order in place, which instructs medical providers not to perform CPR if their heart stops beating or they stop breathing.

The decision to have a DNR order is a complex and personal one, often made by those with terminal illnesses or a poor prognosis, who wish to avoid the potential side effects of resuscitation, such as broken ribs, punctured lungs, or brain damage. While a DNR order allows individuals to choose whether or not they want CPR, it is important to note that it does not include instructions for other treatments such as pain management or nutrition.

Studies have shown that stroke patients with DNR orders are treated differently and are significantly more likely to die within the first 30 days after their stroke compared to those without such orders. This disparity in treatment and outcomes raises ethical concerns and underscores the importance of informed decision-making regarding DNR orders.

CPR (cardiopulmonary resuscitation)

Cardiopulmonary resuscitation (CPR) is a potentially life-saving technique that can be performed on people whose breathing and heartbeat have stopped. CPR is recommended for people who have had a stroke and are not breathing while waiting for emergency services to arrive.

If you are untrained in CPR, the American Heart Association (AHA) recommends initiating hands-only CPR on teenagers and adults. This involves pushing hard and fast in the centre of the chest. If you have received training and have a mouthguard, you can deliver high-quality chest compressions and rescue breaths at a rate of 2 breaths to 30 compressions. If you do not have a mouthguard, you should only perform chest compressions.

If an automated external defibrillator (AED) device is available, it can be used to check the heart rhythm and deliver an electric shock to the chest if necessary.

It is important to note that CPR should not be performed on someone with a "do-not-resuscitate" (DNR) order. A DNR is a medical order written by a healthcare provider that instructs others not to perform CPR if a patient's breathing or heart stops. It is created after discussing it with the patient, the health care proxy, or the patient's family.

DNR (do-not-resuscitate) orders

A do-not-resuscitate (DNR) order is a legal document that means a person has decided not to have cardiopulmonary resuscitation (CPR) attempted on them if their heart or breathing stops. People who choose to have a DNR usually have a terminal illness or other serious medical condition. In most cases, a DNR order is written by a healthcare provider after discussing the benefits and risks of CPR with the patient, their loved ones, or their legal decision-maker.

A DNR order is ideally created before an emergency occurs and allows individuals to choose whether or not they want CPR in an emergency. It is specific to CPR and does not include instructions for other treatments such as pain medication, other medicines, or nutrition. It is important to distinguish that a DNR order does not mean all treatments are discontinued, and standard care is still provided.

To create a DNR order, individuals should discuss their wishes with their healthcare provider and family. The healthcare provider will then fill out the form and include it in the patient's medical record. It is also recommended to include DNR wishes in an advance care directive (living will) and inform the healthcare proxy (healthcare agent) and family of the decision.

It is important to note that DNR orders can be changed at any time. Individuals always have the right to change their mind and request CPR during a medical emergency. In such cases, it is crucial to inform the healthcare provider, destroy any DNR forms, and notify loved ones and caregivers about the decision.

While DNR orders provide individuals with a sense of control over their medical care, it is essential to carefully consider the pros and cons of CPR and make informed decisions. Discussing end-of-life care and advance care planning can be challenging, but it is necessary to ensure patient autonomy and implement care preferences, especially when patients are incapacitated.

Survival rates

The survival rates of stroke patients vary according to several factors, including age, type of stroke, time to treatment, and overall health.

A 2022 study of 313,162 people in Australia and New Zealand found that the risk of death increases with each subsequent stroke. The study also found that those who had a hemorrhagic stroke, caused by blood leaking from an artery in the brain, were more likely to die than those who had an ischemic stroke, caused by blood clots or other particles blocking a blood vessel.

A 2019 German study found that about one in 11 people die within 90 days of an initial stroke, and about one in six die within a year. A 2019 Dutch study found that adults under 50 had a 5.5-fold increased risk of death within 15 years of a stroke.

A 2019 Swedish study found that 49.4% of people who had an ischemic stroke survived for at least five years, while the five-year survival rate for those who had an intracerebral hemorrhage was 37.8%.

A 2022 study including more than 300,000 people in Australia and New Zealand found that having any type of stroke reduced life expectancy by 5.5 years on average. Those who had a hemorrhagic stroke lost 7.4 years of life expectancy on average.

The CDC reports that people who get to the hospital within three hours of the first stroke symptoms often experience less disability after three months than those who receive delayed medical attention.

A Danish study of 5,262 stroke patients found that those who survived a stroke were five times more likely to die between four weeks and one year of the stroke, and twice as likely to die after more than a year.

A Canadian study of stroke survivors aged 61 or older found that 38% of patients were at least 80 years old, and this group had the highest mortality rates during their hospital stays, at 24.2%.

A study of 91,000 stroke survivors in the United States found that almost two-thirds of patients would either need to be readmitted within a year or would die after discharge. However, higher-performing hospitals had lower mortality rates than lower-performing hospitals (9.8% vs. 17.8%).

A Moscow study of 1,538 stroke patients over seven years found that within three weeks of a stroke, 37.3% of patients had died. Over the next seven years, 76.5% of survivors died. The study also found that those who had multiple strokes had a higher mortality rate than those with other health issues.

Brain damage

A stroke is a medical emergency that occurs when the flow of oxygen-rich blood to the brain is blocked or there is sudden bleeding in the brain. Brain cells start to die within minutes of oxygen deprivation, resulting in brain damage.

There are two primary types of strokes: ischemic and haemorrhagic. Ischemic strokes are the more common type and occur when an artery supplying oxygen-rich blood to the brain becomes blocked, often due to blood clots. Hemorrhagic strokes happen when an artery in the brain leaks blood or ruptures, causing damage to brain cells due to the pressure of leaked blood.

Strokes can also be classified as transient ischemic attacks (TIAs) or "mini strokes". During a TIA, the blockage in the vessel is temporary, and symptoms may subside within a few hours. However, a TIA indicates an underlying issue that may lead to a full stroke if not treated.

The occurrence of a stroke can usually be identified by the onset of the following symptoms:

• Drooping of facial muscles, making it difficult to smile.
• Inability to fully lift the arms.
• Difficulty in speaking, with slurred speech.
• Sudden headache, confusion, dizziness, problems with communication or vision.

If you suspect someone is having a stroke, it is crucial to call for emergency medical assistance immediately. Prompt treatment can reduce brain damage, lower the chances of long-term disabilities, and prevent another stroke.

Following a stroke, patients often require rehabilitation to address physical and cognitive deficits. The severity and duration of the rehabilitation process depend on various factors, including the severity of the stroke, patient motivation, the skill of the treatment professionals, and the support network available.

Stroke units

Research has shown that stroke patients treated in hospitals with specialist stroke staff and services benefit from improved care and outcomes. These units are equipped with the necessary expertise and resources to manage the complex needs of stroke patients, including early stroke treatment options such as thrombolysis and endovascular clot retrieval.

Thrombolysis is a drug treatment that must be administered within the first few hours after a stroke to dissolve the clot causing it. Endovascular clot retrieval is a procedure that uses a small device to grab and remove the blood clot. Both treatments are crucial in improving patient outcomes and must be provided as early as possible.

It is important for patients and their families to be aware of which hospitals offer stroke unit care and early treatment options. The speed of treatment after a stroke is critical, as the faster a patient receives treatment, the more likely they are to save brain tissue and minimise long-term damage.

Frequently asked questions