MANAGED CLINICAL NETWORK FOR STROKE Management of Acute Stroke Presenting Within 3 Hours of Onset of Symptoms

Transcription

1 / MANAGED CLINICAL NETWORK FOR STROKE Management of Acute Stroke Presenting Within Hours of Onset of Symptoms (For further information, contact Stroke START Page) For Clinical Advice, contact: Dr Ron MacWalter bleep Dr Alex Doney bleep 9 Consider Stroke at time of FIRST referral Given the time of onset of symptoms, and the location of the patient, could the patient have a head scan performed within hours? If YES, then seconds count, and there should be no delay. Collect all possible data on exclusion criteria (see page ) from referring source. DO NOT WAIT until YOU see the patient or until they have had a scan ROSIER Score (From history or examination) Loss of consciousness Yes - No Seizure Activity Yes - No Speech disturbance Yes + No Unilateral face weakness Yes + No Unilateral arm weakness Yes + No Unilateral leg weakness Yes + No Visual field deficit Yes + No TOTAL Total Score <: Stroke/TIA unlikely, Consider other diagnosis Date First Name Family Name CHI Address: / / (Patient label if available) Time Time of symptom onset Maximum time for commencing thrombolysis (Onset + hours) Referral source: GP ED Ward Other : : : SECONDS COUNT SECONDS COUNT SECONDS COUNT Total Score >/= : Stroke/TIA likely Resolving/Resolved Symptoms/Signs Assess need for urgent investigation as per TIA/Stroke protocol Persisting Symptoms/Signs: CONSIDER THROMBOLYSIS IF < HOURS Complete the Exclusion Criteria for Thrombolysis on Pages -. If NO absolute exclusion criteria, request immediate brain scan, inform radiologist of time-frame Inform on-call consultant (or in Ninewells, Alex Doney or Ron MacWalter 9- Mon-Fri) Take URGENT bloods for glucose (BM), FBC plus clotting / admission bloods as indicated. Ensure thrombolysis kit (Alteplase x mg vials, infusion pump, syringes and lines) available. (Available in Acute Stroke Unit Ward Ninewells) Clerk the patient using the brief form on page. Arrange appropriate high-dependency bed for transfer post-scan... HEAD SCAN RESULT Time Report: : Radiologist name... High density lesion consistent with intracranial haemorrhage.. Hypodenisty in >/ M.C.A territory or equivalent Effacement of C.S.F spaces in >/ M.C.A territory or equivalent.. Scan Contraindications to thrombolysis present? Yes No Signature No contra-indications clinically or radiologically (see page again) & still within hours Verbal consent for thrombolysis from patient.. (if not possible,may use adults with incapacity act, but discuss with duty consultant) Calculate IV bolus and infusion doses of Alteplase from chart on page... (based on actual or estimated weight) Ensure Consultant on call (or Dr Doney/MacWalter) aware of plan to proceed to thrombolysis. IV Alteplase Prescription: Signed Prepared by Given by Time commenced Alteplase bolus dose mg / Alteplase infusion mg over hour / Bolus should be administered by hand over minutes. Infusion rate is same as dose in mg, in mls/hour Transfer to high-dependency area and monitor for close neuro. and general observation.. Pg

2 CONTRA-INDICATIONS TO THROMBOLYSIS. Where cut-offs are given, clinical judgement should be exercised if a patient falls close to the cut-off. Please ensure that this list is considered at the time of first assessment, even if this assessment is by phone. ABSOLUTE CONTRA-INDICATIONS: Present Absent Symptoms beginning more than hours prior to infusion start or when time of symptom onset is unknown Known history of, or suspected intracranial haemorrhage.. Symptoms suggestive of subarachnoid haemorrhage, even if CT-scan is normal Evidence of intracranial haemorrhage (ICH) on the CT-scan Manifest or recent severe or dangerous bleeding.. Known haemorrhagic diathesis Systolic blood pressure> or diastolic BP> mm Hg, or aggressive management (IV medication) necessary to reduce BP to these limits Relative Contra-indications: Patients receiving oral anticoagulants, e.g. warfarin sodium (unless INR <.).. Administration of IV heparin within the previous hours AND an APTT exceeding the upper limit of normal.. Treatment-dose LMWH. Any history of central nervous system damage (i.e. neoplasm, aneurysm, intracranial or spinal surgery).. Recent (less than days) traumatic external heart massage, obstetric delivery Recent (less than days) puncture of a non-compressible blood-vessel (e.g. subclavian vein).. Bacterial endocarditis, pericarditis Acute pancreatitis Documented ulcerative gastrointestinal disease during the last months, oesophageal varices, arterial-aneurysm, arterial/venous malformations Neoplasm with increased bleeding risk Severe liver disease, including hepatic failure, cirrhosis, portal hypertension (oesophageal varices) and active hepatitis.. Major surgery or significant trauma in past months... Minor neurological deficit (NIHSS see page ) or symptoms rapidly improving before start of infusion. Severe stroke as assessed clinically (e.g. NIHS> see page ) and/or by appropriate imaging techniques. Pre-presentation Rankin Score, (see below) indicating significant disability, especially if due to previous stroke... Seizure at onset of stroke. Patients with any history of prior stroke and concomitant diabetes... Prior stroke within the last months Platelet count of below,/mm. Uncorrected blood glucose <. or > mmol/l. Further advice regarding contra-indications is available by contacting Dr Doney or Dr MacWalter or Stroke Registrar (or another Stroke Unit) Modified Rankin Scale (note: this is a stroke outcome scale, and should be interpreted with caution for causes of disability other than previous stroke) Score Description No symptoms at all No significant disability despite symptoms; able to carry out all usual duties and activities Slight disability; unable to carry out all previous activities, but able to look after own affairs without assistance Moderate disability; requiring some help, but able to walk without assistance Moderately severe disability; unable to walk without assistance and unable to attend to own bodily needs without assistance Severe disability; bedridden, incontinent and requiring constant nursing care and attention Dead Pg

3 a Level of Consciousness (LOC) b LOC Questions c LOC Commands. Best Gaze.Visual Fields. Facial Palsy. Best Motor RIGHT ARM. Best Motor LEFT ARM. Best Motor RIGHT LEG. Best Motor LEFT LEG 9. Limb Ataxia. Sensory. Best Language. Dysarthria. Neglect Total Score: National Institutes of Health Stroke Scale (NIHSS) Alert- keenly responsive Drowsy- rousable by minor stimulation to obey, answer, or respond Stuporous- requires repeated stimulation to attend, or is obtunded and requires strong or painful stimulation to make movements (not stereotyped) Comatose- responds only with reflex motor or autonomic effects or totally unresponsive, flaccid Answers both correctly Answers one correctly Both incorrect Patient is asked to state the month & his / her age Obeys both correctly Obeys one correctly Both incorrect Patient is asked to open & close eyes, grip & release normal hand Normal Partial gaze palsy- gaze is abnormal in one or both eyes, no forced deviation/total gaze paresis Forced deviation- or total gaze paresis not overcome by oculocephalic maneouvre No visual loss(or in a coma) partial hemianopia complete hemianopia bilateral hemianopia-including cortical blindness Normal Minor- flattened nasolabial fold, asymmetry on smiling Partial- total or near total paralysis of lower face Complete- absent facial movement in upper and lower face and lower face on one or both sides No drift- holds limb at 9 degrees for full seconds Drift- drifts down but does not hit bed Some effort against gravity No effort against gravity No movement No drift- holds limb at 9 degrees for full seconds Drift- drifts down but does not hit bed Some effort against gravity No effort against gravity No movement No drift- holds arm at degrees for full seconds Drift- drifts down but does not hit bed Some effort against gravity No effort against gravity No movement No drift- holds arm at degrees for full seconds Drift- drifts down but does not hit bed Some effort against gravity No effort against gravity No movement Absent(or in coma) Present in limb Present in or more limbs Normal Partial loss- patient feels pinprick is less sharp or is dull on affected side Dense loss(or in coma)- patient is unaware of being touched on face, arm, leg No dysphasia Mild- moderate dysphasia obvious loss of fluency or comprehension, without significant limitation on ideas expressed or form of expression. Makes conversation about provided material difficult or impossible, e.g. examiner can identify picture or naming card from patient s response. Severe dysphasia- all communication is through fragmentary expression; great need for inference, questioning, and guessing by the listener who carries burden of communication. Examiner cannot identify materials provided from patient response Mute- no usable speech or auditory comprehension, or in coma. Normal articulation Mild- moderate dysarthria- patient slurs some words can be understood with some difficulty. Unintelligible or worse- speech is so slurred as to be unintelligible (absence of or out of proportion to dyshasia) or is mute / anarthic, or in coma No neglect(or in a coma) Partial neglect- visual, tactile, auditory, spatial, or personal inattention or extinction to bilateral simultaneous stimulation in one of the sensory modalities Complete neglect- profound hemi-inattention or hemi-inattention to more than one modality. Does not recognise own hand or orients to only one side of space Pg

4 Pre-thrombolysis BRIEF clerking (full clerking to be completed once thrombolysis commenced or ruled out) Name of Assessor: History of Presenting Complaint: Relevant Past History Examination: General Blood Pressure: CNS Tone Power Sensation Notes: R Reflexes LUL RUL LLL RLL L Time of Assessment: Cranial Nerves: Relevant Drug History (especially warfarin) Allergies GCS: E / V / M / Total / SECONDS COUNT SECONDS COUNT SECONDS COUNT Signed.. Pg

5 Body Weight/ Dose Chart for Alteplase (Actilyse) mg/ml Body Weight (Kg) Approx. Body Weight (Imperial) Total rtpa dose (mg) IV Bolus % of total dose (ml) IV Infusion 9% of total dose (ml/hr) No. of mg rtpa vials required Dose Selected (Tick) st st st st st 9 st st st 9 st 9st 9st 9 9st st st 9 st9 st st 9 st9 st st st st st st 9 st 9 9 st 9 st 9 st 9 st 9 9 st 9 st 9 9 > kg, use 9 mg maximum PATIENTS MUST BE CONTINUOSLY MONITORED PRIOR TO AND DURING DRUG ADMINISTRATION and for at least hrs following administration.. Total dose:.9mgs/kg, based on actual or estimated body weight. Maximum dose is 9mgs.. Must be prescribed on front sheet of protocol, following discussion with responsible Consultant. Reconstitute mg Alteplase vial(s) with mls of Water For Injection via the transfer spike to give a solution with concentration mg/ml.. Initial % of total dose given as an IV manual push over mins administered with an experienced doctor present.. Commence pump immediately after initial bolus. Give remaining 9% of dose IV over mins via an infusion pump (If infusion dose is >ml, second syringe required) Pg

6 STROKE THROMBOLYSIS NURSING CARE PLAN DATE NEEDS/ POTENTIAL PROBLEM GOAL CARE REQUIRED DATE OF REVIEW NURSES SIGNATURE.. has had a stroke and has verbally consented for thrombolysis treatment Drug administered according to protocol and prescription -Cardiac monitoring to be commenced to monitor for early warning signs of cardiac complications -Continuous monitoring of Temperature, Pulse, Blood Pressure, Oxygen Saturation and Neuro obs require to be monitored before the administration of treatment, during and for hrs after treatment. ( Notify medics if systolic BP> mmhg or <ommhg, or diastolic > or < for readings - mins apart) Potential risk of haemorrhage due to the treatment Early detection and treatment of any adverse reactions and side effects -Report any clinically significant changes in neuro or vital signs -Report any signs of bleeding immediately -Follow algorithm for Intracranial Haemorrhage if suspected -Bed rest for hrs following the procedure -Avoid central venous access, arterial puncture and injections for the first hrs -Avoid naso-gastric tube insertion for hrs -Do NOT give drug prescriptions for anti-coagulants, anti-platelets and non steroidal anti-inflammatories for hrs -Avoid the insertion of urinary catheters for minutes prior to the procedure and for hrs after Promote cerebral perfusion and reduce intracranial pressure To minimise complications / maintain levels of cerebral perfusion -Bed rest for hrs following the procedure -Position with head up to an angle of degrees -Maintain oxygen saturation level at >9% May develop headache post treatment To minimise post stroke pain -Position to at degree angle to promote cerebral perfusion -Give analgesia to relieve symptoms (no NSAID) Unable to maintain adequate fluid intake To maintain hydration levels -Determine with medical staff IV fluid regime -Monitor and maintain fluid input and output Notes (Medical/Nursing) Date & Time Pg

7 Information to give to patients / relatives before administration of Alteplase If the criteria above are met then Alteplase is a licensed treatment for acute ischaemic stroke and so written consent is not required. If possible there should be agreement from the patient and / or relative. When the patient cannot agree because of their impairments and no relative is available, then treatment can still be given if it is judged to be in the best interests of the patient. Any explanation should include: There has been a significant stroke cause by a blocked artery preventing blood from getting to a part of the brain and causing permanent damage. With or without treatment there may be some recovery or things could get worse. Stroke is fatal in about a third of people. Only one treatment has been shown to prevent damage to the brain. This treatment, alteplase, dissolves the blood clot blocking the artery and allows blood to get back to the brain. It only proven to work if given within hours of the stroke starting There is a risk that the treatment will cause bleeding in the brain, causing a worsening stroke. This occurs in out of patients treated and is fatal in of these. Despite this, overall the treatment is much more likely to help than to cause harm. Without treatment of people with a stroke, will survive with minimal or no disability with treatment of people with a stroke, will survive with minimal disability Administration of alteplase (Actilyse ). The dosage is.9 mg/kg (maximum dose 9 mg).. % of the dose is given as bolus over minute (use a small syringe and flush). Write drug kardex.. 9% of the dose given as an infusion over hour (start as soon as bolus given). Write drug kardex.. Start the Observation chart.. Do NOT give aspirin, dipyridamole, clopidogrel or heparin. Hand-over to Medical Registrar if required. Medical Review at Hours: Time of review: Pulse: Blood pressure: / Sats: Level of Consciousness (AVPU)? Document any early problems with neurological condition, bleeding, blood pressure or saturations AND action taken. Will require further review and CT (or MRI) scan at hours + Continue documentation on Stroke Pathway Specific issues requiring immediate action Continue observations as per protocol for hours Keep BP less than / for hours Swallow assessment Hydration (in view of ability to swallow) Avoid NG tube for hours TED stockings if continuing hemiparesis Do not give aspirin, dipyridamole, clopidogrel or heparin Specific issues requiring deferred action Start aspirin at hours IF no haemorrhagic change on second CT Pg

8 Notes (Medical/Nursing) Date & Time Pg