ACCESS CENTER:

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1 ACCESS CENTER: Emergency Specialty Services: BRAIN ATTACK Criteria: Stroke symptom onset time less than 6 hours Referring Emergency Department Patient Information Data: Time last known normal: Means of transport to the ED: self/family Ambulance Call to Medical Access Center time: Transfer team arrival time: ED arrival time: Time to head CT: Time to head CT read (if known) time: Mode of Transfer: Out the door time: Time RN Initiation of Brain Attack Order Set: 1. Begin minimum of 2 IVs- One preferably 18 gauge right antecubital 2. Oxygen PRN to maintain O2 sat > 93% 3. Stat Labs drawn and results checked PT, INR, platelets, chem. panel, cardiac enzymes 4. Noncontrast head CT negative for hemorrhage and signs of ischemia 5. NIHSS assessment completed 6. EKG if time allows or if condition warrants 7. Contact Access Center to page neurologist and activate life flight for Brain Attack. 8. Review thrombolytic inclusion/exclusion checklist 9. For patients receiving thrombolytics, maintain SBP < 185, DBP < 105. Give labetalol 10 mg IV over 1-2 minutes. May repeat every 10 minutes, to total dose of 150 mg. Use with caution in patients with bradycardia. 10. If patient is a candidate, administer alteplase: 0.9 mg/kg IV with 10% as a bolus and then the rest over 60 minutes to maximum dose of 90 mg 11. Door to drug goal of 60 minutes. 12. Chest X-ray- if time allows or if condition warrants 13. Diet- NPO Nurse Signature: Physician Signature: Date/Time: Date/Time: 1/24/2012

2 Yes No ABSOLUTE EXCLUSION CRITERIA Emergency Specialist Program: Stroke Thrombolytic Checklist ACCESS CENTER: Hemorrhagic stroke, mass effect or edema on baseline CT, or history of intracranial hemorrhage Suspicion of subarachnoid hemorrhage Intracranial neoplasm, arteriovenous malformation or aneurysm Known bleeding disorder or associated condition with high risk of bleeding. GI or GU bleeding within the past 21 days. Previous cerebral infarction or head trauma within past three months Recent acute myocardial infarction within one month. Sustained or uncontrolled hypertension (Systolic greater than 185 or Diastolic greater than 110 after attempt to treat HTN) Major surgery within 14 days prior Platelet count below 100,000 INR greater than 1.7 Blood glucose below 50 mg/dl or above 400 mg/dl Patient received warfarin (Coumadin ), heparin, or lovenox within 48 hours preceding onset of symptoms and PTT not in normal range Seizure at onset of stroke symptoms or pretreatment Rapidly improving neurologic deficit Sensory loss, ataxia, dysarthria alone or minimal weakness Severe neurological deficits at discretion of neurologist Arterial puncture at non-compressible site within previous 7 days Severe complicated condition, such as AIDS or cancer, that would confound treatment Preexisting neurologic, psychiatric or other illness that would confound treatment If female, patient has positive blood or urine pregnancy test on record Age < 18 years of age Yes No CAUTIONS/WARNINGS Yes No EXPANDED TREATMENT (3-4.5 HRS) CRITERIA Age greater than 80 years All of the above EXCEPT ABSOLUTE CONTRAINDICATIONS: Pericarditis or subacute bacterial Age > 80 years endocarditis Significant liver or kidney dysfunction Taking oral anticoagulants regardless of INR Diabetic hemorrhagic retinopathy NIHSS > 25 Occluded arteriovenous cannula at seriously infected site Combination of previous stroke and diabetes mellitus Lumbar puncture within 7 days Serious trauma in the previous 14 days 1 of 2 11/17/09

3 Emergency Specialist Program: Stroke Thrombolytic Checklist page 2 REASONS FOR NON-TREATMENT WITH THROMBOLYTICS Time Uncontrolled Hypertension Rapid Improvement Patient/Family Refused No IV access Age CT finding Platelet count (less than 100,000) Stroke severity Seizure at onset Recent Surgery/Trauma (previous 14 days) Recent IC surgery (3 mo.) Head trauma/stroke Abnormal aptt, PT/INR Blood Glucose less than 50 or greater than 400 Active internal bleeding (previous 21 days) Other: Additional considerations may apply, and these are guidelines to be used at the discretion of the attending physician. Completed by Date / Time Completed by Date / Time Completed by Date / Time Completed by Date / Time 2 of 2 11/17/09

4 Modified National Institute of Health Stroke (NIHSS) Assessment Tool 1b. ORIENTATION: NAME & AGE 1c. TWO STEP SIMPLE COMMAND: (LOC) ASK TO CLOSE EYES / OPEN EYES, MAKE A FIST / LET GO 2. HORIZONTAL GAZE: MOVE FINGER LT. TO RT. ACROSS MIDLINE OR FOLLOW FINGER OR FACE Cranial Nerve VI (Abducens) 3. VISUAL FIELD: Cranial Nerve III, IV, V INTRODUCE VISUAL FIELD STIMILUS - IF PATIENT LOOKS AT FINGER MOVING, SCORE A 0 FOR NORMAL 5. MOTOR FUNCTION ARM: (ANY DROP IS A DRIFT) BEGIN WITH NONPARETIC LIMB 90 O - SITTING, 45 O - LYING (HOLDS FOR 10 SECONDS ) 6. MOTOR FUNCTION LEG: (ANY WAVERING IS A DRIFT) PATIENT IN SUPINE POSITION HOLDS FOR 5 SECONDS 8. SENSATION: (PIN) - FACE, ARMS, LEGS, AND TRUNK EYES CLOSED, COMPARE SIDE TO SIDE FEELS THE SAME OR EQUAL 9. BEST LANGUAGE AND COMPREHENSION: ABILITY TO EXPRESS NAME ITEMS DESCRIBE A PICTURE READ SENTENCE 11. NEGLECT INFORMATION OBTAINED FROM PRIOR TESTING (If blind with tactile stimuli intact, score 0) DESCRIPTION 0= ANSWERS BOTH QUESTIONS CORRECTLY 1= ANSWERS ONE QUESTION CORRECTLY / UNABLE TO COMPREHEND 2= ANSWERS NEITHER QUESTION CORRECTLY 0= PERFORMS BOTH CORRECTLY (CREDIT GIVEN EVEN IF ATTEMPTED) 1= PERFORMS ONE CORRECTLY 2= PERFORMS NEITHER CORRECTLY 0= NORMAL 1= UNABLE TO CROSS MIDLINE IN ONE OR BOTH EYES 2= FIXED GAZE (Toward involved hemisphere) NOT OVERCOME BY DOLLS EYE MANEUVER 0= NO VISUAL FIELD LOSS 1= (LOSS IN ¼ FIELD) 2= (½ FIELD LOSS) 3= BLIND 0= NO DRIFT HOLDS FOR 10 SECONDS 1= FALLS BEFORE 10 SECONDS, DOES NOT TOUCH BED 2= FALLS TO BED BEFORE 10 SECONDS 3= SOME EFFORT 4= NO MOVEMENT 0= NO DRIFT, HOLDS FOR FULL 5 SECONDS 1= DRIFTS BEFORE 5 SECONDS, DOES NOT TOUCH BED 2= FALLS TO BED BEFORE 5 SECONDS 3= SOME EFFORT 4= NO MOVEMENT 0= NO SENSORY LOSS OR WITHDRAWS TO PAINFUL STIMULI 1= AWARE OF BEING TOUCHED, LESS SHARP OR DULL ON AFFECTED SIDE 2= NOT AWARE OF BEING TOUCHED IN FACE, ARM AND LEG (coma or bilateral sensory loss is scored #2) 0= NO APHASIA 1= REDUCED SPEECH & /OR COMPREHENSION - GETS GENERAL IDEA 2= FRAGMENTED EXPRESSION, ONE WORD ANSWERS (score #2 if missed 2-3 items and sentences) 3= NO USABLE SPEECH OR AUDITORY COMPREHENSION OR UNABLE TO FOLLOW TWO STEP COMMANDS (may write object name) 0= ATTENDS TO PERSONAL, VISUAL, TACTILE, AUDITORY & SPATIAL 1= INATTENTION OF ONE MODALITY 2= HEMI-INATTENTION IN MORE THAN ONE MODALITY SCORE LEFT RIGHT LEFT RIGHT COMPLETED BY: DATE: CIRCLE ONE: ADMISSION POST TPA DISCHARGE

5 t-pa Information sheet t-pa (tissue plasminogen activator) is a medication approved by the FDA for use in the treatment of Acute Ischemic Stroke. The medication is utilized only after specific criteria are met and a head CT is completed to rule out hemorrhagic stroke. The medication can be used up to 3 hours after the onset of symptoms or the last time the patient was "known normal." The thrombolytic drug alteplace (rt-pa) has been licensed for use within 3 hours of ischemic stroke in the USA, Canada, and most European countries. t-pa is a thrombolytic. It works as a "clot buster", dissolving blood clots that can plug arteries in the brain which cause stroke. Successful treatment could mean the patient is more likely to make a good recovery from their stroke. Thrombolytic drugs, however, can also cause serious bleeding in the brain which can be fatal. Please understand that the severity and location of your stroke along with time to treatment can affect your outcome after thrombolytics. Data from one well accepted study, in which all patients were treated in less than 3 hours, 1 out 9 received benefit and 1 out of 16 had a serious bleeding complication. Thrombolytic therapy has now been evaluated in several randomized trials in acute ischemic stroke. At Saint Alphonsus Regional Medical Center, alteplace is used only when strict inclusion and exclusion criteria are met by the patient. Family members and/or the patient have the right to refuse treatment with alteplace (rt-pa). Other alternative treatments related to the patient's medical condition may also be available and will be presented along with their risks and benefits by your physician. Please feel free to ask any questions related to the treatment of stroke. Educational resources dealing with stroke prevention and recognition of signs and symptoms are also available for patients and family members. Signature: Date: Orig: 10/08 N-643