Prevention of Acute Stroke and Transient Ischemic Attack (TIA) Order Set (Stroke Order Set 4)

Transcription

1 Canadian Best Practice Recommendations for Stroke Care: All patients presenting to an emergency department or outpatient setting (family physician s office, ambulatory clinic, out-patient setting etc) with suspected stroke or transient ischemic attack must have an immediate clinical evaluation and investigations to establish the diagnosis, rule out stroke mimics, determine eligibility for thrombolytic therapy, and develop a plan for further management. Date of Stroke Prevention Assessment and Management Visit: Precautions Contact - Droplet- Airborne - Other: Stroke Symptom History Obtain and record stroke symptom history Most recent stroke event: Date of Onset/Last Seen as Normal Time: Determine type of stroke event and record: Acute Ischemic Stroke Subarachnoid hemorrhage Transient Ischemic Attack Intracerebral Hemorrhage Venous Sinus Thrombosis Other Signs and Symptoms (Describe): Stroke Severity and Focal Deficits Baseline assessment with standardized stroke scale National Institute of Health Stroke Scale (NIHSS) Baseline Score: or Canadian Neurologic Scale (CNS) Baseline Score: or Neurovital signs Diagnostic Testing Neuroimaging CT Head Non Contrast (per Stroke Protocol Urgency: STAT Within 24 hours Within week(s); *Date of scan: (dd/mm/yy) Time of scan start (hh:min) or Diffusion Weighted MRI (per Stroke Protocol) Urgency: STAT Within 24 hours Within week(s * Date of scan: (dd/mm/yy) Time of scan start (hh:min) (dd/mm/yy) (dd/mm/yy) *If scan booked for a future date, indicate the booked appointment time. SIGNATURE V1 Page 1 of 6

2 Diagnostic Cardiac 12-lead ECG Record presence of Atrial Fibrillation or Flutter Yes No Holter Monitor Transthoracic Echocardiogram Transesophageal Echocardiogram Include Bubble Study Cardiac CT (per Stroke Protocol) Carotid Imaging Cardiac MRI (per Stroke Protocol) Carotid ultrasound Dopplers Urgency: STAT Within 24 hours CT Angiogram Urgency: STAT Within 24 hours MR Angiogram Urgency: STAT Within 24 hours Date of Carotid Imaging: (dd/mm/yy) Time of scan start (hh:min) CXR PA + Lateral Other: Consults Consults to Physicians EEG Stroke Prevention Clinic Appointment booked: (Date) Stroke Neurologist/Stroke Specialist Appointment booked: (Date) Neurosurgeon Appointment booked: (Date) Vascular Surgeon Appointment booked: (Date) Other: Appointment booked: (Date) Consults to Interdisciplinary Stroke Team Members/External Services Dietitian Pharmacist Psychologist Home Care Services Physical Therapist Speech Language Pathologist Occupational Therapist Physiatrist Social Worker Palliative Care Specialist/Team Psychiatrist Other: Vital Signs and Assessment Baseline temperature, heart rate, blood pressure, respiratory rate Actual Weight kg or Estimated Weight kg Height: cm Body Mass Index. Calculated: kg/metre 2 Waist Circumference cm SpO 2 via pulse oximetry Maintain SpO 2 at % SIGNATURE V1 Page 2 of 6

3 Vital Signs and Assessment Continued Assessments Baseline swallow assessment Date: Record Result: Normal Abnormal If swallow assessment abnormal, initiate referral to speech language pathologist for further assessment Baseline Functional Assessment Alpha-FIM Modified Rankin Score Other Baseline Cognitive Assessment: Assessment Tool (e.g. MOCA): Score: Baseline Depression Screen: Screening Tool (e.g. HAD, PDQ): Score: Baseline Fitness to Drive Assessment (if applicable): Tool: Outcome: Baseline Sleep Apnea screening (if applicable): Tool: Outcome: Lab Investigations CBC PTT INR Capillary Blood Glucose STAT Electrolytes (Na, K, Cl) Creatinine Glucose BUN CK Troponin Ca, Mg ` LDH Hgb A1C Fasting Glucose Fasting Lipid Profile (HDL, LDL, Total Cholesterol, Triglycerides) ALT, ALP, Bilirubin AST TSH If female less than 50 years of age, β HCG or urine pregnancy test ABG Coagulopathy screens: Anticardiolipin (Antiphospholipid) Antibody Lupus Anticoagulant Protein S Protein C Prothrombin Gene Mutation Factor V Leiden Mutation/APC resistance PNH screen Fasting serum homocysteine Antithrombin III ESR C-Reactive Protein (CRP) Antinuclear antibody (ANA) Syphilis Screen Sickle Cell Screen Blood C + S x 3 (endocarditis cultures) Urine C + S Urine R + M Additional Lab tests: Test: Test: Test: SIGNATURE V1 Page 3 of 6

4 Antiplatelet Agents NA No anticoagulants, No antithrombotics until CT or MRI completed and hemorrhage ruled out Acute ASA loading Dose: order at least 160 mg of acetylsalicylic acid (ASA) immediately as a one time loading dose after brain imaging has excluded intracranial hemorrhage acetylsalicylic acid : mg PO enteric coated acetylsalicylic acid (ECASA) one-time loading dose THEN enteric coated acetylsalicylic acid (ECASA) clopidogrel 300 mg PO loading dose THEN clopidogrel 75 mg PO daily mg PO daily ( mg) mg PO ( mg), Extended-release dipyridamole 200 mg/acetylsalicylic acid 25 mg (Aggrenox) 1 capsule PO BID (MD may consider ordering a loading dose of acetylsalicylic acid mg first) Other antithrombotic: (Medication, dose, route, frequency) Note: Canadian Best Practice Recommendations for Stroke Care Recommendation: Short-term concurrent use of acetylsalicylic acid and clopidogrel (up to 90 days) has not shown an increased risk of bleeding; however, longer-term use is not recommended for secondary stroke prevention, unless there is an alternate indication (e.g., drug-eluting carotid artery stent requiring dual antiplatelet therapy), due to an increased risk of bruising and bleeding. Anticoagulant Agents for Patients with Atrial Fibrillation or Other Indication Indication for anticoagulants: No anticoagulants until CT or MRI completed and hemorrhage ruled out Assess baseline creatinine clearance prior to anticoagulant administration, then annually In patients with atrial fibrillation, begin anticoagulation for secondary stroke prevention. apixaban dabigatran rivaroxaban mg PO BID (when available for use in Canada) mg PO BID mg PO daily warfarin loading dose of mg PO daily for days THEN warfarin mg PO daily for days THEN, when therapeutic range achieved, start warfarin maintenance dose: Measure INR on mg PO daily NA days (list days and frequency of INR monitoring) Therapeutic goal on warfarin is an INR between 2.0 and 3.0 (aim for an INR of 2.5) more than 70% of the time, or other therapeutic range goal: Concomitant antiplatelet therapy with oral anticoagulation is not recommended in patients with atrial fibrillation unless there is a specific medical indication such as a coronary stent SIGNATURE V1 Page 4 of 6

5 Blood Pressure Management Recommend following the Canadian Hypertension Education program (CHEP) hypertension management protocols Glycemic Management for Patients with Diabetics Recommend following the Canadian Diabetes Association diabetes management protocols Lipid Management Recommend following the Canadian Cardiovascular Society Dyslipidemia management protocols Nausea Management dimenhydrinate mg PO/NG/IV/PR q4h PRN (use lowest possible for effect for elderly/frail) dimenhydrinate mg PO/NG/IV/PR/IM q4h PRN (use lowest possible for effect for elderly/frail) Pain Management acetaminophen Smoking Cessation mg PO/NG/PR q4h PRN for pain Dose/Route/Frequency: Determine smoking status, and if smoker determine readiness to attempt to quit Referral to Smoking Cessation Program/Specialist: (Name) Appointment Booked: Smoking Cessation Medication* Smoking Cessation Medication* (Date, Time) * Canadian Best Practice Recommendations for Stroke Care : The three classes of pharmacological agents that should be considered as first-line therapy for smoking cessation are nicotine replacement therapy, bupropion, and varenicline (Smoking Cessation recommendation 2.9, Update 2012) SIGNATURE V1 Page 5 of 6

6 Other Medications Discharge/Transition Plan Reason, Reason, Reason, Reason, Provide patient and family education and skills training as required regarding: Stroke signs and symptoms and appropriate actions to take Contact numbers for EMS, neurologist, stroke team, other healthcare professionals Risk Factor modification assist with development/update of an individualized plan Activity levels, activities of daily living Safety and avoidance of falls and injury Rehabilitation Driving Sexual Activity Community Support Group resources Other Provide patient and family with written summary of prevention plan at end of ambulatory care visit (ED, prevention clinic, family physician s office, other community setting) Disposition Admit patient to Emergency Department Facility: Admit patient to Inpatient Facility Facility: Or Refer patient to Stroke Prevention Clinic or Service SPC: Appointment Date: Appointment Time: Refer patient to Home Care services Refer patient to outpatient or community-based rehabilitation for assessment and treatment Facility: Appointment Date: Appointment Time: Follow-up with Family Physician (Name) Send consult letter to Family Physician within 72 hours Other Follow-up Appointments: Name: Specialty: SIGNATURE V1 Page 6 of 6