Ë 1 æ.» (æ æå Èß Ë 1) ISBN :

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1 π«ß π È ªìπ ËÕß Õ àß ÿ æ Õß â π ÿ æ Ë À æ ß ËÕπ ß À«ßº π â ß â ªí À ÿ æ Õß π Õ à ß ª æ ÿâ à âõ π π µà ßÊ π π«ß π È à à âõ ß Õß ªØ µ ºŸâ â ªØ µ µ µà ß ª âõ π π â π Ë π å µ µà ßÕÕ ªÀ Õ Àµÿº Ë «â«ë ªìπ Ë Õ π ß Ë 1 æ.» (æ æå Èß Ë 1) ISBN :

2 π À Õ Õ Õß ªìπ Ëæ àõ Àπ Ëß Õß ß ª ªìπ Àµÿ µ Ë πõ π µâπê Õߪ» π ÈÀ à â π à«ß «æ µ Õ ªí ÿ π «À à Ë âº â à Ë Õ ßÀ Õ Õ â«à «à ÿà ß µà âõ â π «à «Õ µâõß«π Ë Àâ Ë Õ π 3 Ë«ßÀ ß Õ ßπ Èπ πæ µà ßÊ ßµâÕß µ «æ âõ π â π ÿ Õ π Ë æ ËÕ Àâ Õß «π È âõ à ß ª æ Ëß π π Ȫ» ß à π«ß π À Õ Õ Õßµ Õÿ µ π â«ë Õ ßÀ Õ Õ Ë ªìπ µ π «π πª «π π Ë ªìπ π æ ß â π ß ª âµ Àπ ߪí À ß à «ß â Õ «à«õ π ß«µà ßÊ π«ß À Õ Õ Õßµ Õÿ µ π â«ë Õ ßÀ Õ Õ æ ËÕ ªìπ π«ß π Ÿ À Õ Õ Õßµ Õÿ µ πœ Àâ ª æ À«ß Àâ ª πå à æ å ÿ ºŸâ Ë «âõßõ à ß â ß π Ë π «Ÿâ Ë â ªªØ µ â Ÿ µâõß ªìπ µ π «π Ë«ª» π π ßπ È 1. ª ÿ ß πºÿâ ß ÿ «ÿ ºŸâ Ë «Èß Ë 1 π«π Ë 3 π ª ÿ ß πºÿâ ß ÿ «ÿ ºŸâ Ë «Èß Ë 2 π«π Ë 20 π ª ÿ ß πºÿâ ß ÿ «ÿ ºŸâ Ë «Èß Ë 3 π«π Ë 2 æƒ ª ÿ ß πºÿâ ß ÿ «ÿ ºŸâ Ë «æ ËÕæ π«ß À Õ Õ Õßµ Õÿ µ π â«ë Õ œ Àâ «Ÿ å π«π Ë 16 ÿπ π 2549 æ ËÕ æ æå Èß Ë 1 º æ àµàõ ª Õ à ß Áµ π«ß À Õ Õ Õßµ Õÿ µ π â«ë Õ œ π È ªìπ π π π Ëß Ë «à ªØ µ à π Èπ Èßπ È π ªØ µ ß Èπ ÿ æ π Õß æ åºÿâ Ÿ ºŸâªÉ«π Èπ ªìπ π â π È πª «À«ß ªìπÕ à ß Ëß«à π«ß À Õ Õ Õßµ Õÿ µ π â«ë Õ œ π È ª πå À æ å Ë π ªª ÿ µå â æ ËÕ À⪠π ÿ æ «µ Ë π Õ π È à Õ Õ ÿ ºŸâ Ë «æ» µ å À «µà ß Ê ª «Ààߪ» À Õ Õ Õß Ààߪ» Ë â Àâ «à«õ ªìπÕ à ß π «Èß æ å «ß ÿ Ë π πÿπ π πß π Èßπ ÈÕ à ß Ëß (π π) ºŸâÕ π«πª «

3 π ºŸâ π«ß À Õ Õ Õßµ Õÿ µ π â«ë Õ ßÀ Õ Õ 1. π.æ. ÿ «å µ ÿ«π π å ˪ 2. π.æ. π ª π 3. π.æ. µ«ÿµ Õߪ π 1 4. π.æ. ÿ µ À æ Ÿ å ÿ Õߪ π 2 5. æ..»π å µ πµ ƒ» Ï Õߪ π 3 6.».π.æ.π æπ å æ«ß«π å ß π 7. æ.µ.æ.. µ πõ ÿ«µ å ß π 8. æ.õ.º».π.æ. π π π πå ß π 9.».æ.. µπ ß π 10.».æ..π» ß å ß π 11. π.æ. ß å π ππ å ß π 12. π.æ. π µ ÈßÕ ÿ» ªá ß π 13. π.æ.æ å æ ß π 14. æ..æ æ» ÿ æ ß π 15. π.æ.õ «ÿ ««ÿ ß π 16. π.æ. ÿ» Ï π å ß π 17. π.æ. µµ µ Õ π ÿ ß π 18. π.æ. Õ «π ÿ ß π 19. æ.. «µπå À«ßº æ π» ß π 20. π ß ÿ ÿ Õß» ß π 21. π ß ß» ÿ «ß π 22. æ.. π Õ Îπ«ß»å πÿ 23. π..õ µ ºŸâ à«πÿ ºŸâª πß π : π.æ. µ«ÿµ æ..»π å µ πµ ƒ» Ï

4 π À Õ Õ Õß ªìπ Ëæ àõ Àπ Ëß Õß ß ª ªìπ Àµÿ µ Ë πõ π µâπê Õߪ» π ÈÀ â à π à«ß «æ µ Õ ªí ÿ π «À à Ë âº àπ Ë Õ ßÀ Õ Õ â«à «à ÿà ß µà âõ â π «à «Õ µâõß«π Ë Àâ Ë Õ π 3 Ë«ßÀ ß Õ ßπ Èπ πæ µà ßÊ ßµâÕß µ «æ âõ π â π ÿ Õ π Ë æ ËÕ Àâ Õß «π È âõ à ß ª æ Ëß π π Ȫ» ß à π«ß π À Õ Õ Õßµ Õÿ µ π â«ë Õ ßÀ Õ Õ Ë ªìπ µ π «π πª «π π Ë ªìπ π æ ß Õß ß ª âµ Àπ ߪí À ß à «ß â Õ «à«õ π ß«µà ßÊ π«ß À Õ Õ Õßµ Õÿ µ π â«ë Õ œ æ ËÕ ªìπ π«ß π Ÿ À Õ Õ Õßµ Õÿ µ πœ Àâ ª æ àõ Àâ ª πå πæ µà ßÊ πõ π Ë æ π Àâ Èπ ªìπº Àâ Ÿ ºŸâªÉ«À Õ Õ Õßµ Õÿ µ π 𪻠µ π Ÿß Èπ ߪ πåµàõª π Ë Á ªÉ«Õ à ß â ß ÀâÕ µ µ π È ß ºŸâªÉ«Ë Õ «µ ÿ æ «µ Ë ªìπª Ë ÿ æ ª Õ Õ æ â ß â ª πå Àâ à Õ «ß ª» µ À ºŸâ Ë π π«ß π Ÿ À Õ Õ Õßµ Õÿ µ π â«ë Õ œ ª â µâõß µ Àπ «à π«ßπ È ª Õπ π π À ªØ µ à π Èπ Èßπ È Èπ ÿ æ π Õß æ å ºŸâ Ÿ ºŸâªÉ«π π Õ π π À à π È ªª ÿ µå â Àâ À µà æ Èπ ˵àÕ ª 29 ÿπ π 2549 ºŸâ

5 Àπâ π» æ Õß ßæ Ë π π À Õ Õ Õßµ Õÿ µ π â«ë Õ ßÀ Õ Õ 2 π«ß ºŸâªÉ«À Õ Õ Õßµ Õÿ µ π â«ë Õ ßÀ Õ Õ 3 âõ àß È âõàâ π ºŸâªÉ«À Õ Õ Õßµ Õÿ µ π â«ë Õ ßÀ Õ Õ 5 À Ë Õ ßÀ Õ Õ 6 «âõπ 8 Monitor and care during and after thrombolytic treatment 9 Elevated Blood Pressure Treatment Sheet for Thrombolytic Therapy 10 Õ Õâ ßÕ ß 11 ºπ«1. NIHSS score sheet The Barthel Index, The Modified Rankin Scale µ «Õ à ß Stroke fast track care maps and protocols æ» µ å ÿã ß å À « æ» µ å ßæ À «À æ» µ å» æ À «À πª «æ å «ß ÿ CT scan examples for early signs of cerebral ischemia Stroke Unit 46

6 µ ß Àπâ µ ß Ë 1 Doctorûs orders 9 µ ß Ë 2 Elevated blood pressure treatment for thrombolytic therapy 10 µ ß Ë 3 The Modified National Institutes of Health Stroke Scale 16 µ ß Ë 4 The Barthel Index 18 µ ß Ë 5 The Modified Rankin Scale 19

7 π À Õ Õ Õß (stroke, cerebrovascular disease) ªìπ Ëæ àõ πºÿâ ŸßÕ ÿ Ë«πª» Ëæ π â«æ «à ªìπ Àµÿ µ Ë ªìπÕ π 3 Õß À «Áß À 𪻠π ˪ÿÉ π æ «à ªìπ Àµÿ µ Õ π 2 Õß À «(1) πª» â» Õ µ «ÿ Õß À Õ Õ Õß π ÿ π Õß π«π 1,361 π ÿß æ À π ËÕªï æ.» æ «à Õ µ (2) à 690/100,000 Õߪ ËÕ ÿ π 20 ªï à ÿ πªï æ.» â» «πª ºŸâ ŸßÕ ÿ ( π 60 ªï) π π 4 Ë«ª» 3,036 æ «à Õ µ «ÿ Õß À Õ Õ Õß â ß ª 𪻵à ßÊ Ë«(1) ßπ Èπ À Õ Õ Õß ß ªìπ Ë «Ëß Àπ Ëß Õߪ «π«ß π È Õß å Õπ â Àπ «Õß À Õ Õ Õß «â ßπ È çrapidly developed clinical signs of focal (global) disturbance of cerebral function lasting more than 24 hours or leading to death, with no apparent cause other than a vascular originé (3) «π À Õ Õ Õß ß ß Õ«à «π ß π ªìπ Ëß ºŸâªÉ«À Õ Õ Õßπ Èπ à«π À à Õ ß ª ªìπ æ Ë àπ ÕàÕπ ß Ëß π æÿ π µ Õß à ÀÁπ Õß ÀÁπ æ âõπ «π» ËÕ À à π È ªìπÕ à ß æ π Õ à ß Áµ ºŸâªÉ«ß Õ Õ àõ ªìπ àõ ª π 2-3 «π À Õ Èπ â««ß â(4) â ºŸâªÉ«ªí Ë ß à«π πÿπ «π À Õ Õ Õß Ëß Èπ àπ «π À µ Ÿß À«π Ÿ ÿà Ë À «ªìπµâπ ªí ÿ π«ºÿâªé«à Õ Õ Õß âæ π Õ à ßµàÕ π ËÕß «Ë â Õ πªí ÿ π «Àπ Ëß â à Àâ Ë Õ ßÀ Õ Õ π À Õ Õ Õßµ Õÿ µ π Ëß âõ π π π À ª àπ «π Ë Àâ Ë Õ π 3 Ë«ßÀ ß Õ ªØ µ π πæ Ë «æ âõ ß â π ÿ ÀâÕßªØ µ ÀπૺŸâªÉ«π ªìπµâπ π ß Ààß πª» ß àæ âõ Ë ªî Àâ Ë Õ πºÿâªé«à Õ Õ Õßµ Õÿ µ π π 3 Ë«ß Õ Ÿà 2 â π Õ â πºÿâ Àâ à «æ âõ Õß πæ Ë Àâ Èß π â π π Ë ÿ Ë Ë «âõß â πºÿâ ß «à â Õߪ π Ë ß â«à º «ß à «â ßµâπ ªìπª πå µà ÁµâÕß ª æ π å À⪠π â «à À Õ Õ Õß Õ Õ à ß µâõß æ æ å Á«Ë ÿ à Ë Á«â ß âº «ÈßµâÕߪ æ π å«à Àπà«ß π Àâ «π È â â«âõ ß à «ß Àâ πæ π«π â ÿ «æµà ßÊ â«π ËÕß Õ ß æ åõ à ßæÕ æ ß µà à π π â ßπ Èπ π«ß À Õ Õ Õßµ À ÕÕÿ µ π â«ë Õ ßÀ Õ Õ π È ß Èπ æ ËÕ àß» æ ÕßÀπà«ß π Àâ Àâ Ë Õ ß à «â Õ π Àâ Õ µ µ Õ µ æ µ Õ π «µ «π ßæ à â à π æ «

8 » æ Õß ßæ Ë π π À Õ Õ Õßµ Õÿ µ π â«ë Õ ßÀ Õ Õ π µâõß Àâ 24 Ë«ß πà «âõ ßµàÕ ªπ È 1. ª æ å À Õ æ å µ å ÿ π/õ ÿ æ å Ë â ª»π µ Ωñ Õ Àâ Ë Õ (rt-pa) πºÿâªé«à Õ Õ Õßµ Õÿ µ π π æ π â Õß π Ë â Õ π µ 2. ª» æ å 3. CT brain 4. ÀâÕßªØ µ Ë µ «blood sugar, CBC, coagulogram, electrolyte, BUN, Cr 5. À Õ à«πª Õ Õß Õ â àπ fresh frozen plasma, cryoprecipitate, platelet concentrate pack red cell 6. ICU À Õ Stroke Unit (SU) ( Ÿ ºπ«5) 7. Õß rt-pa «â «Ë Àâ àπ ER, ICU À Õ SU 8 π«ß À Õ Õ Õßµ Õÿ µ π â«ë Õ ßÀ Õ Õ

9 ºπ Ÿ Ë 1 π«ß ºŸâªÉ«À Õ Õ Õßµ Õÿ µ π â«ë Õ ßÀ Õ Õ ºŸâªÉ«Ë Õ ß À Õ Õ Õß π 3 Ë«ß æ ª «µ 1. π ÕàÕπ ß â ß â ßÀπ Ëß π 2. æÿ à æÿ à â À Õøíß à â π 3. π «π» π 4. µ ÀÁπ æ âõπà Õ «â ß â ßÀπ Ëß π 1. µ µàõ æ å* 2. «æ basic life support 3. µ µàõ CT brain 4. µ µàõ ICU À Õ SU Õ µ «blood sugar, CBC, coagulogram, electrolyte, BUN, Cr. º CT brain àæ Õ ÕÕ π Õß æ Õ ÕÕ π Õß ª µ æ å* 1. µ «Õ âõ àß È- âõàâ Àâ Ÿ ËÀπâ 5 2. Õ «π Õ Àâ Ÿ ËÀπâ 31, µ µàõª» æ å àõπ Àâ 4. Àâ â Ë ER/ICU/SU Ÿ ºπ Ÿ Ë 2 * ª æ å À Õ æ å µ å ÿ π/õ ÿ æ å Ë â ª»π µ Ωñ Õ œ π«ß À Õ Õ Õßµ Õÿ µ π â«ë Õ ßÀ Õ Õ 9

10 ºπ Ÿ Ë 2 π«ß ºŸâªÉ«À Õ Õ Õßµ Õÿ µ π â«ë Õ ßÀ Õ Õ Ë ER/ICU/SU ER/ICU/SU ΩÑ «ßÕ à ß â µ stroke fast track care map and protocal ºπ«3 CT brain È 24. À ß Àâ À Õ ËÕ Õ «ß à «âõπ - ß µ «âõπ À ß Àâ Àâ µàõµ CPG for ischemic stroke/ Stroke fast track care map* Àâ «âõπ ( Ÿ ËÀπâ 8) * µ µàõ Õ â Ëß π π πÿπ«πª «10 π«ß À Õ Õ Õßµ Õÿ µ π â«ë Õ ßÀ Õ Õ

11 âõ àß È âõàâ π ºŸâªÉ«À Õ Õ Õßµ Õÿ µ π (5, 6, 7, 8) â«ë Õ ßÀ Õ Õ âõ àß È 1. ºŸâªÉ«â «π «à ªìπ À Õ Õ Õßµ Õÿ µ π π 3 Ë«ß 2. Õ ÿ «à 18 ªï 3. Õ ß ª Ë «â â NIHSS 4. º CT scan Õß Õß ÈÕßµâπ àæ «Õ ÕÕ 5. ºŸâªÉ«À Õ µ â ª πå Ë Èπ π Õ Àâ â Ë Õ âõàâ 1. Õ Õß À Õ Õ Õßµ Õÿ µ π Ë à «Ë Ë ªìπÕ à ß π À Õ Õ À ß µ ËππÕπ 2. Õ Õß Õ ÕÕ µâ Èπ ËÕÀÿâ Õß (subarachnoid hemorrhage) 3. Õ ß ª ÈπÕ à ß «Á«À Õ Õ Õ à ß «à ÿπ ß (NIHSS < 4) 4. Õ ß ª Õ à ß ÿπ ß (NIHSS > 18) 5. Õ ËÕ Ë Õ À Õ Õ Õßµ Õÿ µ π Èßπ È 6. «π À µ π à«ß àõπ Àâ Ÿß (SBP > 185 mmhg, DBP > 110 mmhg) 7. ª «µ Õ ÕÕ π Õß àõπ 8. ª «µ ªìπ À Õ Õ Õß À Õ Á Ë» ÿπ ß π 3 Õπ 9. â µâ π Áßµ «Õß Õ (heparin À Õ warfarin) π 48 Ë«ß À Õ à partial-thromboplastin time º ª µ À Õ à prothrombin time «à 15 «π À Õ à International normalized ratio (INR) «à ª Á Õ πâõ «à 100,000/mm ª «µ ºà µ À à π 14 «π 12. Õ ÕÕ π ß πõ À À Õ ß πªí «π 21 «π 13. πè µ π Õ µë «à 50 mg/dl (2.7 mmol/l) À Õ Ÿß «à 400 mg/dl (22.2 mmol/l) π«â Glucose (blood) 1 mg/dl = mmol/l ª «µ myocardial infarction π 3 Õπ 15. À Õ Õ ß πµ Àπàß Ë à Àâ Õ â π 7 «π 16. æ Õ ÕÕ À Õ Á ( Ÿ À ) µ «à ß 17. º CT brain æ π ÈÕ Õßµ «à 1 (hypodensity > 1/3 cerebral hemisphere) À Õæ ª Ë π ª ß π ÕßÀ Õ Õ Õßµ π À à àπ æ Õß «mass effect, sulcal effacement π«ß À Õ Õ Õßµ Õÿ µ π â«ë Õ ßÀ Õ Õ 11

12 À Ë Õ ßÀ Õ Õ ª «À recombinant tissue-plasminogen activator (rt-pa) Ë Õ Ÿà 𪻠πªí ÿ π ËÕ Actilyse (R) Ëß 2 π Õ 50. À Õ 100. µàõ 1 àõß π 1 àõß ª Õ â«ºß rt-pa 1 «πè Ë𪻠ÈÕ 50 1 «Á º «ºß «πè Ëπ 1 Õ π Á À Ÿ 2 Õ π Á æ» Àâ ßÀ Õ Õ 1 Õ π syringe 10 1 Õ π ÿ Àâ ßÀ Õ Õ 1 ÿ ( Ÿ Ÿª Ë 1 2) ÈπµÕπ À ßπ È - 𫪠µ πè Àπ µ «ºŸâªÉ«ª 0.9./. ( π Õß Ÿß ÿ à π 90.) - Õ â «rt-pa Ë À µ Ë π«â - º «πè Ëπ «ºß â Á Ë Õ Ÿà π ÿ ÀâπÈ Ëπ À ªº Õ Ÿà π «ºß - â syringe Ÿ ˺ ⫪ 10% Õß π Ë π«â â«â À Õ Õ π 1 π -µàõ «Ë À Õ â ÿ Àâ ßÀ Õ Õ Ë À â À Õ Õ π 60 π ËÕµâÕß Àâ Õ Ëπ ßÀ Õ Õ Àâ Ë Õ «Àâ ßÀ Õ Õ âπõ Ëπ âõ ««ß 1. À Ë ß Àâ µâ π Á Õ À Õ µâ π Áßµ «Õß Õ π 24 Ë«ß Õß 2. µâõßà ÿ Àâ rt-pa π Ë ß «à «Õ ÕÕ π Õß µ ««π æ âõ Èߪ ª» æ å π 3. à «àà Õ ÀâÕ À «Èß ßÀ Õ Õ À à (central venous access) À Õ ßÀ Õ Õ ß π 24 Ë«ßÀ ß Àâ rt-pa 4. À Ë ß à «πªí «π à«ß «Ë Àâ À Õ À ß Àâ 30 π 5. «ÿ «π À µ à Àâ Ÿß Àâ SBP < 185 mmhg, DBP < 110 mmhg π ËÕß «π À µ Ÿß Ë ßµàÕ Õ ÕÕ π Õß â 12 π«ß À Õ Õ Õßµ Õÿ µ π â«ë Õ ßÀ Õ Õ

13 Ÿª Ë 1 recombinant tissue-plasminogen activator (rt-pa) Ÿª Ë 2 «ÿõÿª å Àâ recombinant tissue-plasminogen activator (rt-pa) π«ß À Õ Õ Õßµ Õÿ µ π â«ë Õ ßÀ Õ Õ 13

14 «âõπ «Ë Õ ÕÕ π Õß πºÿâªé«ë â Ë Õ 1. Õ Õ ß Ë ß «à Õ ÕÕ π Õß - Õ ß ª Ë «ßÕ à ß æ π - ª - «π À µ Ÿß ÈπÕ à ß æ π - Ëπ âõ π 2. «ªØ µ ßπ È - À ÿ Àâ rt-pa - àߺÿâªé«ct brain π - Õ µ «PT, aptt platelet count - µ FFP ª 10 cc/kg - âß æ åª «À Õ æ åºÿâ Ÿ 3. ËÕ Õ ÕÕ π Õß - µ «Õ º µ «PT, aptt platelet count - ª ª» æ å π - Àâ FFP 10 cc/kg - ª ÿ ª π«ß à«π ß â π» Õ ÿ - æ CT scan È æ ËÕ Ÿ«à ª Ë π ª ß Õß π Õß âõπ Õ À Õ à π 24 Ë«ß 14 π«ß À Õ Õ Õßµ Õÿ µ π â«ë Õ ßÀ Õ Õ

15 MONITOR AND CARE DURING AND AFTER THROMBOLYTIC TREATMENT µ ß Ë 1 Doctorûs orders ORDER FOR ONE DAY ORDER FOR CONTINUATION - rt-pa mg IV bolus in 1 minute then - NPO except medications for 24 hrs - rt-pa mg IV drip in 60 minutes - Bed rest - Check vital signs, neurological sign & NIHSS - IV fluid as appropriate after infusion - Record I/O q 15 mins. for 2 hrs. - Medication consider then q 30 mins. for 6 hrs. 1. H 2 receptor blocker/proton pump inhibitor then q 60 mins. until 24 hrs. 2. Antihypertensive drugs if BP > 185/110 - If SBP > 185 or < 110 mm Hg, mmhg ( ŸÀπâ 10) DBP > 110 or < 60 mm Hg please notify doctor - Within 24 hrs after rt-pa infusion, Avoid insertion Foley catheter, NG tube, central venous access, arterial puncture & intramuscular injection If intracranial hemorrhage is suspected 1. Stop infusion of the thrombolytic drug. 2. Repeat CBC, platelet, INR, PTT, PT 3. Emergency CT brain 4. Consult neurosurgeon 5. Cross matching for FFP 6 to 8 units (or 10 cc/kg) π«ß À Õ Õ Õßµ Õÿ µ π â«ë Õ ßÀ Õ Õ 15

16 Elevated Blood Pressure Treatment Sheet for Thrombolytic Therapy Desired BP : SBP not more than 180 mmhg and DBP not more than 105 mmhg Check BP q 15 min. for 2 hrs, then q 30 min. for 6 hrs and finally q hr for 16 hrs µ ß Ë 2 Elevated blood pressure treatment for thrombolytic therapy BP level Treatment If DBP > 140 mmhg Sodium nitroprusside 0.5 ug/kg/min. IV infusion as initial dose and titrate to desired BP If SBP > 180 or DBP > 105 but < 140 mmhg Nicardipine 5 mg/h IV infusion as initial dose and titrate to desired effect by increasing 2.5 mg/h q 5 min to maximum of 15 mg/h; If BP is not controlled, consider sodium nitroprusside 16 π«ß À Õ Õ Õßµ Õÿ µ π â«ë Õ ßÀ Õ Õ

17 Õ Õâ ßÕ ß 1. π æπ å æ«ß«π å. Epidemiology of stroke. π : π æπ å æ«ß«π å,. À Õ Õ Õß (Stroke) ß Èß Ë 2 ÿß æ À π : Õπ â«æ æå, 2544: Viriyavejakul A, Poungvarin N, Vannasaeng S. The prevalence of stroke in urban community of Thailand. J Neurology 1985; 232 (suppl): World Health Organization Meeting on Community Control of Stroke and Hypertension. Control of stroke in the community: methodological considerations and protocol of WHO stroke register. CVD/s/73.6 Geneva: WHO, Adams H P Jr, Brott TG, Crowell RM, et al. Guidelines for the management of patients with acute ischemic stroke. A statement for healthcare professionals from a special writing group of the Stroke Council, American Heart Association. Stroke 1994; 25: The National Institute of Neurological Disorders and Stroke rt-pa Stroke Study Group. Tissue plasminogen activator for acute ischemic stroke. N Engl J Med 1995; 333: Adams HP, Brott TG, Furlan AJ, et al. Guidelines for thrombolytic therapy for acute stroke: a supplement to the guidelines for the management of patients with acute ischemic stroke: a statement of healthcare professionals from a special writing group of the Stroke Council, American Heart Association. Circulation. 1996; 94: Adams HP, Adams RJ, Brott T, et al. Guidelines for the early management of patients with ischemic stroke: a scientific statement from the Stroke Council of the American Stroke Association. Stroke 2003; 34: The National Institute of Neurological Disorders and Stroke rt-pa Stroke Study Group. Tissue Plasminogen Activator for Acute Ischemic Stroke CT, computed tomography; NIHSS, National Institute of Health Stroke Scale; NINDS, National Institute of Neurological Disorders and stroke. N Engl J Med 1995; 333(24): Henry JB. Clinical diagnosis and management by laboratory methods. 18 th ed., WB Saunders Co Masur H, Papke K, Althoff S, et al. Scales and Scores in Neurology: Quantification of Neurological Deficits in Research and Practice, Druckhaus Gotz. Ludwigsburg. 2004; Herndo RM. Handbook of Neurologic Rating Scales, Demos Vermande: 386 Park Avenue South. New York. 1997; , 178, Hacke W, Lees K, Toni D, et al. Acute stroke treatment. Update 2006 (An educational slide kit), product by infill Kommunikation through an educational grant from Boehringer Ingelheim GmbH. (Actilyse). 2006; Royal College of physician of London, National clinical guidelines for stroke. Second edition, The Lavenham Press Ltd. London. 2004; π«ß À Õ Õ Õßµ Õÿ µ π â«ë Õ ßÀ Õ Õ 17

18 ºπ«1 NIHSS score sheet The National Institutes of Health (NIH) Stroke Scale 10 Application: Stroke Area: Scientific studies Duration: minutes Range of results: 0-36; the more points, the more sever the stroke sequelae References: Brott T, Adams HP, Olinger CP et al. Measurements of acute cerebral infarction: a clinical examination scale. Stroke 1989; 20: Level of consciousness 0 Alert, keenly responsive 1 Drowsy, but arousable by minor stimulation to obey, answer, or respond 2 Stuporous, requires repeated stimulation to attend, or lethargic or obtunded, requiring strong or painful stimulation to make movements 3 Coma, responds only with reflex motor or autonomic effects, or unresponsive Level of consciousness-questions Ask patient the month and his/her age. Score first answer. 0 Answers both correctly 1 Answers one correctly 2 Incorrect Level of consciousness-commands Ask patient to open/close hand and eyes. Score if he or she makes unequivocal attempt. 0 Obeys both correctly 1 Obeys one correctly 2 Incorrect Pupillary response 0 Both reactive 1 One reactive 2 Neither reactive 18 π«ß À Õ Õ Õßµ Õÿ µ π â«ë Õ ßÀ Õ Õ

19 Best gaze 0 Normal 1 Partial gaze palsy; abnormal but not forced deviation 2 Forced deviation (total gaze paresis) Confrontation testing using finger movements, inculding double simultaneous stimulation. Use visual theat if consciousness or comprehension limit testing, scoring ç1é for any asymmetry demonstrated. Best visual 0 No visual loss 1 Partial hemianopia 2 Complete hemianopia, to within 5 degrees of fixation Facial palsy 0 Normal 1 Minor 2 Partial 3 Complete Best motor-arm Arms held for 10 sec at 90 degrees if sitting, 45 degree if lying. Grade weaker arm. Place arms in position if comprehension reduced. 0 No drift in 10 sec 1 Drift, after brief hold 2 Cannot resist gravity, falling immediately but some effort made 3 No effort against gravity Best motor-leg While lying, patient to hold weaker leg raised 30 degrees for 5 sec. Place leg if comprehension reduced. 0 No drift in 5 sec 1 Drift, lowering within 5 sec 2 Cannot resist gravity, falling to bed but some effort made 3 No effort against gravity π«ß À Õ Õ Õßµ Õÿ µ π â«ë Õ ßÀ Õ Õ 19

20 Plantar reflex 0 Normal 1 Equivocal 2 One extensor 3 Bilateral extensor Limb ataxia Finger-nose and heel-to-shin tests performed; ataxia is scored only if out of proportion to weakness. If total paralysis, score as absent. 0 Absent 1 Present in arm or leg 2 Present in arm and leg Sensory Tested with pin; only hemisensory loss scored. If comprehension or consciousness reduced, only score if obvious evidence. 0 Normal 1 Partial loss, subjectively different but still felt 2 Dense loss, unaware of being touched Neglect 0 No neglect 1 Partial neglect, visual, tactile, or auditory 2 Complete neglect, affecting more than one modality Dysarthria 0 Normal articulation 1 Mild to moderate dysarthria, slurring some words 2 Near unintelligible or worse 20 π«ß À Õ Õ Õßµ Õÿ µ π â«ë Õ ßÀ Õ Õ

21 Best language Assessed from response during evaluation. 0 No aphasia 1 Mild to moderate aphasia; naming errors, paraphasia, etc. 2 Severe aphasia 3 Mute π«ß À Õ Õ Õßµ Õÿ µ π â«ë Õ ßÀ Õ Õ 21

22 The Modified National Institutes of Health Stroke Scale 11 µ ß Ë 3 The Modified National Institutes of Health Stroke Scale Item Name Response 1A Level of consciousness 0 = Alert 1 = Not alert, but arousable easily 2 = Not alert, obtunded 3=Unresponsive 1B Questions 0 = Answers both correctly 1 = Answers one correctly 2 = Answers neither correctly 1C Commands 0 = Performs both tasks correctly 1 = Performs one task correctly 2 = Performs neither task correctly 2 Gaze 0 = Normal 1 = Partial gaze palsy 2 = Total gaze palsy 3 Visual fields 0 = No visual loss 1 = Partial hemianopsia 2 = Complete hemianopsia 3 = Bilateral hemianopsia 4 Facial palsy 0 = Normal 1 = Minor paralysis 2 = Partial paralysis 3 = Complete paralysis 5 Motor arm 0 = No drift a. Left 1 = Drift before 10 seconds b. Right 2 = Falls before 10 seconds 3 = No effort against gravity 4 = No movement 6 Motor leg 0 = No drift a. Left 1 = Drift before 5 seconds b. Right 2 = Falls before 5 seconds 3 = No effort against gravity 4 = No movement 22 π«ß À Õ Õ Õßµ Õÿ µ π â«ë Õ ßÀ Õ Õ

23 µ ß Ë 3 The Modified National Institutes of Health Stroke Scale (µàõ) Item Name Response 7 Ataxia 0 = Absent 1 = One limb 2 = Two limbs 8 Sensory 0 = Normal 1 = Mild loss 2 = Severe loss 9 Language 0 = Normal 1 = Mild aphasia 2 = Severe aphasia 3 = Mute or global aphasia 10 Dysarthria 0 = Normal 1 = Mild 2 = Severe 11 Extinction/inattention 0 = Normal 1 = Mild 2 = Severe There are 15 items in this version of the NIHSS. Complete scale with instructions can be obtained from the National Institute of Neurological Disorders and Stroke (Lyden et al., 1994). π«ß À Õ Õ Õßµ Õÿ µ π â«ë Õ ßÀ Õ Õ 23

24 ºπ«2 The Barthel Index µ ß Ë 4 The Barthel Index 1. Feeding 10 = Independent. Able to apply any necessary device. Feeds in reasonable time. 5 = Needs help, i.e., for cutting. 0 = Inferior performance. 2. Bathing 5 = Performs without assistance. 0 = Inferior performance. 3. Personal Toilet 5 = Washes face, combs hair, brushes teeth, shaves (manages plug if electric razor) (grooming) 0 = Inferior performance. 4. Dressing 10 = Independent. Ties shoes, fastens fasteners, applies braces. 5 = Needs help but does at least half of task within reasonable time. 0 = Inferior performance. 5. Bowel Control 10 = No accidents. Able to use enema or suppository if needed. 5 = Occasional accidents or needs help with enema or suppository. 0 = Inferior performance. 6. Bladder Control 10 = No accidents. Able to care for collecting device if used. 5 = Occasional accidents or needs help with device. 0 = Inferior performance. 7. Toilet Transfers 10 = Independent with toilet or bedpan. Handles clothes, wipes, flushes, or cleans pan. 5 = Needs help for balance, handling clothes or toilet paper. 0 = Inferior performance. 8. Chair/Bed 15 = Independent, including locks of wheelchair and lifting footrests. Transfers 10 = Minimum assistance or supervision. 5 = Able to sit, but needs maximum assistance to transfer. 0 = Inferior performance. 9. Ambulation 15 = Independent for 50 yards. May use assistive devices, except for rolling walker. 10 = With help for 50 yards. 5 = Independent with wheelchair for 50 yards, only if unable to walk. 0 = Inferior performance. 10. Stair Climbing 10 = Independent. May use assistive devices. 5 = Needs help or supervision. 0 = Inferior performance. 24 π«ß À Õ Õ Õßµ Õÿ µ π â«ë Õ ßÀ Õ Õ

25 µ ß Ë 5 The Modified Rankin Scale Grade Description 0 No symptoms at all. 1 No significant disability despite symptoms: able to carry out all usual duties and activities. 2 Slight disability: unable to carry out all previous activities but able to look after own affairs without assistance. 3 Moderate disability: requiring some help, but able to walk without assistance. 4 Moderately severe disability: unable to walk without assistance, and unable to attend to own bodily needs without assistance. 5 Severe disability: bedridden, incontinent, and requiring constant nursing care and attention. π«ß À Õ Õ Õßµ Õÿ µ π â«ë Õ ßÀ Õ Õ 25

26 ºπ«3 µ «Õ à ß Stroke fast track care maps and protocols 1. æ» µ å ÿã ß å À «ª Õ â«1. Stroke fast track protocol 2. The National Institute of Health Stroke Scale (0-42) (NIHSS) 3. Barthel Index 4. Rankin Scale 5. Stroke discharge summary sheet 2. æ» µ å ßæ ª Õ â«doctorûs order sheet: orders for acute stroke patients 3. æ» µ å» æ ª Õ â«1. Siriraj acute stroke protocol 2. Àπ ß Õ ß µπ Õ «Õß Õ æ π â Ë Õ 3. Dose t-pa (mg) 4. Checklist for intravenous thrombolysis in acute stroke 4. πª «ª Õ â«1. Stroke fast track care map 2. Thrombolysis check list 3. Àπ ß Õ ß «π Õ Ë Õ rt-pa ßÀ Õ Õ πºÿâªé«à Õ Õ Õßµ Õÿ µ π 4. Doctorûs orders sheet 5. NIHSS score sheet (1) 26 π«ß À Õ Õ Õßµ Õÿ µ π â«ë Õ ßÀ Õ Õ

27 µ «Õ à ß Stroke fast track care map and protocol æ» µ å ÿã ß å À «π«ß À Õ Õ Õßµ Õÿ µ π â«ë Õ ßÀ Õ Õ 27

28 æ» µ å ÿã ß å À «µâõß â rt-pa àõπ... π. À Õ «Õ... STROKE FAST TRACK! µ ß «À ºŸâªÉ«Ë â«õ ß stroke Õ à π 3 Ë«ß ËÕºŸâªÉ«... æ» À ß Õ ÿ... ªï HN... «π Ë... æ å R med 2... R neuro 2... R neuro 3... Time Signature Symptoms at onset ÕàÕπ ß π æÿ à µ «Õ Ëπ Ê... Time of arrival Primary doctor Acute stroke Y N Request blood test, CT scan Neurologist Fast track Y N The patient is transfered to CT at History screening for exclusion No Hx of head trauma or stroke within 3 mo No Hx of major Sx or serious trauma within 14 days No Hx of ICH, AVM or aneurysm No Hx of GI or urinary tract hemorrhage within 21 days No Hx of arterial puncture at non compressible site or LP within 7 days No seizure at onset No symptom suggests SAH NIHSS... BP... Laboratory screening for exclusion CT scan result... No evidence of ICH No edema or brain shifting Blood test results BS... PT... PTT... PLT... BS > 50 < 400 mg/dl Plt > 100,000 INR < 1.7 PTT not prolonged Immediate physical examination before rt-pa infusion No rapid spontaneous improvement SBP < 185, DBP < 110 mmhg Consent form is signed NIHSS...BP...DOOR TO NEEDLE TIME... rt-pa Given Y N Departure time from ER Arrival time to stroke unit Total time Thrombolytic is not given Reasons not to use thrombolytic drug Excluded by clinical Minimal neurological deficit Excluded by history Abnormal blood test Spontaneous improve Hemorrhagic stroke Consent form was not signed High blood pressure Delayed processes Note 28 π«ß À Õ Õ Õßµ Õÿ µ π â«ë Õ ßÀ Õ Õ

29 æ» µ å ÿã ß å À «ËÕ... ÿ... HN... The National Institute of Health Stroke Scale (0-42) (NIHSS) Date of examination Level of consciousness Alert 0 Drowsy 1 Stuporous 2 Coma 3 Two questions Õ ÿ Õπ Both correct 0 One correct 1 None correct 2 Two commands À µ µ Õ Õ Obeys both 0 Obeys none 2 Best gaze Õß â π â ß Normal 0 Partial gaze palsy 1 Forced deviation 2 Best visual (visual field) No visual loss 0 Partial hemianopia 1 Complete hemianopia 2 Bilateral hemianopia 3 Facial palsy Normal 0 Minor 1 Partial 2 Complete 3 Best Motor Lt arm π Ëß π 90 Õß» 10 «π No drift 0 Drift 1 Fall in 10 secs 2 No effort against gra 3 No movement 4 Best Motor Rt arm π Ëß π 90 Õß» 10 «π No drift 0 Drift 1 Fall in 10 secs 2 No effort against gra 3 No movement 4 Best Motor Lt leg πõπ 45 Õß» 5 «π No drift 0 Drift 1 Fall in 5 secs 2 No effort against gra 3 No movement 4 Best Motor Rt leg πõπ 45 Õß» 5 «π No drift 0 Drift 1 Fall in 5 secs 2 No effort against gra 3 No movement 4 Limb Ataxia Absent 0 Upper or lower limb 1 Upper & lower limbs 2 Sensory Normal 0 Partial loss 1 Dense loss 2 Neglect No neglect 0 Sensory or visual 1 Sensory & visual 2 Dysarthria Normal articulation 0 Mild to moderate 1 Severe 2 Best language Aphasia No aphasia 0 Mild to moderate 1 Severe 2 Mute 3 Total π«ß À Õ Õ Õßµ Õÿ µ π â«ë Õ ßÀ Õ Õ 29

30 BARTHEL INDEX æ» µ å ÿã ß å À «ON ADMISSION ËÕ... ÿ... HN... WITH HELP INDEPENDENT 1. Feeding Moving from wheelchair to bed and return (includes sitting up in bed) 5 or Personal toilet (wash face, comb hair, shave, clean teeth) Getting on and off toilet (handing clothes, wipe, flush) Bathing self Walking on level surface (if unable propel wheelchair) * Score only if unable to walk 0* 5* 7. Ascend and descend stairs Dressing (includes tying shoes, fastening fasteners) Controlling bowel Controlling bladder 5 10 Total score RANKIN SCALE No symptoms at all 0 No significant disability despite symptoms: able carry out all usual duties and activities. 1 Slight disability: unable to carry out all previous activities but able to look after own affairs without assistance. 2 Moderate disability: requiring some help; but able to walk without assistance. 3 Moderately severe disability: unable to walk without assistance and unable to attend to own bodily needs without assistance. 4 Severe disability: bedridden, incontinent, and requiring constant nursing care and attention 5 30 π«ß À Õ Õ Õßµ Õÿ µ π â«ë Õ ßÀ Õ Õ

31 æ» µ å ÿã ß å À «ËÕ... ÿ... Õ ÿ... HN... Stroke Discharge Summary Sheet Date of admission... Date of discharge... Final Diagnosis Hemorrhagic stroke type... Ischemic Stroke Vessel: Anterior circulation: ACA/MCA Posterior circulation: PCA/VB/AICA/PICA/SCA Cause Emboli : cardiac Type Total anterior circulation infarct Emboli : artery Partial anterior circulation infarct Emboli : unknown Posterior circulation infarct Large vessel thrombosis Lacunar Lacunar stroke : type... Others... Risk of stroke HT AF DM Smoking Alc Dyslipid Others... Complication: Intracerebral hemorrhage Brain edema Others... Other diagnosis CT Investigations Lab: Hct... WBC... PMN...% L...% Eo...% B...% Plt... ESR...mm/hr VDRL... FPG... BUN... Cr... Chol... TG... HDL... LDL... Stool occ bl... CT scan... EKG... MRI not done done scheduled on... MRI brain result... MRA brainresult... MRA neck result... CDUS not done done result... Echocardiogram not done done result... Condition on discharge BP... mmhg Result : improved stable worse dead cause... NIHSS on admission... NIHSS on discharge... Barthel Index... Rankin Scale... Hospital meds... Discharge meds... æ åºÿâµ «... π«ß À Õ Õ Õßµ Õÿ µ π â«ë Õ ßÀ Õ Õ 31

32 æ» µ å ÿã ß å À «ON DISCHARGE ËÕ... ÿ... HN... BARTHEL INDEX WITH HELP INDEPENDENT 1. Feeding Moving from wheelchair to bed and return (includes sitting up in bed) 5 or Personal toilet (wash face, comb hair, shave, clean teeth) Getting on and off toilet (handing clothes, wipe, flush) Bathing self Walking on level surface (if unable propel wheelchair) * Score only if unable to walk 0* 5* 7. Ascend and descend stairs Dressing (includes tying shoes, fastening fasteners) Controlling bowel Controlling bladder 5 10 Total score RANKIN SCALE No symptoms at all 0 No significant disability despite symptoms: able carry out all usual duties and activities. 1 Slight disability: unable to carry out all previous activities but able to look after own affairs without assistance. 2 Moderate disability: requiring some help; but able to walk without assistance. 3 Moderately severe disability: unable to walk without assistance and unable to attend to own bodily needs without assistance. 4 Severe disability: bedridden, incontinent, and requiring constant nursing care and attention 5 32 π«ß À Õ Õ Õßµ Õÿ µ π â«ë Õ ßÀ Õ Õ

33 µ «Õ à ß Stroke fast track care map and protocol æ» µ å ßæ À «À π«ß À Õ Õ Õßµ Õÿ µ π â«ë Õ ßÀ Õ Õ 33

34 æ» µ å ßæ À «À RAMATHIBODI HOSPITAL Department Division Ward ËÕ... Attending Staff Resident H.N... Õ ÿ... ºàπ Ë... DOCTORûS ORDER SHEET Date Hour Date Date Orders for 1 day only Hour Orders for Continuation Hour OFF CBC, PT/INR, PTT BUN/Cr, Electrolytes, glucose Capillary blood glucose 0.9% NSS...ml/h IV drip O2 nasal cannula 2 LPM CT brain without contrast Notify neurology resident on call 12-lead EKG Chest X-ray Please check Foley catheter placement NG tube placement if at high risk of aspiration tpa and post-tpa orders NPO except meds Obtain another IV line (heplock) Keep SBP < 185 and DBP < 110 mmhg May give Nicardipine IV drip Obtain Actilyse (t-pa) (Do not mix until told to do so) Total dose =...mg (0.9 mg/kg, max 90 mg) - 10% of total dose in 1 min - the remaining in 60 min Record BP as follows:- Q15mins 2 hours Q30mins 6 hours Q 1 hour 16 hours Q 4hours if stable Record neuro-signs (GCS) Q 1 hour 24 hours Notify acute stroke on call Neurology resident if BP > 180/110 mmhg or decline in Neuro status or decrease in GCS No arterial puncture No aspirin, aspirin/dipyridamole (Aggrenox ), ticlopidine (Ticlid ), clopidogrel (Plavix ), cilostazole (Pletaal ) heparin, warfarin (Coumadin), Enoxaprarin (Clexane), Nadroparin (Fraxiparine) or any other antithrombotic for first 24 hrs. Post t-pa administration CT scan after t-pa administration 24 hours Sign...code... Admit to Stroke Unit/ICU Dx :... Vitals : Q 4 hours, I/O Activity : Bed rest Head flat (< 30) Fall precaution Aspiration precaution Diet : NPO until cleared by M.D.or swallowing assessment Medications:- - Paracetamol 500 mg po/ng prn pain of fever Q 4 hours - MOM 30 ml po/ng prn constipation QD Sign...code π«ß À Õ Õ Õßµ Õÿ µ π â«ë Õ ßÀ Õ Õ

35 µ «Õ à ß Stroke fast track care map and protocol æ» µ å» æ À «À π«ß À Õ Õ Õßµ Õÿ µ π â«ë Õ ßÀ Õ Õ 35

36 1. «Ë Õ... ºŸâ π... æ» µ å» æ À «À Siriraj Acute Stroke Protocol 2. ß Ë ER «... ºŸâ π æ Õß «... ºŸâ π CBC, BS, electrolyte, BUN, Cr, Coagulogram, INR «... ºŸâ π... (ER physician) 9. Non-contrast CT brain «... ºŸâ π Activate Siriraj acute stroke team «... ºŸâ π... (ER physician) (ER nurse) 4. æ å «ER Ë ª «µ /µ «à ß «... ºŸâ π µ µàõ ß æ å (7308, 7309) «... ºŸâ π... (ER physician) 8. «ª àߺÿâªé«æ ËÕµ «CT brain «... ºŸâ π... (ER nurse) Cerebral infarct Cerebral hemorrhage Stroke mimics æ Àâ π µàõ ªπ È à Àâ æ - Õ π 3 Ë«ß - Õ ÿ >18 ªï - º CT àæ Õ - º Coagulogram ª µ Consent form (Resident/Staff neurology) âπ æ Ë µ À Õ admit µ «À 11. Onset 0-90 π Dose 0.9 mg/kg Àâ 10% iv bolus, 90% iv drip in 1hr «... ºŸâ Àâ... (Resident/Staff neurology on call) 11. Onset π Dose 0.75 mg/kg Àâ 10% iv bolus, 90% iv drip in 1hr «... ºŸâ Àâ... (Resident/Staff neurology on call) 11. Onset π Dose 0.60 mg/kg Àâ 10% iv bolus, 90% iv drip in 1hr «... ºŸâ Àâ... (Resident/Staff neurology on call) 12. ºŸâªÉ«admit Ë Siriraj Acute Stroke Unit (8613, 8614) «... ºŸâ π... (Stroke unit nurse) âß neurosurgeon ««à ºŸâªÉ«â thrombolysis admit Ë Word (Resident/Staff neurology on call) * À Àµÿ πõ «Àâ by pass ºŸâÕ π«πõ «µ µàõºÿâõ π«ßæ» (». π.æ.ª Ï «π ) µ ß 36 π«ß À Õ Õ Õßµ Õÿ µ π â«ë Õ ßÀ Õ Õ

37 æ» µ å» æ Àπ ß Õ ß µπ Õ «Õß Õ æ π â Ë Õ À⺟âªÉ«À ÕºŸâ Õ π πºÿâªé«ªìπºÿâ Õ âõ «ËÕßÀ / π àõß Àπ ß Õ π È â æ â π /π ß/π ß «...Õ ÿ... ªï µ ª µ «ª π µ â µ æπ ß π «À Ë... ß... π π ªìπ ºŸâªÉ«ºŸâ Õ π π π π... ÕߺŸâªÉ«ËÕ π /π ß/π ß «... H.N....A.N.... â æ â â ß Õ Õß «Õß Õ æ π Àâ Ë Õ ßÀ Õ Õ æ å Õß æ» µ å» æ ßµàÕ ªπ È âõ 1 Àâ Ë Õ πºÿâªé««õß Õ æ π π 3 Ë«ß À⺟âªÉ«Õ Ë øóôπµ ««æ Ÿß «à ÿà Ë à â ª 30% âõ 2 â æ â â âõ àß È Õ Õß ß à «â ßµâπ «Èß ßº âõπ Õß â π È Õ 2.1 «Õ ÕÕ π Õß Õ ÕÕ π «µà ß Ê Õß à ß Õ µ Ë ß Õß âõ âõππ Ȫ 7% 2.2 Õ µ æâ π ÿπ ß (Anaphylactic, Angioedema) ª 0.1% ºŸâ Àâ âõ Ÿ ß ËÕ... ß ËÕ... (...) (...) µ Àπàß... ºŸâªÉ«/ ºŸâ Õ π πºÿâªé«ß ËÕ...æ π ß ËÕ...æ π (...) (...) µ Àπàß... µ Àπàß... «π Ë.../.../... «...π. π«ß À Õ Õ Õßµ Õÿ µ π â«ë Õ ßÀ Õ Õ 37

38 æ» µ å» æ À «À BODY WEIGHT (KG) Dose t-pa (mg) Onset 0-90 min min min. 0.9 (mg/kg) 0.75 (mg/kg) 0.6 (mg/kg) π«ß À Õ Õ Õßµ Õÿ µ π â«ë Õ ßÀ Õ Õ

39 æ» µ å» æ À «À Sticker ËÕºŸâªÉ«Checklist for intravenous thrombolysis in acute stroke Initial assessment Onset of stroke clearly established < 3 hours prior to presentation Unequivocal diagnosis of stroke; no seizure at onset Urgent blood work (Blood glucose, CBC, electrolyte, Coagulogram, INR) Emergency non-contrast CT brain Acute Stroke Team notified Urgently request family members to be present ECG Consider insert urinary catheter and NG tube prior to thrombolysis CT assessment Non-contrast CT assessment within 3 hours of stroke No signs of neoplasm, SAH or aneurysm Final assessment At least moderate deficit remaining (NIHSS > 4) 2 nd canula inserted BP below 185/110, may give a single dose of i.v. metoprolol or nicardipine if required 2.7 < blood sugar level < 22 Platelet count > 100,000/mm3, INR < 1.7, normal APTT No suspicion of septic emboli, SAH or pregnancy at present time No previous intracranial haemorrhage/sah, cerebral neoplasm No AMI, stroke or head trauma in previous 3 months No history of haemorrhage in previous 30 days, that might lead to unmanageable haemorrhage with TPA Patient or responsible person provide informed consent (specific information sheet and consent form for rtpa) π«ß À Õ Õ Õßµ Õÿ µ π â«ë Õ ßÀ Õ Õ 39

40 æ» µ å» æ À «À Date Time 1A Consciousness 0=Alert 1=Sleepiness 2=Stupor 3=Coma 1B Question 0 = Answers both questions 1 = Answers only one question 2 = Answers neither question 1C Commands 0 = Performs both tasks 1 = Performs only one task 2 = Performs neither task 2 Gaze 0=Normal 1 = Partial gaze plasy 2 = Total gaze palsy 3 Visual field 0 = No visual loss 1 = Partial hemianopsia 2 = Total hemianopsia 3 = Bilateral hemianopsia 4 Facial Palsy 0 = Without facial paralysis 1 = Minor facial paralysis 2 = Partial facial paralysis 3 = Complete facial paralysis 5 Arm Strength 0=Normal 1 = Drifts down after 10 seconds 2 = Fall before 10 seconds 3 = No effort against gravity 4 = No movement 9 = Limb amputated 6 Leg Strength 0=Normal 1 = Drifts down after 5 seconds 2 = Fall before 5 seconds 3 = No effort against gravity 4 = No movement 9 = Limb amputated 7 Ataxia 0 = Does not present ataxia 1=Ataxia in only one limb 2=Ataxia in 2 limbs 9 = Limb amputated 8 Sensory 0 = Without sensory alteration 1 = Mild to moderate sensory loss 2 = Severe or complete sensory loss 9 Language 0 = Without language alteration 1 = Mild to moderate aphasia 2 = Severe aphasia 3 = Mute or global aphasia 10 Dysarthria 0 = Without dysarthria 1 = Mild or moderate dysarthria 2 = Severe dysarthria or anarthria 9=Intubation 11 Inattention 0 = Without inattention 1 = Mild inattention 2 = Severe inattention Total Signature Left Left Left Left Right Right Right Right Left Left Left Left Right Right Right Right 40 π«ß À Õ Õ Õßµ Õÿ µ π â«ë Õ ßÀ Õ Õ

41 æ» µ å» æ À «À Inclusion and Exclusion Criteria of the National Institute of Neurological Disorders and Stroke (NINDS) study* Inclusion Criteria of NINDS Ischemic stroke of defined onset < 3 hours Deficit measurable on NIHSS Baseline CT of the brain without evidence of hemorrhage Exclusion Criteria of NINDS A prior stroke within the last 3 months prior to presentation (PTP) Major surgery within the last 14 days PTP Serious head trauma within the last 3 months PTP History of intracranial hemorrhage (ICH) Systolic blood pressure (BP) > 185 mmhg or diastolic BP >110 mmhg or if aggressive treatment was required to lower the BP to below these limits Rapidly improving or minor symptoms Symptoms suggestive of subarachnoid hemorrhage (SAH) Gastrointestinal bleeding or urinary tract hemorrhage within the 3 weeks PTP Arterial puncture at a non-compressible site within the last 7 days PTP Seizure at the onset of symptoms Anticoagulants or heparin within 48 hours before stroke onset or elevated PTT (patial thromboplastin time), or elevated PT (prothrombin time) > 15 sec Platelet count < 100,000/ml Blood glucose < 50 mg/dl or above 400 mg/dl *Tissue Plasminogen Activator for Acute Ischemic Stroke CT, computed tomography; NIHSS, National Institutes of Health Stroke Scale; NINDS, National Institute of Neurological Disorders and Stroke The National Institute of Neurological Disorders and Stroke rt-pa Stroke Study Group. N Engl J Med 333(24): , π«ß À Õ Õ Õßµ Õÿ µ π â«ë Õ ßÀ Õ Õ 41

42 42 π«ß À Õ Õ Õßµ Õÿ µ π â«ë Õ ßÀ Õ Õ

43 µ «Õ à ß Stroke fast track care map and protocol πª «æ å «ß ÿ π«ß À Õ Õ Õßµ Õÿ µ π â«ë Õ ßÀ Õ Õ 43

44 πª «æ å STROKE FAST TRACK CARE MAP DATE TIME AT ARRIVAL NAME AGE HN AN Department/ Emergency department Emergency department Intensive care unit Aspect of (preliminary evaluation) (thrombolytic therapy) care Assessment Labs & Tests Medication & Intervention Nursing intervention 1. Record TIME AT ONSET 2. Check vital signs once & BP q 15 min. 3. Assess NIHSS 4. Check inclusion & exclusion criteria 1. Stat blood draw for CBC, PT, aptt, BS 2. Stat non-contrast CT scan of brain TIME AT CT SCAN 1. IV assess NSS keep at rate 40 cc/hr 2. No antiplatelet & anticoagulant agent 3. Avoid of urinary catheterization and nasogastric tube insertion 1. Activate stroke fast track pathway 2. Record vital signs once & BP q 15 min. 3. Immediately follow doctorûs order 1. Record results of CT scan & labs 2. Check vital signs & neuro signs (in NIHSS sheet) 3. q 15 min. for 2 hrs 4. If SBP > 185 or DBP > 110 mmhg, go to elevated BP treatment sheet 5. Record patient weight in kg 1. Stat stool occult blood (bed side kit) 1. Second IV assess : NSS lock in opposite arm 2. Prepare IV rt-pa (concentration 1 mg : 1 cc) 3. Total dose : mg (0.9 mg/kg, max dose 90 mg) Administer mg (10% of total dose) IV over 1min. Administer mg (90% of total dose) IV infusion over 60 min. TIME AT NEEDLE 4. Transfer to ICU TIME TO ICU 5. Avoid arterial punctures, frequent venous punctures and urinary catheterization for 24hrs post rt-pa 6. No antiplatelet & anticoagulant agent for 24 hrs post rt-pa 1. Record vital signs & neuro signs q 15 min. for 2 hrs post rt-pa 2. Notify physicians for SBP > 185 & DBP > 110 mmhg Nutrition NPO NPO NPO Activity Bed rest Strict bed rest Strict bed rest 1. Continue previous monitor of vital signs and neuro signs q 15 min until 2 hrs then q 30 min. for 6 hrs then 60 min. for 16 hrs 2. If suspect for intracranial hemorrhage go to ICH management sheet 3. If SBP > 185 or DBP > 110 mmhg, go to elevated BP treatment sheet 4. Cardiac monitoring (if needed) 5. Check input & output 1. After 24 hrs CT scan to exclude intracranial hemorrhage if hemorrhage present go to ICH management sheet 1. Continue rt-pa infusion then IV NSS at rate 60 cc/hr 2. Oxygen canula (if needed) 3. No antiplatelet & anticoagulant agent for 24 hrs post rt-pa 4. Peptic ulcer prophylaxis (H2-blocker/ Proton pump inhibitor) 5. Continue patientûs regular medication prescribed (if appropriated) 1. Check bleeding & hematoma from puncture sites, check urine, stool emesis or others for blood 2. Notify physicians immediately for evidence of bleeding neurological deterioration SBP > 185 or < 100 mmhg DBP > 105 or < 60 pulse < 50/min * respiration > 24/min 44 π«ß À Õ Õ Õßµ Õÿ µ π â«ë Õ ßÀ Õ Õ

45 πª «æ å THROMBOLYSIS CHECK LIST Name Age HN AN Date: Attending staff Time: Symptom Onset rtpa given: NIHSS INCLUSION criteria (must all be YES) * Age 18 years or older Yes No * Time of onset well established to be less than 3 hours Yes No * Clinical diagnosis of ischemic stroke causing a measurable neurological deficit Yes No * CT without hemorrhage or significant edema Yes No EXCLUSION criteria (must all be NO) * SBP > 185 or DBP > 110 Yes No * Symptoms rapidly improving or minor symptoms (NIHSS = 0-6) Yes No * Coma or severe obtundation (or NIHSS > 25) Yes No * Seizure at onset Yes No * Symptoms of subarachnoid hemorrhage (diffuse headache, stiffness of neck) Yes No * Prior stroke or head trauma within 3 months Yes No * Major surgery within 14 days Yes No * Prior intracranial hemorrhage Yes No * GI hemorrhage or urinary tract hemorrhage within 21 days Yes No * Arterial puncture at a noncompressible site or LP within 7 days Yes No * Recent Myocardial infarction Yes No * Patients receiving heparin within 48 hrs and with an elevated PTT Yes No * PT >15 or INR > 1.7 Yes No * Platelet count < 100,000 Yes No * Plasma glucose < 50 or > 400 Yes No * Hematocrit < 25% Yes No * Pregnant (Note: menstruation is NOT a contraindication) Yes No TREATMENT Total dose to be given (0.9mg/kg) Weight (kg): x 0.9 mg = mg (maximum 90 mg) Give 10% bolus over 1 minute mg (= ml) Give remaining 90% constant infusion over 60 minutes mg (= ml)...m.d. Physicianûs Signature π«ß À Õ Õ Õßµ Õÿ µ π â«ë Õ ßÀ Õ Õ 45

46 πª «æ å Àπ ß Õ ß «π Õ Ë Õ rt-pa ßÀ Õ Õ πºÿâªé«à Õ Õ Õßµ Õÿ µ π ÿà ß πª «πª ««π Ë... Õπ...æ.».... À Õ Õ Õßµ À ÕÕÿ µ π æ π â«àâ Ë Õ ßÀ Õ Õ ªìπ µ π Ë â π ºŸâªÉ«Õ Ë â π 3 Ë«ß π µ Èß µà Ë Õ π ß Ë Àâ ß ÿà ß πª «Õ È ßª πå «âõπ ËÕ Èπ Ë Õ ßÀ Õ Õ ßπ È ª πå Ë â» æ «à ºŸâªÉ«Ë â Ë Õ 31-50% Õ Èπ À ß â 24 Ë«ß Õ Õ ªìπª µ «3 Õπ À ß â ÿà Ë à â Àâ Õ Èπ À ß 24 Ë«ß À Õ Õ Õ ª µ Ë 3 Õπ æ ß à 20-30% «âõπ ËÕ Èπ» æ «à ºŸâªÉ«Õ «âõπõ Ëπ Ê â à «Õ ÕÕ π Õß â 6.4% «ß «âõπõ Ëπ Ê â à «Õ ÕÕ Ë à ß à«πõ Ëπ Ê æâ µàõ à ß Áµ Õ «ºŸâªÉ«Ë À Á à«õ «âõπ â Àπ ß Õ ß «π Õ π È â æ â...ºÿâªé«à ÕºŸâÕπÿ µ* ( «æ π å ºŸâªÉ«ªìπ... ÕߺŸâªÉ«ËÕ...) HN... âõà π µ «Õ Ÿ Õ Ë â«π â«õ π Õ Àâ Ë Õ ßÀ Õ Õ À Àµÿ «ÿ Õ π «âõπ â æ â à Õ ªìπ «º Õß ÿà ß πª «πª «à âõßà ÕøÑÕß âõß π π ÿ à«π µâπ ß Õß πª «µàõ à ß æ âõ ππ È â ß Õ ËÕ «â ªìπÀ π à π Õ Àâ Ë Õ ßÀ Õ Õ ß ËÕ...ºŸâ π Õ */ºŸâ à π Õ * (...) «Ë «âõß ªìπ... ÕߺŸâªÉ«* ß ËÕ...æ π (...) ß ËÕ...æ π (...) «π Ë... Õπ...æ.» π«ß À Õ Õ Õßµ Õÿ µ π â«ë Õ ßÀ Õ Õ

47 Doctorûs orders πª «312 ππ «µ « DATE ONE DAY DATE CONTINUATION - Check vital & neuroûs signs after infusion q 15 mins. for 2 hrs then q 30 mins. for 6 hrs then q 60 mins. until 24 hrs - Maintain BP 185/110 mmhg, if BP out of ranges please notify - Avoid after infusion insertion Foley catheter within 2 hrs insertion NG tube within 24 hrs entral venous access, arterial puncture & intramuscular injection - UA, Stool occult blood If hemorrahage is suspected 1. Stop infusion of the thrombolytic drug. 2. Repeat CBC, platelet, INR, PTT, PT (fibrinogen, D-dimer) 3. CT brain stat 4. Prepare for administration of 6 to 8 FFP 5. Notify neurosurgeon - NPO except meds for 24 hrs - Bed rest - Record I/O - Medication 1. H 2 blocker/ppi Prophylaxis µ ËÕ... π ÿ... Õ ÿ... HN... Diagnosis æâ µ ËÕ... π ÿ... Õ ÿ... HN... Diagnosis æâ µ ËÕ... π ÿ... Õ ÿ... HN... Diagnosis æâ π«ß À Õ Õ Õßµ Õÿ µ π â«ë Õ ßÀ Õ Õ 47

48 πª «æ å NIHSS SCORE SHEET (1) Patient Name Unit # Date / / TOTAL Date/Time of Stroke Onset Stroke Type Examiner DATE/SCORE NIHSS ITEM SCORE DEFINITIONS 1a. Level of 0 = Alert and responsive Consciousness 1 = Response to minor stimuli 2 = Response to painful stimuli 3 = Reflex response or unresponse 1b. Questions 0 = Both correct ask ptûs age 1 = One correct and month 2 = Neither correct 1c. Commands 0 = Both correct open/close eyes 1 = One correct grip/release hand 2 = Neither correct 2. Best Gaze 0=Normal horizontal EOM by 1 = Partial gaze palsy voluntary or Dollûs 2 = Forced eye deviation total paresis 3. Visual Field 0=No visual loss R/L field of good eye 1 = Partial hemianopia, 2 = Complete hemianopia 3 = Bilateral hemianopia 4. Facial Palsy 0=Normal R/L check symmetry of 1 = Minor paralysis (flat NLF) grimace to pain. 2 = Partial paralysis (UMN) 3 = Complete paralysis (U & LMN) 5. Motor Arm 0 = No drift R arms outstretched 1 = Drift 90*(sitting) or 2 = Some antigravity effort 45*(supine) for 10 secs. 3 = No antigravity effort L 4=No movement at all X = Unable to assess (amputation) 6. Motor Leg 0 = No drift R raise leg to 30* 1 = Drift (supine) for 5 secs. 2 = Some antigravity effort 3 = No antigravity effort L 4=No movement at all X = Unable to assess (amputation) 7. Limb Ataxia 0=No ataxia R/L finger to nose 1 = Ataxia in upper or lower ext. or heel to shin 2 = Ataxia in upper & lower ext. X = Unable to assess (amputation) 8. Sensory 0=Normal R/L only stroke-related loss 1 = Mild-mod unilateral loss 2 = Total loss, Coma, bilateral loss 9. Best Language 0=Normal name objects, 1 = Mild-mod aphasia read sentences, 2 = Severe aphasia writing 3 = Mute, global aphasia, coma 10. Dysarthria 0=Normal 1=Mild-mod; slurred 2 = Severe; unintelligible or mute X=Intubation 11. Extinction/Neglect 0=Normal simultaneous touch & 1 = Neglect to double simultaneous visual field test stimulation in any modality 2 = Both neglect TOTAL SCORE 48 π«ß À Õ Õ Õßµ Õÿ µ π â«ë Õ ßÀ Õ Õ

49 ºπ«4 CT scan examples for early signs of cerebral ischemia 12 Ÿª Ë 1 Hyperdense MCA sign (arrow). Ÿª Ë 2 Loss of the anterior half of the insular ribbon (arrow). π«ß À Õ Õ Õßµ Õÿ µ π â«ë Õ ßÀ Õ Õ 49

50 Ÿª Ë 3 Loss of the insular ribbon on the right side (arrows) and hypodensity of the basal ganglia (short arrows). Ÿª Ë 4 Sulcal effacement right frontal lobe (arrow). 50 π«ß À Õ Õ Õßµ Õÿ µ π â«ë Õ ßÀ Õ Õ

51 Ÿª Ë 5 Early signs of a > 2/3 MCA infarction. This patient should not be treated with thrombolysis π«ß À Õ Õ Õßµ Õÿ µ π â«ë Õ ßÀ Õ Õ 51

52 ºπ«5 Stroke Unit 13 Stroke unit À «À Ë«ªÀ ß «Ë ªìπ à«π Ÿ ºŸâªÉ«À Õ Õ Õß ª ª π Ÿ ºŸâªÉ«À«æ æ åºÿâ Ë «æ ß æ âõ Èß æ æ ß À«æ Ë «Ÿâ «π Ÿ ºŸâªÉ«À Õ Õ Õß πõ π È ßµâÕß ª ÿ ª À Õ À«à ß À«æ ºŸâªÉ«µ Õ à ß Ë Õ Õß stroke unit π â ªìπ 3 Õ 1. Acute stroke unit 2. Rehabilitation stroke unit 3. Combined stroke unit Õß stroke unit ß à «â ßµâπ ßæ µà ß Ê stroke unit π Á â æ ËÕ «ÿâ à Õß µ Èß stroke unit «Àâ π«π µ ß ÈπµË 4 µ ß æ 1 πµàõºÿâªé«2 µ ß ÿ ±å ËÕß Õ æ å «ÿõÿª å À stroke unit π«πàπà«àµÿº «ªìπ Õß Stroke unit 1 ËπÕπ 2 À ªŸ ÕߺŸâªÉ«À Õ Õ Õß Ë à à«à Õµ «Õß â ªÑÕß π º 2 Infusion pump 4 æ ËÕ «ÿ Àâ πè ßÀ Õ Õ Àâ àπ ªÑÕß π «º æ ËßÕ ªìπÕ πµ ß «µ â 3 Syringe pump 0-1 «ÿ Àâ πè πª πâõ ªÑÕß π «º æ π Ë Õ πµ Ÿß 4 ËÕß defibrillation 1 æ ËÕ â π à««µºÿâªé«ë µâπà «º ª µ 5 ËÕß «ÿ ÀâÕ À À «0-1 æ ËÕ â π «ÿ ÀâÕ À À «πºÿâªé«ë ªí À π àõ Õ À 6 Ambu bag 4 æ ËÕ â π Õ â ªÕ ºŸâªÉ«π À«à ß à«à Õ À À Õ Ÿ À 7 ËÕß«πÈ µ π Õ ª π È«2 æ ËÕµ ««πè µ π Õ ª µ ߺŸâªÉ«π àß à«π 8 Pad slide 1 À ËÕπ â ºŸâªÉ«9 Monitor 0-1 æ ËÕµ µ æ 52 π«ß À Õ Õ Õßµ Õÿ µ π â«ë Õ ßÀ Õ Õ