AGWS Stroke Thrombolysis Clinical Profoma

Transcription

1 AGWS Stroke Thrombolysis Clinical Profoma Incorporating Salisbury NHS Foundation Trust guidance Date: On Arrival: Affix patient label here) GCS NIHSS Score: Pulse SaO on Air Give O only if < 95 % on Air Temp Give gr. Paracetamol pr/iv if > 7ºC BP L BP R Then use arm with the higher reading Time onset of symptoms: If BP > 85 syst and/or > diast on consecutive measurements give labetolol/nitrates as per protocol (see file) BM If BM <.8 mmol/l give % Glucose iv and reassess, if BM > mmol/l start iv insulin sliding scale ECG (Rhythm?) Call for help: iv access x Time of arrival in ED: FBC, U&E, Clotting, total Cholesterol, Glucose Time in CT: Inform Bed Manager Duty Stroke Physician Thrombolysis started: TPA total dose given: Patient s Weight (Estimate) Clinical Exclusions from Thrombolysis: You must be able to answer NO to all statements Recent CVA (within months) Platelets < From history Any history of intracranial haemorrhage, brain tumor, intra cranial AVM or aneurysm Clinical diagnosis of subarachnoid haemorrhage even if CT normal Treatment dose of molecular weight Heparin within last 4 hrs Rivaroxaban, Dabigatran or Apixaban prescribed On lab results INR >.7 Plasma Glucose <.8 or >. mmol/l APTR >. Coma (GCS < 8) Do not delay thrombolysis to wait for blood results unless on Warfarin On initial assessment Severe Stroke (NIHSS > 5) NIHSS < 4 except isolated disabling symptoms (e.g. Severe dysphasia, homonymous hemianopia) Rapidly improving symptoms or signs BM <.8 or >. Carry on with protocol but await Lab Glucose result before commencing TPA SBP > 85 and /or DBP > after treatment with Labetolol/Nitrates On CT Brain If delay in report the on-call Stroke Physician should be able to view the films Intracranial haemorrhage Other pathologies Caution! If seizure at stroke onset, ensure presentation is a genuine stroke and not a stroke mimic! Discuss with duty doctor giving thrombolysis Regional Stroke Physician contacted (through switchboard) yes no Dec last revised Oct 4 v.

2 General Contraindications to Thrombolysis: You must be able to answer NO to all statements Active internal Bleeding History of active GI or urinary tract bleeding? Major surgery or serious trauma in last 4 days Post CT Scan: Recent lumbar puncture (within week) Recent arterial/venous puncture (within week) at a noncompressible site Active post myocardial infarction pericarditis If no radiological exclusion criteria, reassess patient to exclude rapidly improving signs Obtain verbal consent from patient and document in notes If patient is unable to consent or lacks mental capacity, discuss with family but act in patient s best interest Mix and start rt-pa administration Dose of rt-pa:.9mg/kg or 9mg whichever is lesser. Give % as a bolus over - min and the remaining 9% as a hour infusion via syringe driver (see infusion table in file) Stop infusion if blood results are outside tolerated limits Withhold Aspirin, Heparin and Warfarin for 4 hours During Thrombolysis Check blood results and review eligibility to continue thrombolysis Monitor BP, P, SaO, RR and check tongue for any signs of swelling GCS every 5 min for hours, then ½ hourly for 4 hours If orolingual angioedema develops, alert doctor immediately and give mg Hydrocortisone iv and Chlorpheniramine mg iv. ( i.m. Adrenaline is usually not required in isolated orolingual angioedema) Stop infusion if Anaphylaxis (incidence.5 % in study), marked hypotension Neurological deterioration: conscious level ( points GCS eye/motor score) NIHSS 4 points (from start of infusion) BP > 85/ mmhg if sustained or associated with neurological deterioration New severe headache Major systemic bleeding or other complications eg severe hypertension >85/ (see thrombolysis guidance for more information) If intracerebral haemorrhage suspected, follow ICH algorithm (see guideline) time of transfer destination: Comments (including any reason for delay and/or complications) date and sign all entries Nurse (name and signature) Doctor (name, signature and bleep no)

3 National Institutes of Health Stroke Scale affix patient label Item Title Responses and score on arrival hrs post TPA 4 hrs post TPA Day 7* date and time: A level of consciousness alert drowsy obtunded coma/unresponsive B Orientation questions () answers both correctly answers one correctly answers neither correctly C Response to commands () performs both tasks correctly performs one task correctly performs neither task correctly Gaze normal horizontal movements partial gaze palsy complete gaze palsy Visual fields no visual field defect partial hemianopia complete hemianopia bilateral hemianopia 4 Facial movement normal minor facial weakness partial facial weakness complete unilateral palsy 5 Motor function (arm) a. b. 4 no drift drift before 5 seconds falls before seconds no effort against gravity no movement 6 Motor function (leg) a. b. 4 no drift drift before 5 seconds falls before seconds no effort against gravity no movement 7 limb ataxia no ataxia ataxia in limb ataxia in limbs 8 Sensory no sensory loss mild sensory loss severe sensory loss 9 Language normal mild aphasia severe aphasia mute or global aphasia Articulation normal mild dysarthria severe dysarthria Extinction or inattention absent mild (loss of sensory modality) severe (loss of sensory modalities) * day 7 or day of discharge, whichever comes first Total score: Practitioner initials:

4 Nursing Care plan for the first 4 hours The patient should be given special care: : (: patient to nurse ratio as a minimum). Patient to be given intensive nursing observation for 4 hours (: or : patient ratio) Cardiac monitoring for 4 hours to identify atrial fibrillation or other arrhythmia BP (machine at bedside) and neurological observations: 5 minutes for hours minutes for the next 4 hours hourly for the next 8 hours. 4 Patient to be on bed rest for 4 hours 5 Oxygen saturation measurements for 4 hours (to maintain levels at 95%) 6 Do not pass NG tube (may eat and drink if swallow is safe) 7 No warfarin, NSAIDs or heparin to be given for 4 hours 8 Write on drug chart no warfarin, NSAIDs or heparin for 4 hrs with date/time 9 No CVP line to be inserted or arterial puncture to be carried out for the first 4 hrs Manage hyperglycaemia according to diabetic department protocols If any of the above are not achieved, write in the healthcare record why (date and sign). Nursing management of a deterioration in condition What to look for? ) Deterioration in conscious level or sharp rise in blood pressure: suspect haemorrhage, particularly if there is new headache, acute severe hypertension, nausea or vomiting. ) Fall in blood pressure or change in heart rhythm. ) Problems with airway, tongue swelling (these are possible signs of anaphylaxis) What to do? Nurse to stop Alteplase infusion (if still running) until the patient has been assessed. Contact on-call team at registrar (or consultant) level. Refer to protocol for suspected intracranial haemorrhage or blood loss. Complications (see ICID for more information or laminated sheets on Farley, ED or in thrombolysis box) Hypertension prior to thrombolysis (BP>8/) (only to give treatment if eligible for thrombolysis) Give Labetalol mg IV over minutes and re-check. May be repeated once more at 5 minutes if necessary. Hypertension post Alteplase Consider intracerebral haemorrhage. Intracerebral haemorrhage should be suspected if there is any acute neurological deterioration, new headache, acute severe hypertension, nausea or vomiting. If haemorrhage is not present: Monitor as per nursing protocol and call the relevant doctor. If systolic BP >8 mmhg or diastolic BP >5 mmhg for or more 5 minute readings: Consider giving Labetalol mg IV over minutes (at discretion of the doctor). This may be repeated at the same or double dose every minutes. Maximum dose mg (or consider an infusion at a rate of -8mg/min). For asthmatic patients use Glyceryl trinitrate -microgram/minute as an alternative. Anaphylaxis As per normal management protocols and stop Alteplase infusion. Extracranial haemorrhage As per normal management protocols. Discuss with consultant haematologist if haemorrhage is severe.

5 ROSIER Scale - for recognition of stroke Syncope Yes (-) No () Has there been seizure activity? Yes (-) No () i) asymmetric facial weakness? Yes (+) No () ii) Asymmetric arm weakness? Yes (+) No () iii) Asymmetric leg weakness? Yes (+) No () iv) Speech disturbance? Yes (+) No () v) Visual field defect?] Yes (+) No () Total score (between - and + 5) A diagnosis of stroke is unlikely if score RT-PA dose ready-reckoner One vial Two vials 4 5 Bolus dose Equivalent Total dose (mg (mls) Imperial at mg/ml) given over - weight minutes Estimate of patients weight (kg) Infusion dose (mls) = infusion rate in mls/hr 45 7 st lb st lb st 9 lb st 6 lb st lb st lb st lb st 8 lb st 5 lb st lb st lb st lb

6 SALISBURY NHS FOUNDATION TRUST INTRAVENOUS INFUSION THERAPY SURNAME... Use this section for intravenous infusion therapy and things added to the container FIRST NAMES... A separate prescription is required for each HOSPITAL NUMBER... container Use the regular Prescription Sheet for drugs WARD... injected into the tubing Date IV fluid/additive Volume/Dose Running Time Doctors Signature Batch No. Time Started Nurses Initials Time Ended Doctor must complete the following: Patient s weight = kg ALTEPLASE (.9mg/kg, max dose 9mg) Total dose = mg Loading dose (% of total dose) = mg mins IV infusion (9% of total dose) = mg 6 mins At the end of the infusion flush line with ml of sodium chloride.9% to empty the line