Department Specific Guideline

Transcription

1 Department Specific Guideline Stroke/TIA Management ED Applicable to: Nursing/Medical staff caring Authorised by: Stroke services team for Acute stroke/tia patients Contact person: Clinical nurse manager, ATR Whanganui District Health Board 1. Purpose To guide nursing and medical management of patients with acute stroke and Transient Ischaemic Attack (TIA) in the Emergency Department. 2. Scope Applies to all ED doctors and registered nurses caring for patients with stroke or TIA 3. Guideline 3.1 RN Initial Assessment and Management Establish time of symptom onset: if less than 4.5 hours initiate thrombolysis guideline/checklist If more than 4.5 hours since symptom onset proceed as follows: o Vital Signs: Initiate monitor, check and record blood pressure, pulse oximetry, finger stick glucose and temperature. o IV access: Place gauge catheter o Send bloods: FBC, Coags, U&E, Glucose, CRP and urinalysis. o Obtain 12 lead ECG o Keep patient nil by mouth (NBM) until swallowing screened. Fax SLT referral o Elevate head of bed 30 to prevent aspiration o Provide nasal oxygen 2-4 L/min only if required to maintain pulse oximetry >95% or identified individual parameters o CXR (if indicated) o Avoid urinary catheterisation where possible (important early prognostic indicator) 3.2 Medical Assessment and Management Initial Assessment and Management If patient potential thrombolysis candidate (onset <4.5 hours) initiate thrombolysis guideline/physician check list (guideline 5794) If not thrombolysis candidate proceed as follows: o Request urgent CT head without contrast to rule out intracranial hemorrhage (ICH) o if patient stable obtain CT within hours o if pt deteriorating,?sah,?hydrocephalus,?trauma, on anticoagulation, thrombolysis candidate, or diagnosis of stroke in doubt a CT should be done immediately o If patient significantly hypoglycemic administer 100ml 10% Glucose and reassess for focal neurology as hypoglycemia can mimic acute stroke with focal neuron deficits o Administer Paracetamol 1g po/pr for temperature >37.5 every 4-6 hours as even mild hyperthermia can worsen stroke outcomes Document number: WDHB-5909 Page 1 of 9 Version number:1 Date authorised:11/04/2014 Next review date:11/04/2015 Whanganui District Health Board controlled document. The electronic version is the most up-to-date version. WDHB will not take responsibility in the event of an outdated paper copy being used which may lead to an undesirable consequence.

2 o If stroke suspected do not lower BP unless critical (see below). If systolic BP< 140mmHg initiate IV fluids (normal saline) to maintain cerebral perfusion pressure Transient Ischaemic Attack (patient currently asymptomatic) Determine ABCD² score (see Appendix 1) if ABCD² score is greater or equal to 4 continue with Ischaemic Stroke orders below if ABCD² score is less than 4 refer to outpatient TIA clinic (note ABCD² score on referral) if the following criteria are met: o Patient is NOT on warfarin; o Patient has NOT had two or more TIAs within last week o Patient does NOT have Atrial Fibrillation o Diagnosis of TIA is reasonably certain (syncope, b/l symptoms, and isolated dizziness are not likely TIAs) o BP is under reasonable control systolic BP (e.g. 160/100, but highly dependent on individual) o All other acute medical issues have been addressed o Aspirin 300mg po/pr/sl STAT given (Clopidogrel 300mg if patient Aspirin allergic or intolerant) o Prescriptions to last at least 2 weeks provided for: 1. Aspirin 100mg daily +/- Dipyridamole SR 150mg bd OR Clopidogrel 75mg daily 2. Simvastatin 40mg daily (20mg id frail/elderly) or Atorvastatin 80mg daily 3. An oral antihypertensive (usually ACE inhibitor) unless patient at risk for symptomatic hypotension o Smoking cessation programme offered o Driving restrictions communicated (minimum 1 month - see Appendix 2) o If possible outpatient head CT and if indicated carotid ultrasound (see Inpatient Acute Stroke/TIA Guideline for indications) arranged to be done within 1 week and results copied to TIA clinic Ischaemic Stroke (symptoms persist and CT head is negative for ICH) that has not been thrombolysed. Give Aspirin 300mg stat or Clopidogrel 300mg stat if patient Aspirin allergic (only if CT done) Unless BP >220/120 do not treat acutely If systolic BP >220 mmhg and/or diastolic BP is mmhg: give Labetolol 10mg IV push over 1-2 minutes. The dose may be repeated and/or doubled every 10 minutes up to a total of 150mg. If > 2-3 doses are required start IV infusion of 2-8 mg/min; if Labetalol contraindicated or ineffective use GTN 1-3 μg/kg/min with target of 10-20% BP reduction If diastolic BP>140 use Sodium Nitroprusside drip 0.5-1μg/kg/min titrate until diastolic blood pressure decreases by 20% Intracranial Haemorrhage (confirmed by CT) If large ICH (>10cm³), cerebellar ICH (>3cm³), EDH, SAH, IVH, Hydrocephalus or deteriorating Discuss with Wellington Neurosurgeon on-call. Stop all antiplatelet drugs and anticoagulants Refer to anticoagulation guidelines for reversal of Warfarin For systolic BP >160 mmhg or mean arterial pressure (MAP)* >130 mmhg Labetalol 5-10mg IV push over 2 min, repeat every min prn If BP still uncontrolled after 3rd dose drip 2-8 mg/min BP within parameters If Labetalol contraindicated or ineffective GTN 1-3 μg/kg/min If ineffective or DBP >140mmHg use Sodium Nitroprusside drip 0.5-1μg/kg/min *MAP = DBP+1/3(SBP-DBP) Acute Stroke Discharge Criteria from ED to Home Stroke occurred more than 2 days ago CT has been obtained and is negative for ICH Patient is not in AF or has other unaddressed medical issues including high BP Progression risk deemed to be low (e.g. not a partial MCA territory infarct) Patient s deficit are minor enough to obviate any rehab needs MMSE at baseline Driving restrictions have been communicated (must stop for minimum of 1 month) Document number: WDHB-5909 Page 2 of 9 Version number:1

3 Secondary preventive therapy is implemented (see TIA section above for specifics) Quit smoking cessation offered and documented Urgent outpatient carotid ultrasound (<1 week) has been organized (if anterior circulation stroke, patient is a surgical candidate and willing to undergo surgery if indicated) Refer to outpatient TIA clinic for follow-up Admission Criteria All Stroke/TIA patients who do not meet discharge criteria as outlined above should be admitted to the Acute Stroke Unit on AT&R ward for further management 4. Related WDHB documents WDHB-5794 Thrombolysis for Ischaemic Stroke 5. Appendix Appendix 1 Appendix 2 Appendix 3 Appendix 4 Appendix 5 Appendix 6 ABCD² Score Driving Restrictions after TIA or Stroke (assuming no impairing deficit remains) TIA Medical Management for ED Acute Stroke ED Doctor Pathway Checklist For Thrombolysis For Acute Stroke NIHSS Scoring Form 6. Key words Stroke TIA Acute stroke, Transient ischaemic attack, TIA, Emergency department Document number: WDHB-5909 Page 3 of 9 Version number:1

4 Appendix 1 ABCD² SCORE* A. Age >= 60 1 B. BP >140/90 mmhg 1 C. Clinical features Unilateral weakness or 2 Speech or language impairment (without weakness) 1 D. Duration of TIA 60min min 1 <10 minutes 0 Diabetes (on medication/insulin) 1 Risk of Stroke According to ABCD² score: ABCD² Score: Stroke Risk at 2 days 1.0% 4.1% 8.1% 7 days 1.2% 5.9% 11.7% 90 days 3.1% 9.8% 17.8% Document number: WDHB-5909 Page 4 of 9 Version number:1

5 Appendix 2 Driving Restrictions After TIA Or Stroke (Assuming no impairing deficit remains) Private license Single TIA Multiple TIAs Minimum 1month Minimum 3 months Vocational License (Commercial classes or P Passenger endorsement) Single TIA Multiple TIAs Minimum 6 months No return; 12 months in exceptional circumstances Document number: WDHB-5909 Page 5 of 9 Version number:1

6 Appendix 3 TIA Medical Management For ED Suspected TIA Does the patient have AF and/or is on warfarin? Yes No Admit via on-call medical team Do ABCD ² Score > 4 < 4 CT scan Yes Crescendo sx or >1 event over past 7 days? Haemorrhagic Stroke excluded Admit via on-call medical team No Consider starting/continuing warfarin <50% stenosis Consider Echo Carotid ultrasound (if anterior circulation symptoms) & CT brain as inpatient (<24hrs) Secondary prevention Driving Restrictions >50% stenosis Secondary Prevention Driving Restrictions Order outpatient Carotid ultrasound (if anterior circulation symptoms) and CT brain (<7days) Refer to TIA Clinic Discharge Follow-up in TIA/Stroke Clinic or GP as per Stroke Team Recs Discuss with Stroke Team re: Vascular surgery referral Patient to remain in hospital until Stroke Team/surgeon has been consulted Document number: WDHB-5909 Page 6 of 9 Version number:1

7 Appendix 4: ACUTE STROKE ED DOCTOR PATHWAY 1. Review diagnosis ROSIER score (circle as appropriate) YES NO Loss of Consciousness? -1 0 Seizure activity? -1 0 Is there new acute onset (or on awakening)? Speech disturbance? +1 0 Unilateral face weakness? +1 0 Unilateral arm weakness? +1 0 Unilateral leg weakness +1 0 Visual field deficit? +1 0 TOTAL Score <1 = Stroke unlikely, discontinue pathway and consider other diagnoses Score 1 = Continue pathway 2. Review if candidate for thrombolysis Is there (circle as appropriate) Symptom onset <4½ hours ago? YES NO Significant neurological deficit? YES NO Clinical exclusion of SAH? YES NO NO to ANY = Not for thrombolysis, continue routine stroke management YES to ALL = Discuss with On-Call Physician 3. Discussion with Physician Physician advises against thrombolysis = continue routine stroke management Physician gives go ahead = - request urgent CT - request urgent FBC, UEC, glucose and coags - insert 2 IV cannulae - obtain and interpret ECG - weigh the patient and calculate Alteplase dose; obtain Alteplase but do not open yet - advise CCU of possible admission for stroke thrombolysis Document number: WDHB-5909 Page 7 of 9 Version number:1

8 Appendix 5: CHECKLIST FOR THROMBOLYSIS FOR ACUTE STROKE Inclusion Criteria (Tick as appropriate) Ischaemic stroke with focal neurological deficit, defined as impairment of language, motor function, cognition, co-ordination, neglect, vision, and/or gaze. Significant deficit defined as NIHSS 4 OR severe aphasia, dense homonymous haemianopia, significant ataxia or dominant hand weakness even if NIHSS < 4. Not rapidly, dramatically improving Onset time reliably established to be < 4.5 hours at time of treatment initiation (if wakes with stroke, onset time is when last awake; if unable to identify onset then use time last normal). Previously without advanced neurologic or medical disability that would preclude significant benefit from treatment If ANY = NO or unknown, DO NOT PROCEED YES NO Exclusion Criteria (Tick as appropriate) Evidence of intracranial haemorrhage on head CT Clinical presentation consistent with SAH even if CT brain appears normal Stroke, intracranial surgery, or major head trauma in previous 3 months Any history of intracranial haemorrhage, AVM, OR aneurysm with risk of recurrent bleeding GI/GU haemorrhage in previous 21 days Major surgery OR serious trauma (other than head trauma) in previous 14 days Arterial puncture at non compressible site OR LP in previous 7 days Transmural MI OR post-mi pericarditis in previous 21 days Other serious medical condition that would impose a significant hazard if Alteplase were administered Evidence of acute trauma OR bleeding Suspected septic embolism Seizure at onset of symptoms Hypertension: SBP >185 mm Hg OR DBP >110 mm Hg OR requiring aggressive treatment Glucose <2.7 or > 22 mmol/l Known hereditary/current haemorrhagic diathesis, INR >1.5, APTT >40, or platelet count <100,000/μL Exposure to weight based LMWH within last 48 hours Exposure to oral anticoagulants within last 48 hours UNLESS INR <1.5 (Warfarin) OR APTT AND Thrombin Clotting Time are BOTH normal (Dabigatran) Pregnancy, Parturition OR Lactation within last 30 days If ANY = YES or unknown, DO NOT PROCEED Additional exclusions for the 3 to 4.5 hour time window Coma OR obtundation, fixed eye deviation AND complete hemiplegia or NIHSS 25 A history of diabetes AND prior stroke ANY oral anticoagulant, irrespective of INR CT scan showing evidence of hypodensity over one-third MCA territory Blood pressure >185/110 (no acute treatment permissible to reach target) Age > 80 years old If ANY = YES or unknown, DO NOT PROCEED Document number: WDHB-5909 Page 8 of 9 Version number:1

9 Appendix 6: Document number: WDHB-5909 Page 9 of 9 Version number:1