2017 MMC ED Stroke Packet Table of Contents

Transcription

1 7 MMC ED Stroke Packet Table of Contents Protocols and Pathways. MMC ED Guidelines for Activation of an ED Acute Stroke Alert New!. MMC ED Acute Ischemic Stroke Pathway: Thrombolytic +/- IAT Candidate 3. MMC ED Endovascular Stroke Pathway: IAT but Non-Thrombolytic Candidate Revised! 4. Eligibility Criteria for IV tpa for the Treatment of Acute Ischemic Stroke 5. Management of Pre- and Post-tPA BP Guideline 6. Management of Post-tPA Complications Guideline: Hemorrhage and Angioedema 7. Hemorrhagic Stroke Stabilization Protocol Revised! 8. Endovascular Transfer Communication Protocol 9. Dysphagia screen Protocol Resources. NIH Stroke Scale: Calculation (see laminated picture/words in each trauma bay). RACE Score (used to predict large vessel occlusion) New!. Severity scores: Pre-stroke modified Rankin Score (all stroke patients) Glasgow Coma Scale (all hemorrhagic strokes) ICH Score (for ICH only) Hunt & Hess Score (for SAH only) 3. Guidelines for the Administration of IV tpa (Alteplase) to Acute Stroke Patients 4. References The information in this packet is intended to help facilitate appropriate and consistent care of patients presenting with symptoms of acute stroke. These recommendations/guidelines do not supersede physician judgment nor do they reflect the individual needs of every patient. Revised Feb 7

2 MMC ED Guidelines for Activation of an ED Acute Stroke Alert Guiding principles:. IV-tPA is contraindicated if the LKW is greater than 4.5 hours. a. Perfusion imaging has not been proven to be an effective or safe screening mechanism for selection for treatment with IV-tPA outside the 4.5 hour time window. b. The later in the time window for eligibility, the more closely risk:benefit should be considered. c. The Neurologist may recommend treatment of patients with minor or resolving deficits, or even resolution of deficits if an acute clot is identified on CTA, given that these patients often go on to have poor outcomes without treatment While the efficacy for intra-arterial therapies for stroke (IAT) is less likely to be of benefit beyond 6-8 hours from time LKW, 8-9 we do not use any specific time frame, age or stroke severity to exclude patients from IAT. We select patients for treatment based on whether the CTA demonstrates a large vessel occlusion (LVO) and whether the CTP demonstrates a favorable ratio of core infarct to penumbra. ED Acute Stroke Alert Decision Tree - See references at the end of the ED Stroke Packet. Patient presents with symptoms of acute onset, focal neurological deficits concerning for stroke, whether they be persistent, resolving or resolved Step : Note time Last Known Well Less than 4. hours Activate ED Acute Stroke Alert for rapid imaging, labs and Neurology consult. Neurology will involve the NI if needed. Greater than or equal to 4. hours The patient is not a tpa candidate. Proceed to Step. Step : Patient has symptoms of LVO* and/or a RACE Scale greater than or equal to 5? Yes No STAT CTA/CTP and page the Neurointerventionalist (NI) The NI will involve Neurology if needed Proceed with expedient work up. Page Neurology for consult. *Most common symptoms of large vessel occlusion (LVO): Patients may have some or all of the following features in each pattern Left MCA Right MCA Basilar artery Right hemiparesis Right hemianesthesia Left gaze deviation Aphasia Right side visual field cut Left hemiparesis Left hemianesthesia Right gaze deviation Inattention/neglect of the left side Left side visual field cut Sudden-onset depressed LOC or coma Quadriplegia or hemiplegia Hemianopia Ocular palsies, nystagmus, diplopia Ataxia, vertigo, nausea/vomiting Dysarthria, dysphagia Created Feb 7

3 MMC ED Acute Ischemic Stroke Pathway: Thrombolytic +/- IAT Candidate EMS pre-hospital care: Performs CPSS and RACE Scale (some units) Checks FSBS Places large bore IVs Alerts ED they have a suspected stroke, time patient was Last Known Well (LKW) and ETA EMS Stroke Alert sent to: ED physicians ED CC RNs & Nurse Coordinator CT techs ED Triage Nurse Radiology Resident Pre-registration Prior to patient arrival: Patient is triaged directly to Critical Care (CC) area ED physicians/nurses go to CC to await patient arrival CT techs plan so that scanner will be ready by ETA Patient arrives and is met and evaluated by ED physician and ED nurse Arrival t = ED Physician Evaluation Confirms time Last Known Well (LKW) Performs quick exam and NIHSS and RACE Scale Notes any obvious contraindications to tpa ED physician exam is consistent with acute stroke and no obvious contraindications to tpa/iat are identified ED Nurse Evaluation Places Hoyer pads under patient when moved from EMS stretcher to ED stretcher Ensures large bore IVs in place with screw top connector Checks FSBS if not done by EMS Draws and labels blood with patient stickers Pt is kept NPO. See Dysphagia Screening Protocol. ED physician places ED Acute Stroke Orders, specifying Acute Stroke Thrombolytic Candidate as reason for CT/CTA/±CTP Calls REMIS to activate ED Acute Stroke Alert min If RACE greater than or equal to 5, also page the Neurointerventionalist (NI) ED Nurse sends blood to the lab STAT in a Blue Top container labeled with ED Acute Stroke stickers Transports patient to CT as quickly as possible Patient is weighed on transfer to CT table ED Acute Stroke pages: On-call neurologist/app On-call radiologist CICU&SCU coordinators Stroke nurse coordinator Stroke data coordinator CT techs Lab tech Pharmacist Neurologist calls ED attending w/in 5 min and arrives at bedside (in person or via telestroke) Goal ASAP, max less than 45 min Neurologist reviews all scans/labs and discusses scan results with Radiologist 5 min Head CT with CTA head & neck for all acute stroke patients CTP per treating neurologist or radiologist Radiologist reads scans w/in 5 min of completion and reports findings to the Neurologist Lab calls STAT results to * GOAL less than 45min Decision to whether or not to give IV-tPA is made If tpa is recommended, Neurologist communicates recommendation to the ED staff and discusses risk:benefits of tpa with the patient/pt s family Potential IAT patients are identified ED physician Places order for tpa.9 mg/kg (max dose 9 mg) using weight obtained by CT scale Ensures BP is stabilized less than 85/ prior to initiation of tpa. See Management of Pre and Post tpa BP Guidelines. No interventional procedure planned CICU&SCU coordinators assist with patient transfer to ICU, CICU preferred, unless patient is at high risk for need of craniectomy (large MCA or cerebellar strokes), who should go to SCU3 *Do not delay tpa administration waiting for lab results if the pt has no history or reason to suspect warfarin use, and has no h/o abnormal bleeding Revised Feb 7 ED nurse Calls pharmacy STAT line (x3333) or notifies ED Pharmacist of the order Pharmacist (if not already in ED) Prepares and delivers tpa to the ED 6 min ED nurse Gives % bolus via IV push over min, then infuses rest of tpa over 6 min Close BP monitoring during and after tpa is imperative; BP must be kept less than 8/5 during and x4h post tpa. Neurologist or ED attending will page the NI for patients with RACE Scale greater than or equal to 5 or imaging or exam findings c/w LVO NI reviews images & decides to proceed with IAT NI activates the NIR suite & anesthesiologist and obtains consent from the patient or patient s representative Patient transported to the NIR suite STAT (do not wait for completion of tpa infusion) Door-to-groin puncture GOAL less than min min

4 MMC Endovascular Stroke Pathway: IAT but Non-Thrombolytic Candidate Page the on-call Neurointerventionalist (NI) upon identification or arrival of any patient who may be a candidate for intra-arterial therapies (IAT) for stroke. If the patient is determined by the NI to be a candidate for IAT, the NI will notify: NIR suite staff Anesthesiologist Neurologist Neuro Critical Care Team Patients who present to MMC with RACE Score greater than or equal to 5 or are transferred or with clinical or imaging evidence of large vessel occlusion (LVO) A STAT non-contrast head CT Door-to-CT goal: less than 5 min Hemorrhage or completed infarct on CT? NO CTA shows a proximal LVO? YES YES CTA head and neck in all acute stroke patients unless the patient is felt not to be good IAT candidate B and in whom there are clear risks to contrast exposure C Basilar artery occlusion NO Anterior circulation occlusion Note: For patients p/w symptoms of LVO, CT, CTA and CTP should be ordered with the acute stroke order set and marked as thrombolytic candidate Patient is not an IAT candidate CTA in select patients The patient may be a candidate for decompressive hemicraniectomy Consult neurosurgery or other appropriate service as indicated Patient is not an IAT candidate Depending on timing and exam, NI may request MRI or CTP prior to proceeding to thrombectomy CTP Favorable penumbral pattern Unfavorable penumbral pattern Transport to NIR suite ASAP Patient is not an IAT candidate Goal door-to-groin-puncture: less than min A. Symptoms suggestive of large vessel occlusion (LVO): See ED Guidelines for Activation of ED Acute Stroke Alert B. Potential intra-arterial therapy (IAT) candidates: CTA demonstrates a LVO and CTP demonstrates a favorable ratio of core infarct to penumbra. We do not use any specific time frame, age or stroke severity to exclude patients from IAT. 9 C. Risks of iodinated contrast: Acute or acute on chronic renal failure, especially in the setting of diabetic nephropathy (do not delay CTA in acute stroke evaluation to wait for serum creatinine 3,4, especially if concern for LVO); documented severe contrast allergy; known thyrotoxicosis. Revised Feb 7

5 Eligibility Criteria for use of IV tpa for the Treatment of Acute Ischemic Stroke Concordant with recommendations published in the American Heart Association/American Stroke Association Scientific Statement Contraindications to use of tpa Onset of symptoms or time last known well greater than 4.5 hours from potential tpa administration Head CT shows an acute intracranial hemorrhage Head CT shows a completed infarct (frank hypodensity) Severe head trauma within the last 3 months Patient presenting with signs and symptoms most consistent with subarachnoid hemorrhage Mentally competent patient or legally authorized representative refused tpa not recommended/potentially harmful BP cannot be lowered safely to less than 85/ mmhg with antihypertensive agents History of intracranial hemorrhage (this does not include cerebral microhemorrhages) Platelets less than,, INR greater than.7, aptt greater than 4 sec or PT greater than 5 sec Use of therapeutic or prophylactic dose LMWH within 4 hrs or any UFH use associated with an elevated aptt Use of direct thrombin inhibitors (dabigatran) or factor Xa inhibitors (rivaroxaban, apixaban, edoxaban) within 48 hours Patients with a structural GI malignancy or GI bleed within days Ischemic stroke and symptoms consistent with infective endocarditis Known or suspected aortic dissection Intracranial or intraspinal surgery within the last 3 months Intra-axial intracranial neoplasm (extra-axial intracranial neoplasm is not a contraindication) Safety and efficacy of tpa in these situations is not well-established Age less than 8 (see BBCH Stroke Clinical Practice Guideline) Ischemic stroke within the last 3 months (potential increased risk of ICH should be weighed against potential benefits) Known bleeding diathesis (potential increased risk of ICH should be weighed against potential benefits) Intracranial arterial dissection. (NB: stroke secondary to extracranial dissection is not a contraindication) Unruptured and untreated intracranial vascular malformation (consider tpa use in patients with severe deficits from stroke) Arterial puncture at a non-compressible site in the last 7 days Early postpartum period ( with in 4days after delivery) (recommend consultation with obstetrician to assist with management) Stroke in the setting of known Sickle Cell Disease (hydration, oxygenation and exchange transfusion are first line treatments) tpa may be considered/may be reasonable, especially in the setting of moderate to severe stroke Blood glucose less than 5 or greater than 4 and neurological deficits persist 5 min after correction to euglycemia History of prior GI/GU bleeding (more than days prior to stroke presentation) Lumbar puncture in the last 7 days Pregnancy if the anticipated benefits of treatment outweigh the increase risks of uterine bleeding (recommend consultation with obstetrician and potentially a perinatologist to assist with management) Note: tpa does not cross the placenta Major non-cranial surgery or trauma in the preceding 4 days (potential hemorrhage at the surgical-site or of trauma-related injuries should be weighed against the anticipated benefits of reduced stroke-related deficits) MI within the last 3 months (NSTEMI safer than STEMI; Right or inferior STEMI safer than the left anterior STEMI) Acute pericarditis or LV/LA thrombus in the setting of stroke likely to produce severe disability. Urgent consult with a cardiologist recommended. Use in the setting of stroke likely to produce moderate disability is of uncertain net benefit. H/o diabetic or other hemorrhagic ophthalmic conditions (risk of visual loss weighted against potential reduced stroke-related deficits) Menorrhagia without clinically significant anemia or hypotension (however, if recent or active vaginal bleeding is causing clinically significant anemia, then emergent consultation with a gynecologist is recommended before a decision to use IV tpa) No longer considered to be exclusions Age over 8, stroke and diabetes, and warfarin use with an INR less than.7 in the hour time window Severe stroke (NIHSS greater than 5) in the -3 hour time window (safety and efficacy not established in the hr window) Mild but potentially disabling stroke symptoms in the opinion of the treating physician; tpa in patients with mild but non-disabling symptoms may also be considered after risk:benefit assessment Moderate to severe stroke in patients who demonstrate early improvement but remain moderately impaired and potentially disabled in the judgment of the examiner Small or moderate-sized (less than mm) unruptured and unsecured intracranial aneurysm (risk with giant aneurysm not well established) Seizure at onset of stroke (tpa should not be delayed to perform further imaging studies if clinical uncertainly of stroke vs. seizure) Revised Feb 7

6 Pre and Post tpa Blood Pressure Management Guidelines Patient identified as appropriate IV tpa candidate (See Eligibility Criteria for IV tpa) BP less than 85/? No Yes NOTE: Ischemic stroke patients who are NOT tpa candidates should NOT have BP lowered unless it is greater than /. Give labetalol* 5- mg IV x STAT *if pt has bradycardia or bronchospasm, do not use labetalol, go straight to nicardipine gtt BP less than 85/ within 5 min of IV labetalol? May repeat x if not at goal No Start nicardipine gtt at 5 mg/hr, Increase by.5 mg/hr every 5 min to max 5 mg/hr Yes Proceed with IV-tPA administration. Continue BP checks at a minimum of every 5 min. BP less than 85/ after titration of nicardipine? Maintain BP less than 8/5 during and for 4 hours after tpa administration No Yes tpa is contraindicated Patients requiring BP lowering prior to tpa administration are at higher risk of hemorrhagic transformation. Continue frequent BP monitoring during the infusion and for hours after the infusion is complete. If further BP management is needed, continue close monitoring. If BP remains stable for 4 hours with BP checks every 5min, checks can be changed to every 3 min x4 hours post tpa. Hypotension is rare in acute stroke and should prompt rapid assessment for possible etiologies, such as hypovolemia, internal bleeding, myocardial ischemia, arrhythmias or sepsis. Hypotension should be treated immediately with volume replacement with normal saline, correction of any arrhythmias and consideration of pressors in select patients. Revised Feb 7

7 Management of Post-tPA Complications Monitor all patients given tpa closely for clinical worsening and orolingual swelling during and a minimum of 4 hours after tpa infusion Worsening of neurological deficits, new onset headache or decline in level of consciousness Lingual or perioral edema Stop tpa infusion immediately Send Type & Cross (if not already done) and Massive Transfusion Coag panel STAT CT confirms hemorrhage STAT head CT CT excludes hemorrhage Administer: o Famotidine 4 mg IV x o Diphenhydramine 5 mg IV x o Methylprednisolone 5 mg IV x, may repeat every 6h x4 as needed for continued swelling Provide close respiratory monitoring o Use epinephrine only in the setting of stridor or imminent respiratory compromise o Administer unit pheresis platelets* Resume tpa infusion o o Do not resume tpa Add tpa to patient s allergies o Goal BP < 6/ Fibrinogen Greater than or equal to 5 Less than Do not administer cryoprecipitate Administer units cryoprecipitate STAT INR Greater than or equal to.5 If patient on warfarin, see the Hemorrhagic Stroke Stabilization Protocol under warfarin If patient NOT on warfarin, PCC is not indicated and is not recommended Less than.4 Do not administer further procoagulants *If platelets not immediately available, give Aminocaproic acid 5gm OR Tranexamic Acid gm IV x STAT.,5 The safety and efficacy of these agents has not been studied in acute stroke and may increase the risk of acute thrombosis and seizures. Given the short t / of tpa, the value of attempting to reverse tpa greater than 6 hours after administration is of uncertain benefit. Revised Feb 7

8 MMC Hemorrhagic Stroke Stabilization Protocol 6,7 Patient diagnosed with acute non-traumatic symptomatic intracranial hemorrhage (ICH or SAH) STAT consult Neurocritical Care and Neurosurgery Monitor blood pressure every minutes SAH GOAL BP less than 4/9 ICH GOAL BP less than 6/ 8 Labetalol 5- mg IV every 5- min, up to doses. If BP not at goal: Nicardipine gtt start at 5 mg/hr, by.5 mg/hr every 5min to attain goal; Max 5 mg/hr Initiate administration of reversal agents STAT Review history of anti-coagulation use and obtain STAT Massive Transfusion Coagulation Panel Warfarin (Coumadin, Jantoven) Direct thrombin inhibitor Dabigatran (Pradaxa) Direct FXa inhibitor Rivaroxaban (Xarelto) Apixaban (Eliquis) Edoxaban (Savaysa) See Hemorrhagic Stroke Stabilization Protocol in Epic. Vitamin K 5 mg IV x. 4-Factor PCC (Kcentra) A IV x - INR.6-.9 give 5 units/kg - INR greater than or equal to. give 5 units/kg 3. Repeat INR 3 min post-pcc dose. If INR greater than.5, give additional units/kg Idarucizumab.5 gm IV x, given 5 min apart; Pharmacy c/s required Activated charcoal at standard doses if last dose was within hours Maintain adequate diuresis with fluid replacement and hemodynamic support PCC, FFP and FVIIa do not appear to be effective & should not be administered Hemodialysis can be considered Activated charcoal at standard doses if last dose was within - hours Maintain adequate diuresis with fluid replacement and hemodynamic support Consider Kcentra 5 units/kg to help with clot formation at the site of bleeding Hemodialysis is not indicated IV Unfractionated Heparin Low Molecular Weight Heparin mg protamine per units of heparin given over last hours (ex. units/hr infusion x hours =, units UFH = mg protamine); Max 5 mg protamine If last administration less than 8 hours ago: mg protamine per mg LMWH; Max 5 mg If last administration more than 8 hours ago:.5 mg protamine per mg LMWH; Max 5 mg Platelets less than, Transfuse pheresis unit of platelets Fibrinogen less than mg/dl Transfuse cryoprecipitate unit per kg body weight Patients with signs/symptoms of increased intracranial pressure B Administer mannitol gm/kg IV x Keep head of bed greater than 3 degrees Appropriate use of ventilator support and use ETCO (end-tidal CO ) monitoring Non-traumatic subarachnoid hemorrhage (SAH) Note: Prophylactic anti-seizure medication is NOT indicated for primary ICH. fosphenytoin 5- mg PE/kg C IV over -5 mg PE/min x OR levetiracetam mg IV x A. OPTIONS TO KCENTRA: 3-factor PCC (Profilnine) IV at ml/min INR.6-4. Greater than 4 Profilnine dose 5 units/kg 5 units/kg IV Cross-matched FFP units IV x Factor VIIa mcg/kg IV x B. Signs/symptoms of increased intracranial pressure: Headache, nausea, vomiting, diplopia, anisocoria, increased blood pressure, slow heart rate, altered respiratory pattern, seizures, confusion, depressed level of consciousness, coma C. PE = Phenytoin Equivalent: fosphenytoin.5 mg = phenytoin mg Revised Feb 7

9 Endovascular Transfer Communication Protocol For transfer requests for patients who are potential candidates for endovascular therapies for ischemic stroke Provider at an outside hospital (OSH) identifies a potential candidate for the Endovascular Stroke Pathway. Images will be pushed to Impax STAT whenever possible. OSH Provider calls REMIS and asks to speak to the on call Neurointerventionalist (NI) Neuroimaging will be reviewed if possible. Clinical features including age, time last known well, baseline functional status and family wishes will be considered. Patient felt to be a good endovascular candidate. Transfer to MMC STAT is recommended by the NI. Patient felt NOT to be a good endovascular candidate. The NI considers whether there is need for transfer for other stroke-related care. NI hangs up with REMIS and notifies the NIR suite staff with an ETA for the patient. NI contacts the on call Neurologist if they feel emergent neurology involvement is needed. Yes. Transfer recommended. No. Transfer not recommended. REMIS connects the OSH Provider with the MMC: Emergency Medicine Attending AND Neurocritical Care Attending Who will discuss the case and accept the patient for transfer & make further recommendations as needed. On arrival to MMC ED, an Endovascular Stroke Alert will be activated and a STAT head CT, CTA head/neck and CT perfusion will be performed as needed. Following interpretation of scans, NI will decide on the appropriateness of further intervention. REMIS connects the OSH Provider with the Neurocritical Care Attending who will discuss the case and accept the patient for transfer & make further recommendations as needed. NCC Attending contacts the on call Neurologist if they feel emergent neurology involvement is needed. If the OSH Provider has further emergent strokerelated questions AND there is no local neurologist on call at the consulting hospital, the NI will suggest that REMIS connects the on call MMC Neurologist Potential candidate for The Endovascular Pathway = patients with good baseline functional status with recent symptom onset, a head CT without hemorrhage or completed stroke in the acutely affected territory and symptoms suggestive of large vessel occlusion (LVO): ICA/MCA: Hemiparesis, hemianesthesia, gaze deviation, aphasia, neglect, visual field cut. Basilar artery: Sudden-onset depressed level of consciousness or coma, quadriplegia or hemiplegia, hemianopia, ocular palsies, nystagmus, ataxia, vertigo, nausea/vomiting, dysarthria, dysphagia. Reviewed Feb 7

10 Dysphagia Screen Protocol To be performed in ALL patients with symptoms or a diagnosis of stroke PRIOR TO ANY PO intake (including meds) Yes No Patient has a depressed level of consciousness or is unable to sit upright for testing Patient is currently eating a modified diet secondary to dysphagia Patient has an existing PEG tube or other abdominal feeding tube Patient has a tracheotomy tube NO to ALL of the above YES to ANY of the above Patient should be kept NPO without further screening Consult SLP for formal swallow eval Proceed with 3 oz Water Swallow Screen Protocol: Step : Sit patient upright at 8-9 degrees Ask the patient to drink a teaspoon of water and assess for the following during or immediately after completion of drinking: Coughing Choking Wet voice If any of the above observed patients fails the screen Step : If none of the above observed repeat step If none of the above is observed after two teaspoons of water continue to step 3 Step 3: Ask patient to drink the entire 3-ounces (9mL) of water from a cup or with a straw, in sequential swallows, and slow and steady but without stopping. (Note: Cup or straw can be held by screener or patient) Assess patient for coughing or choking during or immediately after completion of drinking If any of the above is observed the patient fails the screen RESULTS OF DYSPHAGIA SCREEN: PASS FAIL _ Signature Printed Name Date/Time Reviewed Feb 7

11 NIH Stroke Scale a. Level of Consciousness: = Alert (eyes open spontaneously) = Arousable (requires minor stimulation to obey, answer, or respond) = Obtunded (requires repeated stimulation to attend) 3 = Coma (responds only with reflex motor or autonomic effects or totally unresponsive) b. LOC Questions: Ask the month and pts age. There is no partial credit for being close. Only the initial answer should be graded and that the examiner should not "help" the patient with verbal or non-verbal cues. c. LOC Commands: Ask or pantomime commands, i.e. close the eyes and make a fist.. Best Gaze: Horizontal voluntary (tracking) or reflexive (Doll s maneuver) eye movements are tested. 3. Visual fields: Tested by finger counting/hand waving or blink to threat, as appropriate. If there is unilateral blindness or enucleation, test visual fields in the remaining eye. 4. Facial Palsy: Score symmetry of grimace in response to noxious stimuli in the poorly responsive or non-comprehending patient. 5. Motor Arm: The limb is placed extend the arms (palms down) 9 degrees (if sitting) or 45 degrees (if supine). The aphasic patient is encouraged using pantomime. 6. Motor Leg: The leg is placed at 3 degrees (always tested supine). The aphasic patient is encouraged using pantomime. 7. Limb Ataxia: Finger-nose-finger and heel-shin tests are tested bilaterally. Ataxia is scored only if present out of proportion to weakness. 8. Sensory: Sensation to pinprick or grimace to noxious stimuli in the obtunded or aphasic patient. Do not score sensory loss due to cause other than stroke, i.e. neuropathy. 9. Best Language: Use of NIHSS cards is not required, but formally assessing fluency, naming, repetition, and comprehension is recommended.. Dysarthria: If the patient has severe aphasia, the clarity of articulation of spontaneous speech can be rated.. Extinction and Inattention (formerly Neglect): Score only if present. If the patient has aphasia but does appear to attend to both sides, the score is normal. TOTAL = Answers both questions correctly = Answers one question correctly. Intubation, orotracheal trauma, severe dysarthria and language barrier also score. = Answers neither question correctly. Aphasic and stuporous patients who do not comprehend the questions. Coma = = Performs both tasks correctly = Performs one task correctly = Performs neither task correctly. Coma = = Normal; Congenital strabismus, vertical gaze palsy, nystagmus, skew deviation. = Gaze palsy that can be overcome by voluntary or reflexive (Doll s maneuver) eye movement. Isolated cranial nerve palsy. = Forced deviation that cannot be overcome by voluntary or reflexive eye movement = No visual loss or monocular vision loss = Partial hemianopia, quadrantanopia or visual neglect = Complete hemianopia 3 = Bilateral blindness (blind including cortical blindness) = Normal symmetrical movements = Minor paralysis (flattened nasolabial fold, asymmetry on smiling) = Partial paralysis (total or near-total paralysis of lower face) 3 = Complete paralysis of one or both sides (upper and lower face). Coma = 3 = No drift; arm held at 9 (or 45 if lying down) degrees x sec = Drifts, but does not touch bed x sec = Drifts down to bed in less than or equal to sec, but has some effort against gravity 3 = No effort against gravity; arm falls to bed immediately 4 = No movement or coma UN = Amputation or joint fusion, explain: = No drift; leg held at 3 degrees x 5 sec = Drifts, but does not touch bed x 5 sec = Drifts to bed in less than or equal to 5 sec, but has some effort against gravity 3 = No effort against gravity; leg falls to bed immediately 4 = No movement or coma UN = Amputation or joint fusion, explain: _ = Absent. Ataxia is absent in the patient who cannot understand or is paralyzed. = Present in one limb = Present in two limbs UN = Amputation or joint fusion, explain: Coma = Score LEFT RIGHT LEFT RIGHT = Normal sensation = Decreased sensation; pinprick feels less sharp on the affected side. Neglect =. = Absent sensation or bilateral sensory loss. Coma = = No aphasia; normal. = Mild-to-moderate aphasia; some obvious loss of fluency or facility of comprehension, without significant limitation on ideas expressed or form of expression. = Severe aphasia; all communication is through fragmentary expression. Range of information that can be exchanged is limited. 3 = Mute, global aphasia; no usable speech or auditory comprehension. Coma = 3 = Normal. Intubated also scores. = Mild-to-moderate dysarthria; patient slurs at least some words and, at worst, can be understood with some difficulty. = Severe dysarthria; patient's speech is so slurred as to be unintelligible in the absence of or out of proportion to any dysphasia or is mute/anarthric. Coma =. UN = Intubated or other physical barrier, explain: = No abnormality detected. = Visual, tactile, auditory, spatial, or personal inattention or extinction to bilateral simultaneous stimulation in one of the sensory modalities. = Profound hemi-inattention or extinction to more than one modality; does not recognize own hand or orients to only one side of space. Coma =. Examiner: Signature: Date/Time:

12 R.A.C.E. Score Rapid Arterial Occlusion Evaluation Scale. Used to predict large vessel occlusion (LVO). Item Instruction Interpretation Score Facial palsy Ask the pt to show their teeth Symmetric facial movement Slight asymmetry Obvious facial droop Arm motor Extend the paretic arm 9 degrees (if sitting) or 45 Limb does not fall degrees (if supine) x sec Limb drifts, but some effort against gravity Pt unable to lift are against gravity Leg motor Extend the paretic leg 3 degrees (when supine) x5 Limb does not fall sec Limb drifts, but some effort against gravity Pt unable to lift are against gravity Head/gaze Observe eyes and cephalic deviation to one side No deviation, horizontal eye movements intact deviation* Eyes and/or head deviated to one side Aphasia* Ask the pt to follow verbal commands: Performs both tasks Close your eyes Performs one task Make a fist Performs neither task Agnosia Ask the pt, who s arm is this? while showing Recognizes deficits and that the arm is their own them his/her paretic arm Either unable to recognize their deficit or their arm and can you move your arm? Unable to recognize deficit or their own arm RACE SCORE TOTAL* * Presence of gaze deviation or global aphasia (mute and does not follow commands) or any score greater than or equal to 5 = high likelihood of a LVO Added Feb 7

13 Stroke Severity Scores PRE-STROKE Modified Rankin Scale: ALL STROKE Score No disability No disability, no symptoms No disability, but symptoms No significant disability despite symptoms; able to carry out all usual duties and activities 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 (assist devices, i.e. cane or walker, are allowed) 4 Moderately severe disability Unable to walk without personal assistance and unable to attend to own bodily needs without assistance 5 Severe disability Bedridden, incontinent and requiring constant nursing care and attention Glasgow Coma Scale: ALL INTRACRANIAL HEMORRHAGE Eyes Verbal Motor Spontaneous Voice Pain None 4 3 Oriented Confused Inappropriate words Incomprehensible sounds None Obeys Localizes Withdrawal Flexor Extensor None The ICH Score: ALL SPONTANEOUS INTRACRANIAL HEMORRHAGE GCS score on initial presentation (or after resuscitation) ICH volume on initial CT (via ABC/ method) Presence of any IVH on initial CT Infratentorial origin of ICH Age, yrs Greater than or equal to 3 ml Less than 3 ml Yes No Yes No Greater than or equal to 8 years old Less than 8 years old Hunt & Hess Score: ALL SUBARACHNOID HEMORRHAGE Asymptomatic, mild HA, slight nuchal rigidity Moderate-to-severe HA, nuchal rigidity, no deficit other than cranial nerve palsy Drowsy or confusion, mild focal deficit 3 Stuporous, moderate-to-severe hemiparesis 4 Comatose, decerebrate posturing 5 Revised Jan 7

14 Clinical Practice Guidelines for the Administration of tpa for Treatment of Suspected Acute Stroke. MaineHealth recognizes that IV tpa is the standard of care for the treatment of patients presenting with symptoms of acute stroke in whom the benefits are felt to outweigh the risk by the treating physician.. MaineHealth does not require written consent for the use of tpa to treat patients with presumed acute ischemic stroke within the FDA approved guidelines or within the scope of guidelines published by the American Heart Association/American Stroke Association. However, an informed discussion with the patient and/or patient representative regarding risks and benefits of tpa use for stroke is highly recommended, and written consent should be obtained where feasible. Where written consent is not feasible, documentation of this discussion in the patient s medical record is highly recommended. 3. Patients presenting with aphasia or other cognitive impairments that do not allow for an informed discussion regarding the risks and benefits of tpa should not be denied this treatment if, to the best of the treating physician s ability, the patient is determined to be a good candidate for tpa. AHA/ASA Recommendation: In an emergency, when the patient is not competent and there is no immediately available legally authorized representative to provide proxy consent, it is recommended to proceed with IV tpa in an otherwise eligible patient with acute ischemic stroke. 4. There are many clinical situations where a patient presents with symptoms consistent with a stroke, but are ultimately are found to have another explanation for the deficits. We call these stroke mimics. Differentiating stroke from another cause can be difficult, especially given the urgency of the initial work up and goal of rapid tpa administration. AHA/ASA Recommendation: The risk of symptomatic intracranial hemorrhage in the stroke mimic population is quite low; thus, starting intravenous tpa is probably recommended in preference over delaying treatment to pursue additional diagnostic studies. 5. The following language is recommended for consistent information to be provided to patients and their families regarding the risks and benefits of tpa for the treatment of stroke. 9-4 Time frame Risk (severe bleeding complications) Benefit (less disability at 3 months) -9 min (.5 hours) in 5 in min (.5-3 hours) in 8 in min (4.5 hours) in in 4 Reviewed Feb 7

15 7 MMC ED Stroke Packet References. 3 American Heart Association/American Stroke Association Guidelines for the Early Management of Patients With Acute Ischemic Stroke. Stroke. 3;44: Scientific Rationale for the Inclusion and Exclusion Criteria for Intravenous Alteplase in Acute Ischemic Stroke. American Heart Association/American Stroke Association Scientific Statement. Stroke.6;47: Thrombolysis in Patients With Mild Stroke Results From the Austrian Stroke Unit Registry. Stroke. 4;45: Computed tomography and computed tomography angiography findings predict functional impairment in patients with minor stroke and transient ischaemic attack. International Journal of Stroke.9;4: Early MRI and outcomes of untreated patients with mild or improving ischemic stroke. Neurology.6;67: Poor outcomes in patients who do not receive intravenous tissue plasminogen activator because of mild or improving ischemic stroke. Stroke.5;36: Recombinant tissue plasminogen activator for minor strokes: The National Institute of Neurological Disorders and Stroke rt-pa Stroke Study experience. Ann Emerg Med.5;46: Time to Treatment With Endovascular Thrombectomy and Outcomes From Ischemic Stroke: A Meta-analysis. JAMA.6;36: Thrombectomy within 8 Hours after Symptom Onset in Ischemic Stroke. NEJM.5;37: Safety and Efficacy of Solitaire Stent Thrombectomy Individual Patient Data Meta-Analysis of Randomized Trials. Stroke.6;47: Design and Validation of a Prehospital Stroke Scale to Predict Large Arterial Occlusion; The Rapid Arterial Occlusion Evaluation Scale. Stroke;4;45: Comparing Vessel Imaging: Noncontrast Computed Tomography/Computed Tomographic Angiography Should Be the New Minimum Standard in Acute Disabling Stroke. Stroke.6;47: Low rate of contrast-induced Nephropathy after CT perfusion and CT angiography in acute stroke patients. J Neurol.7;54: Renal Safety of CT Angiography and Perfusion Imaging in the Emergency Evaluation of Acute Stroke. AJNR. 8;9: Treatment of Intracerebral Hemorrhage with Tranexamic Acid After Thrombolysis with Tissue Plasminogen Activator. Neurocritical Care. Feb American Heart Association/American Stroke Association Guidelines for the Management of Spontaneous Intracerebral Hemorrhage Stroke. Stroke.5;46: American Heart Association/American Stroke Association Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage. Stroke.;43: The ATACH- Trial. Intensive Blood-Pressure Lowering in Patients with Acute Cerebral Hemorrhage. NEJM.6;375: The NINDs Trial. Tissue Plasminogen Activator for Acute Ischemic Stroke. NEJM.995;333: ECASSIII. Thrombolysis with Alteplase 3 to 4.5 Hours after Acute Ischemic Stroke. NEJM.8;359: Time to Treatment With Intravenous Tissue Plasminogen Activator and Outcome From Acute Ischemic Stroke. JAMA.3;39: Ultra-early Thrombolysis in Acute Ischemic Stroke Is Associated With Better Outcome and Lower Mortality. Stroke.;4: Treatment Time-Specific Number Needed to Treat Estimates for Tissue Plasminogen Activator Therapy in Acute Stroke Based on Shifts Over the Entire Range of the Modified Rankin Scale. Stroke.9;4: Symptomatic Intracerebral Hemorrhage in Acute Ischemic Stroke After Thrombolysis With Intravenous Recombinant Tissue Plasminogen Activator; A Review of Natural History and Treatment. JAMA Neurol. 4;7(9):8-85. Revised Feb 7