Thrombolysis Assessment

Transcription

1 Thrombolysis Assessment Brief Clinical Summary of symptom onset of arrival of patient of assessment BP GCS BM If BM <3.5 mmol/l treat and reassess Do not delay the CT scan move patient as soon as CT are ready Acute Stroke Team Bleeped Acute Stroke Team Arrived 7

2 INCLUSION CRITERIA Yes No Clinical signs and symptoms of acute stroke? Clear time of onset? Presentation within 3 hours of onset? Between 18 and 80 years of age? NIHSS score > 4 and < 25? MONDAY to FRIDAY hrs (if not discuss transfer with SECAmb) All inclusion criteria MUST be met to proceed with thrombolysis Rapidly improving or minor stroke symptoms? Stroke or serious head injury within 3 months? Major surgery, CPR or Given birth within 14 days? EXCLUSION CRITERIA Yes No History of intracranial haemorrhage, aneurysm, neoplasm, spinal or cranial surgery or haemorrhagic retinopathy? Symptoms suspicious of SAH (even with normal CT)? SBP > 185 mmhg or DBP > 110 mmhg? Known clotting disorder? On anticoagulant (heparin or warfarin)? Suspected iron deficiency anaemia or thrombocytopenia? Blood glucose < 3 mmol/l or > 22 mmol/l? Seizure at start of symptoms? Premorbid dependency? Endocarditis, myocarditis or pericarditis? Acute pancreatitis, oesophageal varices, ulcerative GI disease within 3 months, aortic aneurysm, active hepatitis, cirrhosis? Prior stroke AND diabetes? Puncture of non-compressible blood vessel in last 14 days? A patient with any exclusion criteria MUST NOT receive thrombolysis If ALL of the inclusion criteria are met call the Acute Stroke Consultant On-Call via switchboard and ask them to attend immediately Acute Stroke Consultant Notified Acute Stroke Consultant Arrived 8

3 NIHSS *use this score if comatose Item Details 0hr 2hr 24hr 7d 3m 1a LOC 1b LOC Questions (month) (age) 1c LOC Commands (open & close eyes) (grip non-paretic hand) 2 Best Gaze (horizontal) 0 Alert 1 Not alert minor stimulation 2 Not alert repeated or strong stimulation 3 Responds only with reflexes or totally unresponsive 0 Answers both correctly 1 Answers one correctly 2 Answers neither correctly* 0 Performs both tasks correctly 1 Performs one task correctly 2 Performs neither correctly 0 Normal 1 Partial gaze palsy 2 Forced deviation 3 Visual 0 No visual loss 1 Partial hemianopia 2 Total hemianopia 3 Bilateral hemianopia (any blindness)* 4 Facial palsy 0 Normal 1 Minor paralysis 2 Partial paralysis (lower face) 3 Complete paralysis (one or both sides)* 5 Motor arm (90 degrees sitting) (45 degrees lying) (10 sec) 6 Motor Leg (30 degrees lying) (5 sec) 7 Limb ataxia (finger nose) (heel shin) 8 Sensory (pin prick) (face, arm and leg) 9 Best language (use picture in pack) 10 Dysarthria (use list in pack) 11 Extinction & inattention Total NIHSS 0 No drift 1 Drift falls within 10 sec but does not hit bed 2 Some effort against gravity but hits bed in 10 sec 3 No effort against gravity 4 No movement* UN amputation 0 No drift 1 Drift falls within 5 sec but does not hit bed 2 Some effort against gravity but hits bed in 5 sec 3 No effort against gravity 4 No movement* UN amputation 0 Absent 1 Present in one limb 2 Present in two limbs UN amputation or joint fusion 0 Normal 1 Mild to moderate loss (can still feel pin) 2 Sever to total sensory loss (cannot feel pin)* 0 No aphasia 1 Mild to moderate aphasia 2 Severe aphasia (fragmented) 3 Mute, global aphasia* 0 Normal 1 Mild to moderate dysarthria 2 Severe dysarthria (unintelligible)* UN intubated or other physical barrier 0 No abnormality 1 Visual, tactile, auditory, spatial or personal inattention 2 Profound hemi-inattention Premorbid score if known: Modified Rankin Score Premorbid score if known: 9

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7 You know how. Down to earth. I got home from work. Near the table in the dining room. They heard him speak on the radio last night. MAMA TIP-TOP FIFTY-FIFTY THANKS HUCKLEBERRY BASEBALL PLAYER Acute Stroke Pathway 13

8 Radiological findings Interpreted by: RADIOLOGICAL EXCLUSION CRITERIA Yes No Evidence of Intracranial haemorrhage? Swelling, hypodensity or sulcal effacement in more than 1/3 of either MCA territory or all of ACA or PCA territories? Other pathological cause? A patient with any exclusion criteria MUST NOT receive thrombolysis Decision to Thrombolyze 1. Patient meets ALL inclusion and NO exclusion criteria YES 2. Consent has been obtained (or best interests decision) YES - Explain risks and benefits if possible Decision made by Signed Name of CT brain scan of CT reporting of thrombolysis Prescription of alteplase (use dose chart in thrombolysis bag and attached to this proforma) Total dose = 0.9mg/kg (up to a maximum of 90mg) Patient s weight = kg Total dose = mg Give an initial bolus dose of 10% of the total dose = mg Then infuse the other 90% over 60 minutes = mg 14

9 Prescribe on the patient s drug chart as a stat dose and infusion During the infusion Ensure patient is clerked fully on the Stroke Pathway and drug chart written Neuro-observations every 15 minutes for 2 hours (use the attached observation chart) Also look for: STOP INFUSION if: Things to avoid Extravasation Haematoma at puncture sites Signs of anaphylaxis BP rises above 185/110 mmhg (2 readings) Neurological deterioration (NIHSS drop of 2 points) Hypotension Haemorrhage suspected (headache/vomiting/agitation) Overt haemorrhage from any source Anaphylaxis Do not insert a urinary catheter Do not insert a naso-gastric tube Do not prescribe antiplatelet drugs for 24 hours Do not prescribe anticoagulation Do not perform arterial puncture Following the infusion Neuro-observations every 30 minutes for 4 hours, then follow the HASU Observation Chart until CT scan and reassessment at 24 hours. Problems Stop the infusion and follow the protocols on ASU/in the thrombolysis pack BP rises over 185/110 mmhg (two readings) Intracranial haemorrhage Labetalol 10mg iv (repeat once if needed) or try GTN infusion for gentle reduction Follow the ASU protocol Fast bleep SpR and warn CT scanning Follow the ASU Protocol 15

10 Extracranial haemorrhage Anaphylaxis Fast bleep SpR and follow the ASU Protocol Treat as usual Alteplase dose chart for Acute Ischaemic Stroke Patient's Weight (Kg) Total dose (mg) Bolus Dose (10%) Infusion Dose (90%) Patient's Weight (Kg) Total dose (mg) Bolus Dose (10%) Infusion Dose (90%) NB: Maximum dose is 90mg 16

11 When photocopying the form please replace this page with the HASU observation chart Intentionally blank 17