Canadian Best Practice Recommendations for Stroke Care: All patients presenting to an emergency department with suspected stroke or transient ischemic attack must have an immediate clinical evaluation and investigations to establish the diagnosis, rule out stroke mimics, determine eligibility for thrombolytic therapy, and develop a plan for further management. Does the patient have allergies or hypersensitivities? No Yes: Refer to allergy documentation and process Precautions Contact - Reason: Droplet - Reason: Airborne - Reason: Triage and Stroke Symptom Onset CTAS Level on Arrival to ED (Circle appropriate level): 1 2 3 4 5 Obtain and document stroke symptom onset time (time when patient last seen 'normal' - LSN, or last known well LKW) Document: Date of Onset: (dd/mm/yyyy) Time of onset: (hh:minute) Activate Code Stroke Protocol Date activated: (dd/mm/yyyy) Time activated (hh:minute) Consults Stroke Neurologist/Stroke Team: Document: (date, time called) (time arrived) Initiate Telestroke consult to (name of consulting site), (date, time called) Neurosurgeon - Reason: Document: (date, time called) (time arrived) Interventional Neuroradiology - Reason: Document: (date, time called) (time arrived) Other consult - Reason: Document: (date, time called) (time arrived) Physiatrist Physiotherapist Occupational Therapist Speech Language Pathologist Social Worker Dietitian Pharmacist Palliative Care Team Diagnostics ***goal is to perform CT within 25 minutes of arrival to ED if considered for possible tpa*** CT Head Non-Contrast STAT or Diffusion Weighted MRI STAT - Reason: Acute stroke Document: Date of scan (dd/mm/yyyy) Time of scan start (hh/minute) ECG STAT CXR PA + Lateral - Reason: Stroke Severity and Focal Deficits Baseline assessment with standardized stroke scale on arrival, then q h National Institutes of Health Stroke Scale (NIHSS) Document: Baseline Score: OR Canadian Neurologic Scale (CNS) Document: Baseline Score: OR GCS Document: Baseline Score: Motor Strength (e.g., pronator drift) SIGNATURE 05-21-13 V2 Page 1 of 5
Vitals/Monitoring Actual weight kg OR Estimated weight kg Baseline T, then q1h. If T greater than 37.5 C, notify MD Baseline HR, RR, BP, then q h Continuous cardiac monitoring OR If in unmonitored bed, vitals q h If SBP greater than 185 mmhg or DBP greater than 110 mmhg for 2 or more readings taken 10 minutes apart, notify MD Monitor patient for worsening or new stroke symptoms. If symptoms appear, notify Stroke Team STAT. Fluid intake and output Baseline swallowing screen upon arrival Date (dd/mm/yyyy) Time (hh:minute) Document: Result: Normal Abnormal If swallowing screen is abnormal, refer patient to a SLP or OT for a detailed assessment, diet recommendations and therapy plan Document: Referral Date: Other Vitals/Monitoring: (dd/mm/yyyy) Respiratory O 2 flow rate at 2 6 L/minute by nasal cannulae (preferable) or at 5 10 L/minute by face mask Titrate O 2 to achieve a target SpO 2 93 96% OR Titrate O 2 to achieve a target SpO 2 to % Patient with known chronically elevated PaCO 2 Titrate O 2 to achieve a target SpO 2 88-92% OR Titrate O 2 to achieve a target SpO 2 to % O 2 flow rate at 1-2 L/minute by nasal cannulae or as per Venturi/Venti-mask package insert at 24-28% Lab Investigations CBC APTT INR Capillary Blood Glucose SAT Electrolytes, Creatinine, GFR BUN Glucose HbA1C Troponin ABG If female less than 50 years of age, serum β HCG TSH Sickle Cell Screen Blood C + S x 2 STAT Blood group and screen SIGNATURE 05-21-13 V2 Page 2 of 5
IV Therapy Bolus IV 0.9% NaCl ml over IV Fluid 0.9% NaCl at ml/h WITH 20 mmol KCl/L 40 mmol KCl/L Establish a second line with a Saline Lock Thrombolysis Assessment Assess patient for acute thrombolysis eligibility. Refer to Canadian Best Practice Recommendations for Stroke Care tpa Eligibility Criteria (Appendix 1) at end of this order set. If tpa criteria met. MD to complete Management of Stroke Patients Who Receive Acute Thrombolytic Therapy (r-tpa) Canadian Stroke Best Practices Order Set (Order Set 2) Patient meets tpa eligibilty criteria: If tpa criteria met If tpa criteria met: MD (or delegate) to complete Canadian Stroke Best Practices Management of Stroke Patients Who Receive Acute Thrombolytic Therapy (tpa) Order Set (Order Set #2) Patient DOES NOT meet tpa eligibility (continue this order set) Document Reason: not ischemic stroke LSN/LKW time more than 4.5 hours stroke too severe stroke too mild MD decision family/patient refused patient palliative Contraindication: (specify) Other reason: (specify Discharge Plan Admission ***MD (or delegate) to complete Canadian Stroke Best Practices Acute Stroke or TIA Admission Order Set (Order Set 3) *** Admit to Stroke Unit/ Neurovascular Unit Admit to ICU Admit to other inpatient unit: Admit to Palliative Care/End-of-Life Care Unit SIGNATURE 05-21-13 V2 Page 3 of 5
Discharge from ED to Home or Place of Residence ***MD (or delegate) to complete Canadian Stroke Best Practices Prevention of Stroke and Transient Ischemic Attack (TIA) Order Set (Order Set 4) Discharge from ED to home or place of residence Referrals Refer patient to Stroke Prevention Clinic (SPC) Refer patient to Home Care services Refer patient to out-patient or community-based rehabilitation for assessment and treatment Refer patient to other out-patient service: (specify) Patient and Family Education Provide stroke/tia education and skills training to patient, family, and caregivers Additional Orders SIGNATURE 05-21-13 V2 Page 4 of 5
Appendix 1: Canadian Stroke Best Practices Criteria for Acute Thrombolytic Therapy These criteria are designed to guide clinical decision-making; however, the decision to use tpa in these situations should be based on the clinical judgment of the treating physician. This criteria has been adapted in accordance with the criteria identified in National Institute of Neurological Disorders and Stroke (NINDS) tpa Stroke Study and the European Cooperative Acute Stroke Study (ECASS III, IST3). Treatment Inclusion Criteria Diagnosis of ischemic stroke causing measurable neurologic deficit in a patient who is18 years of age or older. For adolescents, decision to administer tpa should be based on clinical judgment, presenting symptoms, and patient age; and, if possible, consultation with a pediatric stroke specialist. Time from last known well (onset of stroke symptoms) less than 4.5 hours before tpa administration. Exclusion Criteria Historical History of intracranial hemorrhage in previous six months. Stroke or serious head or spinal trauma in the preceding three months. Recent major surgery, such as cardiac, thoracic, abdominal, or orthopedic. Arterial puncture at a non-compressible site in the previous seven days. Any other condition that could increase the risk of hemorrhage after tpa administration. Clinical Symptoms suggestive of subarachnoid hemorrhage. Stroke symptoms due to another non-ischemic acute neurological condition such as seizure with post-ictal Todd's paralysis or focal neurological signs due to severe hypo- or hyperglycemia. Hypertension refractory to antihypertensives such that target blood pressure <185/110 cannot be achieved. Laboratory Blood glucose concentration below 2.7 mmol/l or above 22.2 mmol/l. Elevated activated partial-thromboplastin time. International Normalized Ratio greater than 1.7. Platelet count below 100,000 per cubic millimetre. CT or MRI Findings Any hemorrhage on brain CT or MRI. CT showing early signs of extensive infarction, represented by a score of less than five on the Alberta Stroke Program Early CT Score [ASPECTS], or MRI showing an infarct volume greater than 150 cc on diffusion-weighted imaging. Updated by the Canadian Best Practice Recommendations for Stroke Care Acute Care Writing group, May 21st, 2013 May 21st, 2013 2013 Page 5 of 5