Thrombolysis for acute ischaemic stroke Rapid Assessment Protocol NORTHERN IRELAND Regional Protocol (Version 002 July 08) Patient Details Time of onset? Capillary Blood glucose 2.8-22.2 mmol/l? Blood pressure <185/110 mmhg? Date Time of arrival at hospital: Time of assessment: Baseline information Pre-stroke modified Rankin (circle): 0 No symptoms at all 1 No significant disability despite symptoms; able to carry out all usual duties and activities 2 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 4 Moderately severe disability; unable to walk without assistance and unable to attend to own bodily needs without assistance 5 Severe disability; bedridden, incontinent and requiring constant nursing care and attention Past medical History (circle if applies) Hypertension Diabetes Hyperlipidaemia Current smoker Previous Smoker AF CHF Previous stroke (when?) History, general examination and positive neurological findings
History/Examination continued COMPLETE NIHSS See separate sheet
NIH Stroke Scale 1a. Level of consciousness 0 Alert 1 Not alert, rousable with min. stimulation 2 Not alert, requires repeated stimulation to attend 3 Coma Time 0 h 2h 24 h 7da y 1b. LOC questions 0 Answers both correctly 1 Answers one correctly 2 Both incorrect 1c. LOC commands 0 Obeys both correctly 1 Obeys one correctly 2 Both incorrect 2. Best gaze 1 Partial gaze palsy 2 Forced gaze palsy 3. Visual field testing 0 No visual field loss 1 Partial hemianopia 2 Complete hemianopia 3 Bilateral hemianopia (incl. cortical blindness) 4. Facial Palsy symmetrical movement 1 Minor paralysis (flattened nasolabial fold, asymmetrical smile) 2 Partial paralysis 3 Complete paralysis of one or both sides 5. Motor function Right arm 6. Motor function Left arm 7. Motor function Right leg 8. Motor function Left leg 1 Drift 2 Some effort against gravity 3 No effort against gravity 4 No movement 9 Untestable (amputation/ joint fused)(don t add score) 1 Drift 2 Some effort against gravity 3 No effort against gravity 4 No movement 9 Untestable (amputation/ joint fused)(don t add score) 1 Drift 2 Some effort against gravity 3 No effort against gravity 4 No movement 9 Untestable (amputation/ joint fused)(don t add score) 1 Drift 2 Some effort against gravity 3 No effort against gravity 4 No movement 9 Untestable (amputation/ joint fused)(don t add score)
9. Limb ataxia 0 No ataxia 1 Present in one limb 2 Present in both limbs 10. Sensory (use pinprick to test arms, trunk, legs and face, comparing both sides) 11. Best language (ask patient to describe picture and name items) 12. Dysarthria (ask patient to read several words) 13. Extinction and inattention (use visual and sensory double stimulation) 1 Mild to moderate decrease in sensation 2 Severe to total sensory loss 0 No aphasia 1 Mild to moderate aphasia 2 Severe aphasia 3 Mute articulation 1 Mild to moderate slurring of words 2 Near unintelligible or unable to speak 9 Intubated or other physical barrier (don t add score) 1 Inattention or extinction to bilateral stimulus in one sensory modality 2 Hemi-attention, severe or to both modalities Total score
Important note: Not all contra-indications may be absolute. Equivalent US guidance in brackets. Discuss any contra-indications with on-call consultant Contraindication y n Contraindication y n Known hypersensitivity Neoplasm with increased bleeding risk Significant bleeding disorder with past 6 months or known haemorrhagic diathesis Manifest or recent severe bleeding (US - within last <21 days) Major Surgery or significant trauma in past 3 months (US - major Sx within 14 days, head trauma within 3 months) Current endocarditis, pericarditis, acute pancreatits On oral anticoagulants eg warfarin (US - with INR >1.7) or Heparin within last 48h and elevated thrombolplastin time Persistent SBP > 185 mmhg or DBP > 110mmHg, or IV pharmacotherapy necessary to reduce BP to these limits Suspected subarachnoid haemorrhage, even if CT normal Seizure at onset of stroke Known history of intracranial haemorrhage or any history of CNS damage ie neoplasm, aneurysm, intracranial or spinal surgery Stroke within last 3 months or any history of prior stroke and concomitant diabetes Age under 18 or over 80 y Minor neurological deficit or symptoms rapidly improving Recent less than 10 days traumatic external heart massage, obstetrical delivery, puncture of non-compressible blood vessel eg subclavian or jugular vein. (US 7 days) Documented ulcerative GI disease in last 3 months, oesophageal varices, arterial-aneurysms, A-V malfromations Severe liver disease, including hepatic failure, cirrhosis, portal hypertension - oesophageal varices and active hepatitis Severe stroke as assessed clinically eg NIHSS > 25 and/or by appropriate imaging techniques Pregnancy - if possibility, do test. Not listed as licence contraincation, but potential risks and very little experience in pregnancy Blood glucose <2.8 or >22.2 mmol/l Platelet count <100,000/ mm 3
CT scan Time of scan Reported by Time of report Has haemorrhage been excluded? Y N Has non-stroke pathology which would contraindicate thrombolysis been excluded? Y N Is there evidence that acute stroke is due to extensive infarction involving MCA territory? Y N Is there a dense MCA sign? (please note this is not a contraindication to treatment) Y N REPORT DECISION TO ADMINISTER rtpa Yes / No Responsible clinician Check list complete and favourable Y N CT findings favourable Y N Patient information leaflet provided and discussed Y N Patient consent or assent from friend/relative obtained Y N Names of friend relatives spoken to Weight estimated / measured (circle) = Total dose calculated = rtpa bolus given mg, at time If rtpa not given record reason(s): DOSAGE CALCULATION Total dose = Wt (kg) x 0.9 mg, maximum dose 90 mg Give 10% as bolus, then infuse remainder over 60 min Patient to be admitted to monitoring bed in ASU and protocol followed as overleaf
MEDICAL CARE AFTER THROMBOLYSIS General Management 1. Monitor BP closely (see monitoring below) 2. Avoid central venous access and arterial puncture first 24 hrs 3. Avoid placement of indwelling bladder catheter during infusion and for at least 30 min after end infusion 4. Avoid nasogastric tube insertion first 24 hrs 5. Record NIHSS (and concurrent BP) at baseline, 2h, 24+/-2h, 7 days Monitoring During and following Thrombolysis 1. During infusion close monitoring neurological status, BP, HR (15 min intervals) 2. After infusion continue close monitoring (15 min for 2h, 30 min for 6h, hourly for 16h) 3. Staff need to be aware of risk of intracerebral and systemic haemorrhage 4. No aspirin or heparin for 24hrs 5. Repeat CT at 24-36 hrs or earlier if deterioration Signs Symptomatic ICH 1. Neurological Deterioration 2. New Headache 3. Acute Hypertension 4. Nausea and vomiting During Alteplase Infusion STOP infusion if: 1. Anaphylaxis, marked hypotension 2. Neurological deterioration, conscious level (2 points GCS eye/motor score) or NIHSS >4 points 3. BP >185/110 mm Hg if sustained or associated with neurological deterioration 4. Major systemic bleeding, GI or intra-abdominal haemorrhage Management Neurological Deterioration 1. Define new deficit (ie measure the NIHSS and GCS) 2. Arrange urgent CT 3. Measure fibrinogen, PT, PTT, FBC 4. Group and save Causes of Deterioration during / following Thrombolysis 1. Intracerebral Haemorrhage 2. Recurrent cerebral infarction 3. Seizure 4. Hypotension 5. Sepsis 6. Hypoglycaemia 7. Cerebral oedema
Management Active Bleeding 1. Use mechanical control where possible compression venous/arterial puncture sites 2. BP - Intracranial bleed 3. BP, shock - GI/intra-abdominal bleeding 4. Transfuse, coagulation tests, surgical opinion 5. Delay surgery until fibrinolytic state corrected Management Symptomatic Cerebral Haemorrhage 1. Inform haematologist 2. Consider administering 6-8 units cryoprecipitate and 6-8 units platelets (platelet infusion indicated if patient has had antiplatelet therapy in previous 7 days) 3. Discuss with neurosurgery 4. Consider second CT 5. Clotting disturbances must be corrected prior to neurosurgery, otherwise manage as for primary ICH Management of Blood Pressure 1. Monitor BP for 24 hours 2. If BP > 230/120 mm Hg single reading, or BP > 185/110 mm Hg 5 min apart Labetalol 10mg iv, repeated 10-20 min or Nitroprusside / nitrate infusion titrated (only after consultant discussion) 3. Target BP < 185 / 110 mm Hg Hypotension / Anaphylaxis 1. Evidence suggests 1.5% of cases may have a severe reaction 2. ABC management 3. Adrenaline for angioedema, severe hypotension 4. Volume replacement, maintain systolic BP >110 mm Hg 5. Consider steroids / antihistamines