Administering ThrombolysisEarly Management

Angela RootsStroke Practice FacilitatorAngela.Roots@nhs.net

What have we learnt so far?

What we have learnt so far...Why thrombolyseInclusion/exclusion

◦Family ◦Medical history/pre-morbid state◦LAS

decision makingAssessment (NIHSS)ScansTime

On arrivalLAS phone aheadBleep system activatedStroke team waiting in ED History from LAS & familyAdmit patient, portable

monitoring, CT Scan

What next?ConsentIV accessObservationsPre-empting riskDoseAdministrationCommunication

ConsentUp to 4.5 hoursPost 4.5 hoursPt aphasic / confused / mental

health problemsFamily disagreesWhat would you do??

IV access2 cannulasMinimise and monitor puncture

sitesAsk for assistance after 3 failed

attempts

ObservationshypertensiveIf DBP>110mmHg or SBP >180

mmHg:IV labetalol 10 -20 mg over 1 minute,

repeated after 10 minutes till response Max. total dose 300 mg/24 hours

(HR>60bpm)

IV GTN (0.5-10mg/hour) and use same target parameters

What is your local policy?

ObservationshypertensiveHigher risk of bleedAvoid rapid drop in blood

pressureMonitor heart rateHeadache

Observations

Blood Sugar levels◦?cause of neurological deficit

INR◦Main laboratory◦CoaguCheck

Plan ahead, what are the risks?Bleeding

◦Puncture sites◦Wounds◦GI◦Cathlabs

DeteriorationAnaphylaxisOvernight coverStaffing skill mixCeiling of care

Dose0.9mg/kg

Weight requiredEstimated vs actual

90mg maximum dose

Estimate the weight

52kg

89.6kg

Dose and administration10% total dose given as a bolus over 2 minutes then remainder via infusion pump over 1 hour

Dose and administrationKeep dose calculation

chart handyEnsure clear prescription

of total dose or bolus then infusion to avoid confusion once bolus administered

Avoid double concentration 1mg/1ml

Dose and administrationOften need more than 1 vial of

drug so 2 syringes to be completed

Monitor for extravasation carefully

Keep check on infusion pump rate during the hour

Ensure the infusion tubing is flushed slowly at completion to ensure the 2ml in the infusion tubing is administered

Dose and administrationBefore you give the drug;

◦Stop, stand back, reassess◦Signs of improvement?

LocationED Resus areaBolus in CT scanning department

(fully monitored)HASU ? What do you think?

CommunicationPatient, family, carersWard

◦Staffing capacity ◦Skill mix◦Cardiac monitored bed

Bed manager/ site nurse practitioner

So do you think

we should thrombolyse?

Yes! Lets go, time

is brain!!!