Stroke Thrombolysis Pathway

Stroke Thrombolysis Pathway

This document is to be used in conjunction with the ‘Medical Care Management for Stroke Patients’ document. It is also the front page of the contact assessment; it is to be photocopied with the referral details when referring the patient to any other Health Care Professional.

Ward / Dept: FGH RLI WGH

Demographic Information Next of Kin/Significant other Information Affix patient label

Unit /ID No. 1.Name

Name Address

Address

Telephone No. Night Call

Relationship Next of kin Emergency contact

Post Code Key holder Main Carer

Date of Birth Age 2.Name

Religion Address

Telephone Number

Preferred Name Telephone No. Night Call

Occupation Relationship Next of kin Emergency contact

Ethnic origin Gender M F Key holder Main Carer

GP Name/Surgery Discharge Address/phone number if different above

Telephone Number

Dentist

Reason for admission

Social

Admitted from Home Nursing Home Residential Home Other

Lives Alone Partner/Relative Dependants specify

In a House Bungalow Sheltered Other

Patient has a social worker (if yes, identify) Contacted

Admission/Discharge Information

Date/Time of Admission Named Nurse

Estimated Date of Discharge ID Band in situ Disclaimer Signed

Actual Date/Time Discharge Patient understands reason for admission

Consultant Relatives/Carer aware of admission

Bed/Trolley/Room Number Relative/Carer understands reason for admission

Transferred to: Ward Date Time

Ward Date Time

Ward Date Time

2

Instructions for use.

All staff using the Stroke Thrombolysis pathway please sign sample signature record below.

This document is to be filed in the patients case notes on discharge.

Print Name Full Signature Initials Professional Title Date

3

Cardiac and Stroke Networks in Lancashire & Cumbria

STROKE THROMBOLYSIS PATHWAY

This Document is Private and Confidential

Visitors and members of the public must not view without

the consent of the patient.

Patient Information

This is a Multidisciplinary Integrated Care Pathway (ICP).

The pathway will be kept at the foot of your bed as it is a document that all members of staff will refer to whilst providing your care, however if you wish it to be kept at the Nursing station please inform the Nursing staff.

It contains a record of your planned treatment/management, if you want to know more about your care please follow the pathway.

If you have any questions please do not hesitate to ask one of the nursing staff or doctors.

Remember this pathway is a guide to your expected care.

As an individual your health care requirements may vary from this pathway.

Do not worry if events do not occur at the exact time stated in the pathway, patient’s progress at different rates and the team involved in your care will use their professional judgement to adapt your care accordingly.

Any variation from the pathway will be recorded and explained to you at your request.

If you would like to know more about how we use your information please ask a member of staff for the leaflet “How we use your Health Records”

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EVENT TIME (24 hr clock)

DELAYS

Stroke onset

Ambulance arrived at scene

Ambulance departed scene

Ambulance arrived at ED

Stroke team bleeped

Stroke team arrived in ED

Patient left ED

CT scan completed

Thrombolysis started

Transfer to CCU

Transfer to ASU

Stroke Thrombolysis – Timing Sheet (24 hr clock)

5

FOR THE ATTENTION OF ALL STAFF

This Integrated Care Pathway has been developed for use as a plan of care for patients:

…………………………………………………………………………………………..

It is intended as a guide only; all staff must maintain professional responsibility and accountability when

using this pathway.

Decisions regarding an individual patient’s care remain at the discretion of the professional.

Please read instructions below and sign accountability section before using the pathway.

Instruction and information for staff

This pathway is to be completed by ALL members of the multidisciplinary team

involved in the patients care and will form part of the patients health record

All sections (where relevant) must be completed

All professionals using this pathway must complete all parts of the accountability

section

It supports decision making but does not constrain your clinical autonomy

Where available the pathway is evidence-based

When an activity has been completed, sign and record the time. If responsibility

for completion of an activity is shared all disciplines must sign

In exercising professional judgement alteration from the pathway must be noted

as a variance and must be recorded on the variance sheet

Please note variances may be positive or negative

Put a V in the box next to the activity and then record the variance on the

variance sheet

Record an explanation of the variance on the variance sheet

Record action taken as a result of the variance on the variance sheet

There is a multidisciplinary notes/communication section to record e.g. additional

care given. These must be signed and dated

Any additional documentation e.g. blood results must be filed with the ICP in the

patients case notes upon discharge

If you have any queries about using the ICP please contact the author/originator

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ONCE COMPLETED PLEASE FILE ICP IN PATIENTS HOSPITAL CASENOTES

Acute Stroke Thrombolysis Pathway

Write patient details or affix Identification label

Hospital Number: Name: Address: Date of Birth: NHS Number:

Abbreviations used in this section to be listed here with the full description:

GCS Glasgow Coma Score

NG Nasogastric tube

IM Intramuscular

NIHSS National Institute Health Stroke Scale

BP Blood pressure

FBC Full Blood Count

BS Blood Sugar

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(* If BS < 3.5millimols treat urgently and reassess once blood glucose normal)

Date & Time of symptom onset _________________ BP = GCS Best eye response Best motor response Best verbal response Has there been any loss of consciousness or syncope? Y (-1) N (0) Has there been any seizure activity? Y (-1) N (0)

Is there a NEW ACUTE onset or on awakening from sleep: Asymmetric facial weakness Y (1) N (0) Asymmetric arm weakness Y (1) N (0) Asymmetric leg weakness Y (1) N (0) Speech Disturbance Y (1) N (0) Visual Field Deficit Y (1) N (0)

TOTAL SCORE (-2 to +5)

A score > 0 indicates possible stroke Signature: ……………………………… Print Name:………………………………… Designation: ……………………………. Date: / /

*BS


ROSIER = Recognition of Stroke in the Emergency Room

BS = Blood Glucose

GCS = Glasgow Coma Score

BP = Blood Pressure

ED = Emergency Department

ROSIER

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The following MUST be answered YES before considering thrombolysis:

ROSIER > 0 YES

Clear time of onset within the previous 2 hours YES

Age between 18 – 80 years. YES

Patient NOT comatose or severely obtunded YES

NO seizure activity YES

Patient previously independent YES

Blood glucose between 2.8 and 22 mmols (BM sufficient) YES

Patient is NOT on warfarin (or anticoagulants) YES

IF the answer to the above questions are ALL YES then page the Stroke Team, insert TWO cannulae and send URGENT bloods – FBC, biochemistry screen, glucose, coagulation screen and group and save. Weight if possible.

IF ALL YES CONTACT STROKE TEAM AND COMMENCE NURSING CARE PATHWAY

IF ANY ARE ANSWERED NO THEN PATIENT IS NOT SUITABLE FOR

THROMBOLYSIS

Signature: Print name: Designation: Date:

Emergency Department

Acute Stroke Thrombolysis


ROSIER= Recognition of Stroke in the Emergency Room

Mmols= millimols

BS = Blood Glucose

FBC= Full blood count

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Inclusion criteria for stroke; The following must be answered YES:

Does the patient have symptoms of acute stroke? YES

Was the patient previously independent? YES

Age between 18 and 80? YES

Is there a clear time of onset within the last 120 minutes (2 hours) YES

Is there a measurable deficit on the NIH stroke scale? (5 - 25) YES

Exclusion criteria for stroke;

Was there a seizure at the time of symptom onset? NO

Is there a history of intracranial hemorrhage? NO

Is the history suggestive of SAH? NO

Is systolic BP > 185 mmHg BP: NO

Is diastolic BP > 110 mmHg NO

Has any new BP treatment been given to attain these limits? NO

Has the patient been given anticoagulant treatment within the last 48 hours, with an increased PTT?

NO

Has there been arterial puncture at a non-compressible site within the last 7 days?

NO

Has the patient undergone major surgery within the last 2 weeks? NO

Has there been any GI or urinary tract hemorrhage within the last 3 weeks?

NO

Has the patient suffered a stroke within the last 3 months? NO

Has the patient suffered a head trauma within the last 3 months? NO

History of anaphylaxis to rtPA? NO

Is plasma glucose < 2.7 or > 22.2 mmols/L? NO

If available

Is PT > 15 seconds? NO

Is platelet count < 100,000? NO

Following CT scan – must be answered YES

Has the CT brain scan since onset of stroke excluded haemorrhage? YES

Has the CT scan been reviewed by the stroke thrombolysis lead? YES

Has thrombolysis been discussed with patient and / or family? YES

Information sheet given and verbal consent / assent documented YES

Is there a monitoring bed available YES

Modified Rankin Score (note: this is a stroke outcome scale, and should be interpreted with caution for causes of disability other than previous stroke) Description Score No symptoms at all 0 No significant disability despite symptoms; able to carry out all usual duties and activities. 1 Slight disability; unable to carry out all previous activities, but able to look after own affairs without assistance

2

Moderate Disability; requiring some help, but able to walk without assistance 3 Moderately severe disability; unable to walk without assistance and unable to attend to own bodily needs without assistance

4

Severe disability; bedridden, incontinent and requiring constant nursing care and attention 5 Dead 6

Total Score

Thrombolysis for acute stroke checklist

Stroke Team Assessment

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National Institute of Health Stroke Scale (NIHSS) Pre 2 hrs

24hrs

7 day

1a Level of Consciousness (LOC)

Alert- keenly responsive Drowsy- rousable by minor stimulation to obey, answer, or respond Stuporous- requires repeated stimulation to attend, or is obtunded and requires strong or painful stimulation to make movements (not stereotyped) Comatose- responds only with reflex motor or autonomic effects or totally unresponsive, flaccid

0 1 2 3

0 1 2 3

0 1 2 3

0 1 2 3

1b LOC Questions

Answers both correctly Answers one correctly Both incorrect Patient is asked to state the month & his / her age

0 1 2

0 1 2

0 1 2

0 1 2

1c LOC Commands

Obeys both correctly Obeys one correctly Both incorrect Patient is asked to open & close eyes, grip & release normal hand

0 1 3

0 1 3

0 1 3

0 1 3

2. Best Gaze Normal Partial gaze palsy- gaze is abnormal in one or both eyes, no forced deviation/total gaze paresis Forced deviation- or total gaze paresis not overcome by oculocephalic manoeuvre

0 1 2

0 1 2

0 1 2

0 1 2

3.Visual Fields No visual loss(or in a coma) partial hemianopia complete hemianopia bilateral hemianopia-including cortical blindness

0 1 2 3

0 1 2 3

0 1 2 3

0 1 2 3

4. Facial Palsy Normal Minor- flattened nasolabial fold, asymmetry on smiling Partial- total or near total paralysis of lower face Complete- absent facial movement in upper and lower face and lower face on one or both sides

0 1 2 3

0 1 2 3

0 1 2 3

0 1 2 3

5. Best Motor RIGHT LEG

No drift- holds limb at 90 degrees for full 10 seconds Drift- drifts down but does not hit bed Some effort against gravity No effort against gravity No movement

0 1 2 3 4

0 1 2 3 4

0 1 2 3 4

0 1 2 3 4

6. Best Motor LEFT LEG

No drift- holds limb at 90 degrees for full 10 seconds Drift- drifts down but does not hit bed Some effort against gravity No effort against gravity No movement

0 1 2 3 4

0 1 2 3 4

0 1 2 3 4

0 1 2 3 4

7. Best Motor RIGHT ARM

No drift- holds arm at 45 degrees for full 5 seconds Drift- drifts down but does not hit bed Some effort against gravity No effort against gravity No movement

0 1 2 3 4

0 1 2 3 4

0 1 2 3 4

0 1 2 3 4

8. Best Motor LEFT ARM

No drift- holds arm at 45 degrees for full 5 seconds Drift- drifts down but does not hit bed Some effort against gravity No effort against gravity No movement

0 1 2 3 4

0 1 2 3 4

0 1 2 3 4

0 1 2 3 4

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9. Limb Ataxia Absent(or in coma) Present in 1 limb Present in 2 or more limbs

0 1 2

0 1 2

0 1 2

0 1 2

10. Sensory Normal Partial loss- patient feels pinprick is less sharp or is dull on affected side Dense loss(or in coma)- patient is unaware of being touched on face, arm, leg

0 1 2

0 1 2

0 1 2

0 1 2

11. Best Language

No dysphasia Mild- moderate dysphasia obvious loss of fluency or comprehension, without significant limitation on ideas expressed or form of expression. Makes conversation about provided material difficult or impossible, e.g. examiner can identify picture or naming card from patient’s response. Severe dysphasia- all communication is through fragmentary expression; great need for inference, questioning, and guessing by the listener who carries burden of communication. Examiner cannot identify materials provided from patient response Mute- no usable speech or auditory comprehension, or in coma.

0 1 2 3

0 1 2 3

0 1 2 3

0 1 2 3

12. Dysarthria Normal articulation Mild- moderate dysarthria- patient slurs some words can be understood with some difficulty. Unintelligible or worse- speech is so slurred as to be unintelligible (absence of or out of proportion to dysphasia) or is mute / anarthic, or in coma

0 1 2

0 1 2

0 1 2

0 1 2

13.Neglect No neglect(or in a coma) Partial neglect- visual, tactile, auditory, spatial, or personal inattention or extinction to bilateral simultaneous stimulation in one of the sensory modalities Complete neglect- profound hemi-inattention or hemi-inattention to more than one modality. Does not recognise own hand or orients to only one side of space

0 1 2

0 1 2

0 1 2

0 1 2

Total Score

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Alteplase (t-PA) Dosage Schedule for Acute Stroke

Vol. Of 1mg/1ml t-PA Vol. Of 1mg/1ml t-

PA

Patient weight (Kg) Total dose at

0.9mg/kg (mg) 10%

Bolus (ml) 90% Infusion

(ml) Patient

weight (Kg) Total dose at

0.9mg/kg (mg) 10%

Bolus (ml)

90% Infusion

(ml)

40 36 3.6 32.4 70 63 6.3 56.7

41 36.9 3.7 33.2 71 63.9 6.4 57.5

42 37.8 3.8 34 72 64.8 6.5 58.3

43 38.7 3.9 34.8 73 65.7 6.6 59.1

44 39.6 4 35.6 74 66.6 6.7 59.9

45 40.5 4.1 36.4 75 67.5 6.8 60.7

46 41.4 4.1 37.3 76 68.4 6.8 61.6

47 42.3 4.2 38.1 77 69.3 6.9 62.4

48 43.2 4.3 38.9 78 70.2 7 63.2

49 44.1 4.4 39.7 79 71.1 7.1 64

50 45 4.5 40.5 80 72 7.2 64.8

51 45.9 4.6 41.3 81 72.9 7.3 65.6

52 46.8 4.7 42.1 82 73.8 7.4 66.4

53 47.7 4.8 42.9 83 74.7 7.5 67.2

54 48.6 4.9 43.7 84 75.6 7.6 68

55 49.5 5 44.5 85 76.5 7.7 68.8

56 50.4 5 45.4 86 77.4 7.7 69.7

57 51.3 5.1 46.2 87 78.3 7.8 70.5

58 52.2 5.2 47 88 79.2 7.9 71.3

59 53.1 5.3 47.8 89 80.1 8 72.1

60 54 5.4 48.6 90 81 8.1 72.9

61 54.9 5.5 49.4 91 81.9 8.2 73.7

62 55.8 5.6 50.2 92 82.8 8.3 74.5

63 56.7 5.7 51 93 83.7 8.4 75.2

64 57.6 5.8 51.8 94 84.6 8.5 76.1

65 58.5 5.9 52.6 95 85.5 8.6 76.9

66 59.4 5.9 53.5 96 86.4 8.6 77.8

67 60.3 6 54.3 97 87.3 8.7 78.6

68 61.2 6.1 55.1 98 88.2 8.8 79.4

69 62.1 6.2 56 99 89.1 8.9 80.2

100kg &

over 90 9 81

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Integrated Care Plan

Restrictions for 24 hours (variants to this MUST be documented):

Patient are ADVISED to be on Bed Rest

AVOID Nasogastric tube

NO central venous access, arterial puncture or IM injections

NO anticoagulants, aspirin or non-steroidal anti-inflammatory drugs

NO urinary catheter

Measurements / Interventions

Timing Actions Signature

Intravenous Recombinant tissue plasminogen activator (Alteplase)

10% is given as bolus. The remaining over a period of sixty minutes.

Dosage 0.9mg per Kg. Maximum 90mg. As per dosage schedule NO OTHER INFUSIONS THROUGH SAME CANNULA

Glasgow Coma Score

Every 15 minutes for 1 hour before infusion

If GCS < 2 points inform medics, increase frequency and complete NIHSS

Every 15 minutes for 2 hours after commencing infusion

Then every 30 minutes for the following 6 hours

Then hourly until 24 hours after starting infusion

NIHSS Prior to commencement of infusion

Deterioration > 4 points inform medics – repeat CT scan

Repeat sooner if change GCS, as indicated above

2 hours following commencement of infusion

24 hours following infusion and at 7 days

Heart rate and rhythm

Continually via the cardiac monitor

Rate < 50 or >120 inform medics

OR

NEW AF or arrhythmia. Do 12 lead

ECG and inform medics

Oxygen Saturation

Continually via the cardiac monitor

If saturations < 95%:

Check airway, reposition and suction if necessary.

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Check for obstruction: Observe tongue for signs swelling or excessive bleeding mouth teeth and gums Give O2 via mask or nasal cannula 24%. Inform medics for review

Blood pressure RECORD using a manual cuff

Every 15 minutes for 1 hour before infusion. If Bp > 185/110 repeat in 5-10mins if remains high treat

Maintain Bp BELOW 185mmHg systolic and 110mmHg diastolic – On 2 consecutive readings 5-10 minutes apart.


Labetalol 10mg IV over 2 mins then 10-20 every 10-15mins up to a maximum 150 , stop when response adequate)

Then every 30 minutes for following 6 hours


Temperature Every 15 minutes for 1 hour before infusion

Core temp >37.8oc (using temporal artery thermometer) Cool. Remove clothing, use fans or tepid sponging. Give Paracetamol 1gram 6 hourly. Orally or PR >38.5 oc. Infective process. Sputum. MSU. Blood cultures. Inform medics.


Then every 30 minutes for following 6 hours


Blood Glucose Record on admission. If abnormal or diabetic record 4 hourly

< 3 mmols – Inform medics and give glucose as prescribed >10 mmols – inform medics. Consider insulin therapy.

15

Observe for:

Overt bleeding

Check patient for external signs of bleeding when carrying out observations. Skin, gum and nose bleeding usually do not require action

Other bleeding – STOP tPA. Compress site if possible Inform medics Give fluid replacement Check clotting and fibrinogen IF deterioration continue with fluid resuscitation and give packed cells, cryoprecipitate, fresh frozen plasma and platelets, on the advice of a haematologist.

Observe for:

Anaphylactic reactions; Hypotension Bronchospasm Rash Angio-oedema

When carrying out observations STOP tPA

Continue with O2 and IV fluids Inform medics Give Chlorphenamine 10 milligrams and Hydrocortisone 200 milligrams IV IF SEVERE breathing problems or hypotension give adrenaline IM 500 micrograms repeated if necessary every 5 minutes. NOTE No other IM injection can be given for 24 hours

Observe for:

Neurological deterioration, New headache, vomiting or acute rise in BP

STOP tPA

Inform medics Repeat CT head immediately

Bloods for FBC, fibrinogen and clotting.

Follow up CT Scan at 24 - 36 hours and MUST be done before commencing on aspirin therapy

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0hrs 15 30 45 1hr 1hr15 1hr30 1hr45 2hr 2hr30 3hr 3hr30 4hr 5hr 6hr 8hr 12hr 16hr 20hr 24hr

TIME (24 HR CLOCK)

eyes open

sleepy but can be fully

awakend by voice

sleepy requiring painful

stimuli to open eyes

No response to stimuli

Normal no speech difficulty

Some speech difficulty

No speech

Can lift up

moves but cannot lift

Cannot move

Can lift up

moves but cannot lift

Cannot move

40

39

38

37

36

35

160

140

120

100

80

60

40

240

220

200

190

180

170

160

150

140

130

120

110

100

90

80

70

50

40

IF FALL OF

1 SQUARE

OR MORE

SINCE 0hrs

SEE OVER

IF TOTAL

FALL OF 2

SQUARES

OR MORE

SINCE 0hrs

SEE OVER

SINCE THROMBOLYSIS

STROKE THROMBOLYSIS OBSERVATION COMPLICATION (STOC) CHART

Blo

od

Pre

ssu

re

PATIENT NAME

Co

nscio

us l

evel

Sp

eech

Heart

Rate

Arm

DATE OF BIRTH / / . DATE TODAY / / . TIME OF THROMBOLYSIS: hrs

Le

g

O2 SATS

IF <94%

SEE OVER

BM (Unless on GKI)

02 % OR L/MIN

IF SBP

<95mmHg

SEE OVER

Te

mp

era

ture

IF SBP >

185mmHg

SEE OVER

IF DBP >

110mmHg

SEE OVER

.

17

Suggested Interventions

NEUROLOGICAL DETERIORATION SINCE THROMBOLYSIS

IF THERE IS A FALL IN CONSCIOUS LEVEL SINCE THROMBOLYSIS BY 1 SQUARE OR MORE OR IF SPEECH + ARM + LEG TOTAL FALLS BY 2 SQUARES OR MORE SINCE THROMBOLYSIS THEN:

STOP ALTEPLASE INFUSION IF IT IS STILL RUNNING CHECK BP AND BM INFORM DOCTOR DOCTOR CONSIDER URGENT CT HEAD CONTACT STROKE PHYSICIAN ON CALL IF UNSURE NIL BY MOUTH UNLESS ABLE TO REASSESS SWALLOW CHECK CLOTTING IF HAEMORRHAGE OR MASSIVE OEDEMA ON CT SCAN THEN CONTACT

NEUROSURGEONS IF HAEMORRHAGE AND CLOTTING ABNORMAL THEN GIVE CRYOPRECIPITATE

HYPER / HYPOTENSION IF SYSTOLIC BP ABOVE 185mm Hg OR IF DIASTOLIC ABOVE 110mm Hg AT ANY TIME THEN:

CONFIRM WITH MANUAL MEASUREMENT (AND CONTINUE WITH MANUAL MEASUREMENTS)

CHECK FOR PAIN AND TREAT CAUSE IF STILL ABOVE RANGE RECHECK IN 5 MINUTES INFORM DOCTOR CONSIDER IV GTN (If GTN started then use GTN protocol and chart)

IF SYSTOLIC BP BELOW 95mmHg THEN:

STOP GTN INFUSION IF RUNNING CHECK FOR EXTERNAL OR INTERNAL BLEEDING (SEE BELOW) RECHECK IN 5 MINUTES IF STILL BELOW RANGE INFORM DOCTOR GIVE IV FLUIDS IF APPROPRIATE URGENT BLOODS FOR FBC / CLOTTING

HYPOXIA IF OXYGEN SATURATION BELOW 94% THEN:

SIT THE PATIENT UP! INCREASE O2 IF APPROPRIATE INFORM DOCTOR

BLEEDING

IF MAJOR BLEEDING STOP ALTEPLASE INFUSION INFORM DOCTOR GIVE IV FLUIDS URGENT BLOODS FOR FBC/CLOTTING

MBH 1680B

18

Intracranial Haemorrhage Algorithm Haemorrhage following initiation of thrombolytic therapy for stroke

Note 1:

Preparations for giving platelets and Cryoprecipitate can be initiated at the first suspicion of haemorrhage so that they would be ready if needed.

Local guidance is that 2 doses of platelets are administered (8 units)

Local guidance is that 2 doses of cryoprecipitate are administered (10 units)

Potential volume is 850 ml so care with patients who have heart failure Note 2:

Recommend any patient with symptomatic haemorrhage is discussed with the Consultant on call to consider whether neurosurgical referral is beneficial

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Documents

Stroke Thrombolysis Pathway