แนวทางรักษา stroke-fast-track 2007

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ISBN : 974-8133-47-8

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2. π.æ.¡—¬∏—™ “¡‡ π ª√–∏“π

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4. π.æ. ÿ™“µ‘ À“≠‰™¬æ‘∫Ÿ≈¬å°ÿ≈ √Õßª√–∏“π 2

5. æ.≠.∑—»π’¬å µ—πµ‘ƒ∑∏‘»—°¥‘Ï √Õßª√–∏“π 3

6. ».π.æ.π‘æπ∏å æ«ß«√‘π∑√å §≥–∑”ß“π

7. æ≈.µ.æ.≠.®‘µ∂πÕ¡ ÿ«√√≥‡µ¡’¬å §≥–∑”ß“π

8. æ.Õ.º».π.æ. “¡“√∂ π‘∏‘π—π∑πå §≥–∑”ß“π

9. ».æ.≠.¥‘…¬“ √—µπ“°√ §≥–∑”ß“π

10. √».æ.≠.π‘®»√’ ™“≠≥√ß§å §≥–∑”ß“π

11. π.æ.¬ß§å™—¬ π‘≈–ππ∑å §≥–∑”ß“π

12. π.æ. ¡“π µ—ÈßÕ√ÿ≥»‘≈ªá §≥–∑”ß“π

13. π.æ.æ‘‡™…∞ ‡¡∏“√—°…å™’æ §≥–∑”ß“π

14. æ.≠.æ√æ‘¡≈ ¡“» °ÿ≈æ√√≥ §≥–∑”ß“π

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16. π.æ. ÿ√»—°¥‘Ï ‚°¡≈®—π∑√å §≥–∑”ß“π

17. π.æ.°‘µµ‘™“µ‘ Õ‘π∑ÿ √ §≥–∑”ß“π

18. π.æ.‡¡∏“ Õ¿‘«—≤π“°ÿ≈ §≥–∑”ß“π

19. æ.≠.¢«—≠√—µπå À«—ßº≈æ—≤π»‘√‘ §≥–∑”ß“π

20. π“ß ÿ≥’ ¿“≥ÿ‡√◊Õß√—»¡’ §≥–∑”ß“π

21. π“ß· ß∑» ¡ÿ ‘°∂“«√ §≥–∑”ß“π

22. æ.≠.°“≠®π“ Õ—Îπ«ß»å ‡≈¢“πÿ°“√

23. π. .Õ‘ √’ µ√’°¡≈ ºŸâ™à«¬‡≈¢“πÿ°“√·≈–ºŸâª√– “πß“π

§≥–∫√√≥“∏‘°“√ : π.æ. ¡™“¬ ‚µ«≥–∫ÿµ√

æ.≠.∑—»π’¬å µ—πµ‘ƒ∑∏‘»—°¥‘Ï

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¥â«¬°“√©’¥¬“≈–≈“¬≈‘Ë¡‡≈◊Õ¥∑“ßÀ≈Õ¥‡≈◊Õ¥¥” 5

°“√∫√‘À“√¬“≈–≈“¬≈‘Ë¡‡≈◊Õ¥∑“ßÀ≈Õ¥‡≈◊Õ¥¥” 6

°“√√—°…“¿“«–·∑√° âÕπ 8

Monitor and care during and after thrombolytic treatment 9

Elevated Blood Pressure Treatment Sheet for Thrombolytic Therapy 10

‡Õ° “√Õâ“ßÕ‘ß 11

¿“§ºπ«°

1. NIHSS score sheet 12

2. The Barthel Index, The Modified Rankin Scale 18

3. µ—«Õ¬à“ß Stroke fast track care maps and protocols 20

3.1 §≥–·æ∑¬»“ µ√å ®ÿÃ“≈ß°√≥å¡À“«‘∑¬“≈—¬ 21

3.2 §≥–·æ∑¬»“ µ√å ‚√ßæ¬“∫“≈√“¡“∏‘∫¥’ ¡À“«‘∑¬“≈—¬¡À‘¥≈ 27

3.3 §≥–·æ∑¬»“ µ√å»‘√‘√“™æ¬“∫“≈ ¡À“«‘∑¬“≈—¬¡À‘¥≈ 29

3.4 ∂“∫—πª√– “∑«‘∑¬“ °√¡°“√·æ∑¬å °√–∑√«ß “∏“√≥ ÿ¢ 37

4. CT scan examples for early signs of cerebral ischemia 43

5. Stroke Unit 46

“√∫—≠µ“√“ß

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µ“√“ß∑’Ë 1 Doctorûs orders 9

µ“√“ß∑’Ë 2 Elevated blood pressure treatment for thrombolytic therapy 10

µ“√“ß∑’Ë 3 The Modified National Institutes of Health Stroke Scale 16

µ“√“ß∑’Ë 4 The Barthel Index 18

µ“√“ß∑’Ë 5 The Modified Rankin Scale 19

‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß (stroke, cerebrovascular disease) ‡ªìπ‚√§∑’Ëæ∫∫àÕ¬„πºŸâ ŸßÕ“¬ÿ∑—Ë«‚≈° „πª√–‡∑»

∑’Ëæ—≤π“·≈â« æ∫«à“‡ªìπ “‡Àµÿ°“√µ“¬∑’Ë ”§—≠‡ªìπÕ—π¥—∫ 3 √Õß®“°‚√§À—«„®·≈–‚√§¡–‡√Áß ”À√—∫„πª√–‡∑»

®’π·≈–≠’ËªÿÉπ æ∫«à“‡ªìπ “‡Àµÿ°“√µ“¬Õ—π¥—∫ 2 √Õß®“°‚√§À—«„®(1) „πª√–‡∑»‰∑¬‰¥â¡’°“√»÷°…“Õ—µ√“§«“¡™ÿ°

¢Õß‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß„π™ÿ¡™π‡¡◊Õß ®”π«π 1,361 √“¬ „π°√ÿß‡∑æ¡À“π§√ ‡¡◊ËÕªï æ.». 2526 æ∫«à“¡’Õ—µ√“

‡∑à“°—∫ 690/100,000 ¢Õßª√–™“°√∑’ËÕ“¬ÿ‡°‘π 20 ªï(2) ·≈–≈à“ ÿ¥„πªï æ.». 2541 ‰¥â¡’°“√»÷°…“«‘®—¬„πª√–™“°√

ºŸâ ŸßÕ“¬ÿ (‡°‘π 60 ªï) „π™π∫∑ 4 ¿“§∑—Ë«ª√–‡∑» 3,036 √“¬ æ∫«à“¡’Õ—µ√“§«“¡™ÿ°¢Õß‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß

„°≈â‡§’¬ß°—∫ª√–™“°√„πª√–‡∑»µà“ßÊ ∑—Ë«‚≈°(1) ¥—ßπ—Èπ ‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß®÷ß‡ªìπ‚√§∑’Ë¡’§«“¡ ”§—≠¬‘Ëß

‚√§Àπ÷Ëß¢Õßª√–™“°√‰∑¬ ·≈– ¡§«√®—¥∑”·π«∑“ß°“√√—°…“‚√§π’È

Õß§å°“√Õπ“¡—¬‚≈°‰¥â°”Àπ¥§”®”°—¥§«“¡¢Õß‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß‰«â¥—ßπ’È

çRapidly developed clinical signs of focal (global) disturbance of cerebral function lasting more than 24

hours or leading to death, with no apparent cause other than a vascular originé(3)

°“√«‘π‘®©—¬‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß¬—ß§ß∂◊Õ«à“ °“√«‘π‘®©—¬∑“ß§≈‘π‘°‡ªìπ ‘Ëß ”§—≠ ºŸâªÉ«¬‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßπ—Èπ

à«π„À≠à®–¡’Õ“°“√∑“ß√–∫∫ª√– “∑‡ªìπ·∫∫‡©æ“–∑’Ë ‡™àπ ÕàÕπ·√ß§√÷Ëß ’° °≈◊π≈”∫“° æŸ¥≈”∫“° ‡¥‘π‡´

µ“¡Õß‰¡à‡ÀÁπ ¡Õß‡ÀÁπ¿“æ´âÕπ ‡«’¬π»’√…– ‚¥¬∑’ËÕ“°“√‡À≈à“π’È®–‡ªìπÕ¬à“ß‡©’¬∫æ≈—π Õ¬à“ß‰√°Áµ“¡ ºŸâªÉ«¬

∫“ß√“¬Õ“®¡’Õ“°“√·∫∫§àÕ¬‡ªìπ§àÕ¬‰ª„π 2 - 3 «—π À√◊Õ¥’¢÷Èπ·≈â«‡≈«≈ß‰¥â(4) ·≈–∂â“ºŸâªÉ«¬¡’ªí®®—¬‡ ’Ë¬ß®–™à«¬

π—∫ πÿπ°“√«‘π‘®©—¬‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß¡“°¬‘Ëß¢÷Èπ ‡™àπ §«“¡¥—π‚≈À‘µ Ÿß ‡∫“À«“π Ÿ∫∫ÿÀ√’Ë ‚√§À—«„® ‡ªìπµâπ

ªí®®ÿ∫—π«‘∏’°“√√—°…“ºŸâªÉ«¬‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß‰¥âæ—≤π“¡“Õ¬à“ßµàÕ‡π◊ËÕß «‘∏’∑’Ë‰¥â√—∫°“√¬Õ¡√—∫„πªí®®ÿ∫—π

«‘∏’Àπ÷Ëß ‰¥â·°à °“√„Àâ¬“≈–≈“¬≈‘Ë¡‡≈◊Õ¥∑“ßÀ≈Õ¥‡≈◊Õ¥¥”„π‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßµ’∫·≈–Õÿ¥µ—π ´÷Ëß¡’¢âÕ®”°—¥

„π°“√¥”‡π‘π°“√À≈“¬ª√–°“√ ‡™àπ ¡’°“√«‘π‘®©—¬·≈–‡√‘Ë¡°“√„Àâ¬“≈–≈“¬≈‘Ë¡‡≈◊Õ¥¿“¬„π 3 ™—Ë«‚¡ßÀ≈—ß‡°‘¥Õ“°“√

“¡“√∂ªØ‘∫—µ‘„π ∂“πæ¬“∫“≈∑’Ë¡’§«“¡æ√âÕ¡∑“ß¥â“π∫ÿ§≈“°√ ÀâÕßªØ‘∫—µ‘°“√ ·≈–Àπà«¬√—∫ºŸâªÉ«¬„π ‡ªìπµâπ

∂“π∫√‘°“√∫“ß·Ààß„πª√–‡∑»‰∑¬¬—ß‰¡àæ√âÕ¡∑’Ë®–‡ªî¥„Àâ∫√‘°“√©’¥¬“≈–≈“¬≈‘Ë¡‡≈◊Õ¥„πºŸâªÉ«¬‚√§À≈Õ¥‡≈◊Õ¥

¡Õßµ’∫·≈–Õÿ¥µ—π¿“¬„π 3 ™—Ë«‚¡ß Õ¬Ÿà 2 ¥â“π §◊Õ ¥â“πºŸâ„Àâ∫√‘°“√ ‚¥¬‰¡à¡’§«“¡æ√âÕ¡¢Õß ∂“πæ¬“∫“≈

∑’Ë„Àâ∫√‘°“√ ∑—Èß„π¥â“π ∂“π∑’Ë·≈–∫ÿ§≈“°√∑’Ë‡°’Ë¬«¢âÕß ·≈–¥â“πºŸâ√—∫∫√‘°“√ ‚¥¬¬—ß¡’§«“¡‰¡à‡¢â“„®¢Õßª√–™“™π

∑’Ë¡“√—∫∫√‘°“√ ∂÷ß·¡â«à“º≈°“√√—°…“«‘∏’¥—ß°≈à“«¢â“ßµâπ®–‡ªìπª√–‚¬™πå ·µà°ÁµâÕß¡’°“√ª√–™“ —¡æ—π∏å„Àâª√–™“™π

‡¢â“„®«à“ ‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß¡’Õ“°“√Õ¬à“ß‰√ ·≈–®–µâÕß¡“æ∫·æ∑¬å‚¥¬‡√Á«∑’Ë ÿ¥‡∑à“∑’Ë®–‡√Á«‰¥â ®÷ß®–‰¥âº≈¥’

√«¡∑—ÈßµâÕßª√–™“ —¡æ—π∏å«à“Àπà«¬ß“π„¥ “¡“√∂„Àâ°“√√—°…“«‘∏’π’È‰¥â

¥â«¬¢âÕ®”°—¥¥—ß°≈à“« ®÷ß∑”„Àâ ∂“πæ¬“∫“≈®”π«π¡“°·¡â¡’∫ÿ§≈“°√®“° “¢“«‘™“™’æµà“ßÊ §√∫∂â«π

·≈–¡’‡§√◊ËÕß¡◊Õ∑“ß°“√·æ∑¬åÕ¬à“ßæÕ‡æ’¬ß ·µà‰¡à “¡“√∂¥”‡π‘π°“√‰¥â ¥—ßπ—Èπ ·π«∑“ß°“√√—°…“‚√§À≈Õ¥‡≈◊Õ¥

¡Õßµ’∫À√◊ÕÕÿ¥µ—π¥â«¬°“√©’¥¬“≈–≈“¬≈‘Ë¡‡≈◊Õ¥∑“ßÀ≈Õ¥‡≈◊Õ¥¥”π’È ®÷ß¡’¢÷Èπ‡æ◊ËÕ àß‡ √‘¡»—°¬¿“æ¢ÕßÀπà«¬ß“π

„Àâ “¡“√∂„Àâ∫√‘°“√©’¥¬“≈–≈“¬≈‘Ë¡‡≈◊Õ¥¥—ß°≈à“«‰¥â Õ—π®–∑”„Àâ “¡“√∂≈¥Õ—µ√“µ“¬ Õ—µ√“æ‘°“√ µ≈Õ¥®π√–¬–

‡«≈“°“√√—°…“µ—«„π‚√ßæ¬“∫“≈·≈–§à“„™â®à“¬„π¿“æ√«¡

∫∑π”

8 ·π«∑“ß°“√√—°…“‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßµ’∫·≈–Õÿ¥µ—π¥â«¬°“√©’¥¬“≈–≈“¬≈‘Ë¡‡≈◊Õ¥∑“ßÀ≈Õ¥‡≈◊Õ¥¥”

»—°¬¿“æ¢Õß‚√ßæ¬“∫“≈∑’Ë “¡“√∂¥”‡π‘π°“√√—°…“‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßµ’∫·≈–Õÿ¥µ—π

¥â«¬°“√©’¥¬“≈–≈“¬≈‘Ë¡‡≈◊Õ¥∑“ßÀ≈Õ¥‡≈◊Õ¥¥”

∂“π∫√‘°“√µâÕß “¡“√∂„Àâ∫√‘°“√ 24 ™—Ë«‚¡ß „πÀ—«¢âÕ¥—ßµàÕ‰ªπ’È

1. ª√– “∑·æ∑¬å À√◊Õ·æ∑¬å‡«™»“ µ√å©ÿ°‡©‘π/Õ“¬ÿ√·æ∑¬å ∑’Ë‰¥â√—∫ª√–°“»π’¬∫—µ√Ωñ°Õ∫√¡°“√„Àâ “√≈–≈“¬

≈‘Ë¡‡≈◊Õ¥ (rt-PA) „πºŸâªÉ«¬‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßµ’∫·≈–Õÿ¥µ—π„π√–¬–‡©’¬∫æ≈—π‚¥¬‰¥â√—∫°“√√—∫√Õß

®“° ∂“∫—π∑’Ë‰¥â√—∫°“√¬Õ¡√—∫„π√–¥—∫™“µ‘

2. ª√– “∑»—≈¬·æ∑¬å

3. CT brain

4. ¡’ÀâÕßªØ‘∫—µ‘°“√∑’Ë “¡“√∂µ√«® blood sugar, CBC, coagulogram, electrolyte, BUN, Cr

5. “¡“√∂À“‡≈◊Õ¥·≈– à«πª√–°Õ∫¢Õß‡≈◊Õ¥‰¥â ‡™àπ fresh frozen plasma, cryoprecipitate, platelet con-

centrate ·≈– pack red cell

6. ¡’ ICU À√◊Õ Stroke Unit (SU) (¥Ÿ¿“§ºπ«° 5)

7. ¡’°“√ ”√Õß¬“ rt-PA ‰«â∫√‘‡«≥∑’Ë„Àâ°“√√—°…“ ‡™àπ ER, ICU À√◊Õ SU

·π«∑“ß°“√√—°…“‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßµ’∫·≈–Õÿ¥µ—π¥â«¬°“√©’¥¬“≈–≈“¬≈‘Ë¡‡≈◊Õ¥∑“ßÀ≈Õ¥‡≈◊Õ¥¥” 9

1. µ‘¥µàÕ·æ∑¬å* 2. «—¥ —≠≠“≥™’æ·≈– basic life support 3. µ‘¥µàÕ∑” CT brain 4. µ‘¥µàÕ ICU À√◊Õ SU

‡®“–‡≈◊Õ¥µ√«® blood sugar, CBC,

coagulogram, electrolyte, BUN, Cr.

·ºπ¿Ÿ¡‘∑’Ë 1


¥â«¬°“√©’¥¬“≈–≈“¬≈‘Ë¡‡≈◊Õ¥∑“ßÀ≈Õ¥‡≈◊Õ¥¥”

* ª√– “∑·æ∑¬å À√◊Õ ·æ∑¬å‡«™»“ µ√å©ÿ°‡©‘π/Õ“¬ÿ√·æ∑¬å∑’Ë‰¥â√—∫ª√–°“»π’¬∫—µ√Ωñ°Õ∫√¡œ

æ∫‡≈◊Õ¥ÕÕ°„π ¡Õß

ª√÷°…“µ“¡√–∫∫

‰¡àæ∫‡≈◊Õ¥ÕÕ°„π ¡Õß

·æ∑¬å*

1. µ√«® Õ∫¢âÕ∫àß™’È-¢âÕÀâ“¡°“√„Àâ¬“ ¥Ÿ∑’ËÀπâ“ 5

2. ¢Õ§«“¡¬‘π¬Õ¡°“√„Àâ¬“ ¥Ÿ∑’ËÀπâ“ 31, 40

3. µ‘¥µàÕª√– “∑»—≈¬·æ∑¬å°àÕπ„Àâ¬“

4 . “¡“√∂„Àâ¬“‰¥â∑’Ë ER/ICU/SU

¥Ÿ·ºπ¿Ÿ¡‘∑’Ë 2

1. ·¢π¢“™“ ÕàÕπ·√ß ¢â“ß„¥¢â“ßÀπ÷Ëß∑—π∑’

2. æŸ¥‰¡à™—¥ æŸ¥‰¡à‰¥â À√◊Õøíß‰¡à‡¢â“„®∑—π∑’

3. ‡¥‘π‡´ ‡«’¬π»’√…–∑—π∑’

4. µ“‡ÀÁπ¿“æ´âÕπÀ√◊Õ¡◊¥¡—«¢â“ß„¥¢â“ßÀπ÷Ëß∑—π∑’

æ¬“∫“≈

´—°ª√–«—µ‘

º≈ CT brain

ºŸâªÉ«¬∑’Ë¡’Õ“°“√ ß —¬‚√§À≈Õ¥

‡≈◊Õ¥ ¡Õß¿“¬„π 3 ™—Ë«‚¡ß


·ºπ¿Ÿ¡‘∑’Ë 2


¥â«¬°“√©’¥¬“≈–≈“¬≈‘Ë¡‡≈◊Õ¥∑“ßÀ≈Õ¥‡≈◊Õ¥¥” ∑’Ë ER/ICU/SU

ER/ICU/SU ‡ΩÑ“√–«—ßÕ¬à“ß„°≈â™‘¥µ“¡ stroke fast track care map and protocal ¿“§ºπ«° 3

„Àâ°“√√—°…“¿“«–·∑√°´âÕπ

(¥Ÿ∑’ËÀπâ“ 8)

- —ß‡°µ¿“«–·∑√°´âÕπ¿“¬À≈—ß

°“√„Àâ¬“ 48 ™¡.

- „Àâ°“√√—°…“µàÕµ“¡

CPG for ischemic stroke/

Stroke fast track care map*

‰¡à¡’ ¡’

CT brain ´È” 24 ™¡. À≈—ß„Àâ¬“

À√◊Õ‡¡◊ËÕ¡’Õ“°“√‡≈«≈ß

¿“«–·∑√° âÕπ

* “¡“√∂µ‘¥µàÕ¢Õ√—∫‰¥â∑’Ëß“π π—∫ πÿπ«‘™“°“√ ∂“∫—πª√– “∑«‘∑¬“


¢âÕ∫àß™’È·≈–¢âÕÀâ“¡„π°“√√—°…“ºŸâªÉ«¬‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßµ’∫·≈–Õÿ¥µ—π

¥â«¬°“√©’¥¬“≈–≈“¬≈‘Ë¡‡≈◊Õ¥∑“ßÀ≈Õ¥‡≈◊Õ¥¥”(5, 6, 7, 8)

¢âÕ∫àß™’È

1. ºŸâªÉ«¬‰¥â√—∫°“√«‘π‘®©—¬«à“‡ªìπ‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßµ’∫·≈–Õÿ¥µ—π¿“¬„π 3 ™—Ë«‚¡ß

2. Õ“¬ÿ¡“°°«à“ 18 ªï

3. ¡’Õ“°“√∑“ß√–∫∫ª√– “∑∑’Ë “¡“√∂«—¥‰¥â‚¥¬„™â NIHSS

4. º≈ CT scan ¢Õß ¡Õß‡∫◊ÈÕßµâπ‰¡àæ∫¿“«–‡≈◊Õ¥ÕÕ°

5. ºŸâªÉ«¬À√◊Õ≠“µ‘‡¢â“„®ª√–‚¬™πå·≈–‚∑…∑’Ë®–‡°‘¥¢÷Èπ®“°°“√√—°…“ ·≈–¬‘π¬Õ¡„Àâ°“√√—°…“ ‚¥¬„™â¬“≈–≈“¬

≈‘Ë¡‡≈◊Õ¥

¢âÕÀâ“¡

1. ¡’Õ“°“√¢Õß‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßµ’∫·≈–Õÿ¥µ—π∑’Ë‰¡à∑√“∫‡«≈“∑’Ë‡√‘Ë¡‡ªìπÕ¬à“ß™—¥‡®π À√◊Õ¡’Õ“°“√¿“¬À≈—ß

µ◊ËππÕπ

2. ¡’Õ“°“√¢Õß‚√§‡≈◊Õ¥ÕÕ°„µâ™—Èπ‡¬◊ËÕÀÿâ¡ ¡Õß (subarachnoid hemorrhage)

3. Õ“°“√∑“ß√–∫∫ª√– “∑¥’¢÷ÈπÕ¬à“ß√«¥‡√Á« À√◊Õ¡’Õ“°“√Õ¬à“ß‡¥’¬«·≈–‰¡à√ÿπ·√ß (NIHSS < 4)

4. ¡’Õ“°“√∑“ß√–∫∫ª√– “∑Õ¬à“ß√ÿπ·√ß (NIHSS > 18)

5. ¡’Õ“°“√™—°‡¡◊ËÕ‡√‘Ë¡¡’Õ“°“√‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßµ’∫·≈–Õÿ¥µ—π§√—Èßπ’È

6. §«“¡¥—π‚≈À‘µ„π™à«ß°àÕπ„Àâ°“√√—°…“ Ÿß (SBP > 185 mmHg, DBP > 110 mmHg)

7. ¡’ª√–«—µ‘‡≈◊Õ¥ÕÕ°„π ¡Õß¡“°àÕπ

8. ¡’ª√–«—µ‘‡ªìπ‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß À√◊Õ¡’∫“¥‡®Á∫∑’Ë»’√…–√ÿπ·√ß¿“¬„π 3 ‡¥◊Õπ

9. ‰¥â√—∫¬“µâ“π°“√·¢Áßµ—«¢Õß‡≈◊Õ¥ (heparin À√◊Õ warfarin) ¿“¬„π 48 ™—Ë«‚¡ß À√◊Õ¡’§à“ partial-thrombo-

plastin time º‘¥ª°µ‘ À√◊Õ¡’§à“ prothrombin time ¡“°°«à“ 15 «‘π“∑’ À√◊Õ¡’§à“ International

normalized ratio (INR) ¡“°°«à“ 1.5

10. ¡’ª√‘¡“≥‡°≈Á¥‡≈◊Õ¥πâÕ¬°«à“ 100,000/mm3

11. ¡’ª√–«—µ‘ºà“µ—¥„À≠à¿“¬„π 14 «—π

12. ¡’‡≈◊Õ¥ÕÕ°„π∑“ß‡¥‘πÕ“À“√À√◊Õ∑“ß‡¥‘πªí “«–¿“¬„π 21 «—π

13. ¡’√–¥—∫πÈ”µ“≈„π‡≈◊Õ¥µË”°«à“ 50 mg/dl (2.7 mmol/L) À√◊Õ Ÿß°«à“ 400 mg/dl (22.2 mmol/L)

§”π«≥‰¥â®“° Glucose (blood) 1 mg/dl = 0.05551 mmol/L9

14. ¡’ª√–«—µ‘ myocardial infarction ¿“¬„π 3 ‡¥◊Õπ

15. ¡’°“√‡®“–À≈Õ¥‡≈◊Õ¥·¥ß„πµ”·Àπàß∑’Ë‰¡à “¡“√∂°¥Àâ“¡‡≈◊Õ¥‰¥â ¿“¬„π 7 «—π

16. æ∫¡’‡≈◊Õ¥ÕÕ°À√◊Õ¡’°“√∫“¥‡®Á∫ (°√–¥Ÿ°À—°) ®“°°“√µ√«®√à“ß°“¬

17. º≈ CT brain æ∫‡π◊ÈÕ ¡Õßµ“¬¡“°°«à“ 1 °≈’∫ (hypodensity > 1/3 cerebral hemisphere) À√◊Õæ∫°“√

‡ª≈’Ë¬π·ª≈ß„π√–¬–·√°¢ÕßÀ≈Õ¥‡≈◊Õ¥ ¡Õßµ’∫¢π“¥„À≠à ‡™àπ æ∫ ¡Õß∫«¡ mass effect, sulcal

effacement


°“√∫√‘À“√¬“≈–≈“¬≈‘Ë¡‡≈◊Õ¥∑“ßÀ≈Õ¥‡≈◊Õ¥¥”

ª√‘¡“≥·≈–«‘∏’°“√∫√‘À“√¬“

¬“ recombinant tissue-plasminogen activator (rt-PA) ∑’Ë¡’Õ¬Ÿà„πª√–‡∑»‰∑¬„πªí®®ÿ∫—π™◊ËÕ Actilyse(R)

´÷Ëß¡’ 2 ¢π“¥ §◊Õ 50 ¡°. À√◊Õ 100 ¡°. µàÕ 1 °≈àÕß ·≈–„π 1 °≈àÕß ª√–°Õ∫¥â«¬ ºß¬“ rt-PA 1 ¢«¥

πÈ”°≈—Ëπª√“»®“°‡™◊ÈÕ 50 ´’´’ 1 ¢«¥ ‡¢Á¡º ¡¢«¥¬“ºß·≈–¢«¥πÈ”°≈—Ëπ 1 Õ—π ‡¢Á¡ ”À√—∫¥Ÿ¥¬“ 2 Õ—π

‡¢Á¡æ‘‡»…„Àâ¬“∑“ßÀ≈Õ¥‡≈◊Õ¥¥” 1 Õ—π syringe 10 ´’´’ 1 Õ—π ·≈–™ÿ¥„Àâ¬“∑“ßÀ≈Õ¥‡≈◊Õ¥¥” 1 ™ÿ¥ (¥Ÿ√Ÿª∑’Ë 1

·≈– 2)

¢—ÈπµÕπ°“√∫√‘À“√¬“¡’¥—ßπ’È

- §”π«≥ª√‘¡“≥¬“µ“¡πÈ”Àπ—°µ—«ºŸâªÉ«¬ ‚¥¬¡’ª√‘¡“≥ 0.9 ¡°./°°. (¢π“¥¢Õß¬“ Ÿß ÿ¥‰¡à‡°‘π 90 ¡°.)

- ‡≈◊Õ°„™â¢«¥¬“ rt-PA ∑’Ë‡À¡“– ¡µ“¡∑’Ë§”π«≥‰¥â

- º ¡¢«¥πÈ”°≈—Ëπ·≈–¢«¥¬“ºß‚¥¬„™â‡¢Á¡∑’Ë¡’Õ¬Ÿà„π™ÿ¥ ‚¥¬„ÀâπÈ”°≈—Ëπ‰À≈‰ªº ¡Õ¬Ÿà„π¢«¥¬“ºß

- „™â syringe ¥Ÿ¥¬“∑’Ëº ¡·≈â« ª√‘¡“≥ 10% ¢Õß¢π“¥¬“∑’Ë§”π«≥‰¥â·≈â«©’¥‡¢â“À≈Õ¥‡≈◊Õ¥¥”

„π 1 π“∑’

- µàÕ¢«¥¬“∑’Ë‡À≈◊Õ‡¢â“°—∫™ÿ¥„Àâ¬“∑“ßÀ≈Õ¥‡≈◊Õ¥¥”∑’Ë¡’¡“°—∫¬“·≈–À¬¥‡¢â“À≈Õ¥‡≈◊Õ¥¥”„π 60 π“∑’

‡¡◊ËÕµâÕß°“√„Àâ “√≈–≈“¬Õ◊Ëπ∑“ßÀ≈Õ¥‡≈◊Õ¥¥”¢≥–„Àâ¬“≈–≈“¬≈‘Ë¡‡≈◊Õ¥ §«√„Àâ∑“ßÀ≈Õ¥‡≈◊Õ¥¥”‡ âπÕ◊Ëπ

¢âÕ§«√√–«—ß

1. À≈’°‡≈’Ë¬ß°“√„Àâ¬“µâ“π‡°≈Á¥‡≈◊Õ¥ À√◊Õ¬“µâ“π°“√·¢Áßµ—«¢Õß‡≈◊Õ¥ ¿“¬„π 24 ™—Ë«‚¡ß¢Õß°“√√—°…“

2. µâÕßÀ¬ÿ¥„Àâ rt-PA ∑—π∑’∑’Ë ß —¬«à“¡’¿“«–‡≈◊Õ¥ÕÕ°„π ¡Õß ·≈–√’∫∑”°“√µ√«®«‘π‘®©—¬ æ√âÕ¡∑—Èßª√÷°…“

ª√– “∑»—≈¬·æ∑¬å∑—π∑’

3. ‰¡à§«√„ àÀ≈Õ¥„ÀâÕ“À“√ √«¡∑—Èß·∑ßÀ≈Õ¥‡≈◊Õ¥¥”„À≠à (central venous access) À√◊Õ·∑ßÀ≈Õ¥‡≈◊Õ¥·¥ß

¿“¬„π 24 ™—Ë«‚¡ßÀ≈—ß„Àâ rt-PA

4. À≈’°‡≈’Ë¬ß°“√„ à “¬ «πªí “«–„π™à«ß‡«≈“∑’Ë„Àâ¬“À√◊Õ¿“¬À≈—ß°“√„Àâ¬“ 30 π“∑’

5. §«∫§ÿ¡§«“¡¥—π‚≈À‘µ‰¡à„Àâ Ÿß ‚¥¬„Àâ SBP < 185 mmHg, DBP < 110 mmHg ‡π◊ËÕß®“°§«“¡

¥—π‚≈À‘µ Ÿß ®–‡ ’Ë¬ßµàÕ°“√‡°‘¥‡≈◊Õ¥ÕÕ°„π ¡Õß‰¥â


√Ÿª∑’Ë 1 ¬“ recombinant tissue-plasminogen activator (rt-PA)

√Ÿª∑’Ë 2 «— ¥ÿÕÿª°√≥å°“√„Àâ¬“ recombinant tissue-plasminogen activator (rt-PA)


°“√√—°…“¿“«–·∑√°´âÕπ

°“√√—°…“¿“«–∑’Ë¡’‡≈◊Õ¥ÕÕ°„π ¡Õß„πºŸâªÉ«¬∑’Ë‰¥â√—∫¬“≈–≈“¬≈‘Ë¡‡≈◊Õ¥

1. Õ“°“√·≈–Õ“°“√· ¥ß∑’Ë ß —¬«à“¡’‡≈◊Õ¥ÕÕ°„π ¡Õß

- Õ“°“√∑“ß√–∫∫ª√– “∑∑’Ë‡≈«≈ßÕ¬à“ß©—∫æ≈—π

- ª«¥»’√…–

- §«“¡¥—π‚≈À‘µ Ÿß¢÷ÈπÕ¬à“ß©—∫æ≈—π

- §≈◊Ëπ‰ âÕ“‡®’¬π

2. §«√ªØ‘∫—µ‘¥—ßπ’È

- À¬ÿ¥„Àâ¬“ rt-PA

- àßºŸâªÉ«¬∑” CT brain ∑—π∑’

- ‡®“–‡≈◊Õ¥µ√«® PT, aPTT ·≈– platelet count

- ‡µ√’¬¡ FFP ª√–¡“≥ 10 cc/kg

- ·®âß·æ∑¬åª√– “∑«‘∑¬“ À√◊Õ·æ∑¬åºŸâ¥Ÿ·≈

3. ‡¡◊ËÕ¡’‡≈◊Õ¥ÕÕ°„π ¡Õß

- µ√«® Õ∫º≈°“√µ√«® PT, aPTT ·≈– platelet count

- ª√÷°…“ª√– “∑»—≈¬·æ∑¬å∑—π∑’

- „Àâ FFP 10 cc/kg

- ª√–™ÿ¡ª√÷°…“·π«∑“ß°“√√—°…“√à«¡°—π∑“ß¥â“π»—≈¬°√√¡·≈–Õ“¬ÿ√°√√¡

- æ‘®“√≥“∑” CT scan È” ‡æ◊ËÕ¥Ÿ«à“¡’°“√‡ª≈’Ë¬π·ª≈ß¢Õß¢π“¥¢Õß°âÕπ‡≈◊Õ¥À√◊Õ‰¡à ¿“¬„π 24 ™—Ë«‚¡ß


q

q

q

MONITOR AND CARE DURING AND AFTER THROMBOLYTIC TREATMENT

µ“√“ß∑’Ë 1 Doctorûs orders

ORDER FOR ONE DAY ORDER FOR CONTINUATION

- rt-PA _____mg IV bolus in 1 minute then - NPO except medications for 24 hrs

- rt-PA _____mg IV drip in 60 minutes - Bed rest

- Check vital signs, neurological sign & NIHSS - IV fluid as appropriate

after infusion - Record I/O

15 mins. for 2 hrs. - Medication consider

then 30 mins. for 6 hrs. 1. H2 receptor blocker/proton pump inhibitor

then 60 mins. until 24 hrs. 2. Antihypertensive drugs if BP > 185/110

- If SBP > 185 or < 110 mm Hg, mmHg (¥ŸÀπâ“ 10)

DBP > 110 or < 60 mm Hg

please notify doctor

- Within 24 hrs after rt-PA infusion, Avoid

insertion Foley catheter, NG tube,

central venous access, arterial puncture &

intramuscular injection

If intracranial hemorrhage is suspected

1. Stop infusion of the thrombolytic drug.

2. Repeat CBC, platelet, INR, PTT, PT

3. Emergency CT brain

4. Consult neurosurgeon

5. Cross matching for FFP 6 to 8 units

(or 10 cc/kg)


Elevated Blood Pressure Treatment Sheet

for Thrombolytic Therapy

Desired BP : SBP not more than 180 mmHg and DBP not more than 105 mmHg

Check BP 15 min. for 2 hrs, then 30 min. for 6 hrs and finally hr for 16 hrs

µ“√“ß∑’Ë 2 Elevated blood pressure treatment for thrombolytic therapy

q qq

q

BP level

If DBP > 140 mmHg

If SBP > 180 or

DBP > 105 but < 140 mmHg

Treatment

Sodium nitroprusside 0.5 ug/kg/min. IV infusion as

initial dose and titrate to desired BP

Nicardipine 5 mg/h IV infusion as initial dose and titrate

to desired effect by increasing 2.5 mg/h 5 min to

maximum of 15 mg/h; If BP is not controlled,

consider sodium nitroprusside


‡Õ° “√Õâ“ßÕ‘ß

1. π‘æπ∏å æ«ß«√‘π∑√å. Epidemiology of stroke. „π : π‘æπ∏å æ«ß«√‘π∑√å, ∫°.‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß

(Stroke) ©∫—∫‡√’¬∫‡√’¬ß§√—Èß∑’Ë 2 °√ÿß‡∑æ¡À“π§√ : ‡√◊Õπ·°â«°“√æ‘¡æå, 2544: 1 - 37.

2. Viriyavejakul A, Poungvarin N, Vannasaeng S. The prevalence of stroke in urban community of

Thailand. J Neurology 1985; 232 (suppl): 93.

3. World Health Organization Meeting on Community Control of Stroke and Hypertension. Control of

stroke in the community: methodological considerations and protocol of WHO stroke register.

CVD/s/73.6 Geneva: WHO, 1973.

4. Adams H P Jr, Brott TG, Crowell RM, et al. Guidelines for the management of patients with acute

ischemic stroke. A statement for healthcare professionals from a special writing group of the

Stroke Council, American Heart Association. Stroke 1994; 25: 1901-14.

5. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Tissue

plasminogen activator for acute ischemic stroke. N Engl J Med 1995; 333: 1581-7.

6. Adams HP, Brott TG, Furlan AJ, et al. Guidelines for thrombolytic therapy for acute stroke: a

supplement to the guidelines for the management of patients with acute ischemic stroke: a

statement of healthcare professionals from a special writing group of the Stroke Council,

American Heart Association. Circulation. 1996; 94: 1167-74.

7. Adams HP, Adams RJ, Brott T, et al. Guidelines for the early management of patients with ischemic

stroke: a scientific statement from the Stroke Council of the American Stroke Association.

Stroke 2003; 34: 1056-83.

8. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Tissue

Plasminogen Activator for Acute Ischemic Stroke CT, computed tomography; NIHSS, National

Institute of Health Stroke Scale; NINDS, National Institute of Neurological Disorders and stroke.

N Engl J Med 1995; 333(24): 1581-7.

9. Henry JB. Clinical diagnosis and management by laboratory methods. 18th ed., WB Saunders Co.

1991.

10. Masur H, Papke K, Althoff S, et al. Scales and Scores in Neurology: Quantification of Neurological

Deficits in Research and Practice, Druckhaus Gotz. Ludwigsburg. 2004; 149 - 50.

11. Herndo RM. Handbook of Neurologic Rating Scales, Demos Vermande: 386 Park Avenue South.

New York. 1997; 163 - 164, 178, 180.

12. Hacke W, Lees K, Toni D, et al. Acute stroke treatment. Update 2006 (An educational slide kit),

product by infill Kommunikation through an educational grant from Boehringer Ingelheim GmbH.

(Actilyse). 2006; 50.

13. Royal College of physician of London, National clinical guidelines for stroke. Second edition, The

Lavenham Press Ltd. London. 2004; 13 - 7.


¿“§ºπ«° 1

NIHSS score sheet

The National Institutes of Health (NIH) Stroke Scale10

Application: Stroke

Area: Scientific studies

Duration: 10 - 15 minutes

Range of results: 0 - 36; the more points, the more sever the stroke sequelae

References: Brott T, Adams HP, Olinger CP et al. Measurements of acute cerebral infarction: a clinical

examination scale. Stroke 1989; 20: 864 - 70.

Level of consciousness

0 Alert, keenly responsive

1 Drowsy, but arousable by minor stimulation to obey, answer, or respond

2 Stuporous, requires repeated stimulation to attend, or lethargic or obtunded,

requiring strong or painful stimulation to make movements

3 Coma, responds only with reflex motor or autonomic effects, or unresponsive

Level of consciousness-questions

Ask patient the month and his/her age. Score first answer.

0 Answers both correctly

1 Answers one correctly

2 Incorrect

Level of consciousness-commands

Ask patient to open/close hand and eyes. Score if he or she makes unequivocal attempt.

0 Obeys both correctly

1 Obeys one correctly

2 Incorrect

Pupillary response

0 Both reactive

1 One reactive

2 Neither reactive


Best gaze

0 Normal

1 Partial gaze palsy; abnormal but not forced deviation

2 Forced deviation (total gaze paresis)

Confrontation testing using finger movements, inculding double simultaneous stimulation. Use visual theat if

consciousness or comprehension limit testing, scoring ç1é for any asymmetry demonstrated.

Best visual

0 No visual loss

1 Partial hemianopia

2 Complete hemianopia, to within 5 degrees of fixation

Facial palsy

0 Normal

1 Minor

2 Partial

3 Complete

Best motor-arm

Arms held for 10 sec at 90 degrees if sitting, 45 degree if lying. Grade weaker arm. Place arms in position

if comprehension reduced.

0 No drift in 10 sec

1 Drift, after brief hold

2 Cannot resist gravity, falling immediately but some effort made

3 No effort against gravity

Best motor-leg

While lying, patient to hold weaker leg raised 30 degrees for 5 sec. Place leg if comprehension reduced.

0 No drift in 5 sec

1 Drift, lowering within 5 sec

2 Cannot resist gravity, falling to bed but some effort made

3 No effort against gravity


Plantar reflex

0 Normal

1 Equivocal

2 One extensor

3 Bilateral extensor

Limb ataxia

Finger-nose and heel-to-shin tests performed; ataxia is scored only if out of proportion to weakness. If total

paralysis, score as absent.

0 Absent

1 Present in arm or leg

2 Present in arm and leg

Sensory

Tested with pin; only hemisensory loss scored. If comprehension or consciousness reduced, only score if

obvious evidence.

0 Normal

1 Partial loss, subjectively different but still felt

2 Dense loss, unaware of being touched

Neglect

0 No neglect

1 Partial neglect, visual, tactile, or auditory

2 Complete neglect, affecting more than one modality

Dysarthria

0 Normal articulation

1 Mild to moderate dysarthria, slurring some words

2 Near unintelligible or worse


Best language

Assessed from response during evaluation.

0 No aphasia

1 Mild to moderate aphasia; naming errors, paraphasia, etc.

2 Severe aphasia

3 Mute


The Modified National Institutes of Health Stroke Scale11

µ“√“ß∑’Ë 3 The Modified National Institutes of Health Stroke Scale

Item Name Response

1A Level of consciousness 0 = Alert

1 = Not alert, but arousable easily

2 = Not alert, obtunded

3 = Unresponsive

1B Questions 0 = Answers both correctly

1 = Answers one correctly

2 = Answers neither correctly

1C Commands 0 = Performs both tasks correctly

1 = Performs one task correctly

2 = Performs neither task correctly

2 Gaze 0 = Normal

1 = Partial gaze palsy

2 = Total gaze palsy

3 Visual fields 0 = No visual loss

1 = Partial hemianopsia

2 = Complete hemianopsia

3 = Bilateral hemianopsia

4 Facial palsy 0 = Normal

1 = Minor paralysis

2 = Partial paralysis

3 = Complete paralysis

5 Motor arm 0 = No drift

a. Left 1 = Drift before 10 seconds

b. Right 2 = Falls before 10 seconds

3 = No effort against gravity

4 = No movement

6 Motor leg 0 = No drift

a. Left 1 = Drift before 5 seconds

b. Right 2 = Falls before 5 seconds

3 = No effort against gravity

4 = No movement


µ“√“ß∑’Ë 3 The Modified National Institutes of Health Stroke Scale (µàÕ)

Item Name Response

7 Ataxia 0 = Absent

1 = One limb

2 = Two limbs

8 Sensory 0 = Normal

1 = Mild loss

2 = Severe loss

9 Language 0 = Normal

1 = Mild aphasia

2 = Severe aphasia

3 = Mute or global aphasia

10 Dysarthria 0 = Normal

1 = Mild

2 = Severe

11 Extinction/inattention 0 = Normal

1 = Mild

2 = Severe

There are 15 items in this version of the NIHSS. Complete scale with instructions can be obtained from the

National Institute of Neurological Disorders and Stroke (Lyden et al., 1994).


¿“§ºπ«° 2

The Barthel Index

µ“√“ß∑’Ë 4 The Barthel Index

1. Feeding 10 = Independent. Able to apply any necessary device. Feeds in reasonable time.

5 = Needs help, i.e., for cutting.

0 = Inferior performance.

2. Bathing 5 = Performs without assistance.


3. Personal Toilet 5 = Washes face, combs hair, brushes teeth, shaves (manages plug if electric razor)

(grooming) 0 = Inferior performance.

4. Dressing 10 = Independent. Ties shoes, fastens fasteners, applies braces.

5 = Needs help but does at least half of task within reasonable time.


5. Bowel Control 10 = No accidents. Able to use enema or suppository if needed.

5 = Occasional accidents or needs help with enema or suppository.


6. Bladder Control 10 = No accidents. Able to care for collecting device if used.

5 = Occasional accidents or needs help with device.


7. Toilet Transfers 10 = Independent with toilet or bedpan. Handles clothes, wipes, flushes,

or cleans pan.

5 = Needs help for balance, handling clothes or toilet paper.


8. Chair/Bed 15 = Independent, including locks of wheelchair and lifting footrests.

Transfers 10 = Minimum assistance or supervision.

5 = Able to sit, but needs maximum assistance to transfer.


9. Ambulation 15 = Independent for 50 yards. May use assistive devices, except for rolling walker.

10 = With help for 50 yards.

5 = Independent with wheelchair for 50 yards, only if unable to walk.


10. Stair Climbing 10 = Independent. May use assistive devices.

5 = Needs help or supervision.



µ“√“ß∑’Ë 5 The Modified Rankin Scale

Grade Description

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.


¿“§ºπ«° 3

µ—«Õ¬à“ß Stroke fast track care maps and protocols

1. §≥–·æ∑¬»“ µ√å ®ÿÃ“≈ß°√≥å¡À“«‘∑¬“≈—¬ª√–°Õ∫¥â«¬

1. Stroke fast track protocol

2. The National Institute of Health Stroke Scale (0 - 42) (NIHSS)

3. Barthel Index

4. Rankin Scale

5. Stroke discharge summary sheet

2. §≥–·æ∑¬»“ µ√å ‚√ßæ¬“∫“≈√“¡“∏‘∫¥’ª√–°Õ∫¥â«¬ Doctorûs order sheet: orders for acute stroke patients

3. §≥–·æ∑¬»“ µ√å»‘√‘√“™æ¬“∫“≈ª√–°Õ∫¥â«¬

1. Siriraj acute stroke protocol

2. Àπ—ß ◊Õ· ¥ß‡®µπ“¢Õ√—∫°“√√—°…“¿“«– ¡Õß¢“¥‡≈◊Õ¥‡©’¬∫æ≈—π ‚¥¬°“√„™â¬“≈–≈“¬≈‘Ë¡‡≈◊Õ¥

3. Dose t-PA (mg)

4. Checklist for intravenous thrombolysis in acute stroke

4. ∂“∫—πª√– “∑«‘∑¬“ª√–°Õ∫¥â«¬

1. Stroke fast track care map

2. Thrombolysis check list

3. Àπ—ß ◊Õ· ¥ß§«“¡¬‘π¬Õ¡©’¥¬“≈–≈“¬≈‘Ë¡‡≈◊Õ¥ rt-PA ∑“ßÀ≈Õ¥‡≈◊Õ¥¥”„πºŸâªÉ«¬‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßµ’∫

·≈–Õÿ¥µ—π

4. Doctorûs orders sheet

5. NIHSS score sheet (1)


µ—«Õ¬à“ß Stroke fast track care map and protocol

§≥–·æ∑¬»“ µ√å ®ÿÃ“≈ß°√≥å¡À“«‘∑¬“≈—¬

§≥–·æ∑¬»“ µ√å ®ÿÃ“≈ß°√≥å¡À“«‘∑¬“≈—¬

µâÕß‰¥â rt-PA °àÕπ ............ π. ‡À≈◊Õ‡«≈“Õ’° ....................

STROKE FAST TRACK !

µ“√“ß‡«≈“ ”À√—∫ºŸâªÉ«¬∑’Ë¡“¥â«¬Õ“°“√ ß —¬ stroke ¡’Õ“°“√¡“‰¡à‡°‘π 3 ™—Ë«‚¡ß

™◊ËÕºŸâªÉ«¬............................................. ‡æ» ™“¬ À≠‘ß Õ“¬ÿ............. ªï HN.................. «—π∑’Ë................

·æ∑¬å R med 2 ...................... R neuro 2.......................... R neuro 3...................... Time Signature

Symptoms at onset ÕàÕπ·√ß ™“ ‡¥‘π‡´ æŸ¥‰¡à™—¥ µ“¡—« Õ◊Ëπ Ê...........................

Time of arrival

Primary doctor Acute stroke Y N

Request blood test, CT scan

Neurologist Fast track Y N

The patient is transfered to CT at

History screening for exclusion

No Hx of head trauma or stroke within 3 mo

No Hx of major Sx or serious trauma within 14 days

No Hx of ICH, AVM or aneurysm

No Hx of GI or urinary tract hemorrhage within 21 days

No Hx of arterial puncture at non compressible site or LP within 7 days

No seizure at onset

No symptom suggests SAH

NIHSS .................................. BP..................................

Laboratory screening for exclusion

CT scan result ............................................................................................

No evidence of ICH No edema or brain shifting

Blood test results BS............ PT................ PTT.................... PLT......................

BS > 50 < 400 mg/dl Plt > 100,000

INR < 1.7 PTT not prolonged

Immediate physical examination before rt-PA infusion

No rapid spontaneous improvement SBP < 185, DBP < 110 mmHg

Consent form is signed

NIHSS ..............BP.................DOOR TO NEEDLE TIME............................

rt-PA Given Y N

Departure time from ER

Arrival time to stroke unit

Total time

Thrombolytic is not given

Reasons not to use thrombolytic drug

Excluded by clinical Minimal neurological deficit Excluded by history

Abnormal blood test Spontaneous improve Hemorrhagic stroke

Consent form was not signed High blood pressure Delayed processes

Note


§≥–·æ∑¬»“ µ√å ®ÿÃ“≈ß°√≥å¡À“«‘∑¬“≈—¬

™◊ËÕ.......................................... °ÿ≈................................. HN.................................

The National Institute of Health Stroke Scale (0 - 42) (NIHSS)

Date of examinationLevel of consciousness Alert 0

Drowsy 1Stuporous 2Coma 3

Two questions ∂“¡Õ“¬ÿ·≈–‡¥◊Õπ Both correct 0One correct 1None correct 2

Two commands À≈—∫µ“ ≈◊¡µ“·≈–°”¡◊Õ·∫¡◊Õ Obeys both 0Obeys none 2

Best gaze ¡Õß¥â“π¢â“ß Normal 0Partial gaze palsy 1Forced deviation 2

Best visual (visual field) No visual loss 0Partial hemianopia 1Complete hemianopia 2Bilateral hemianopia 3

Facial palsy Normal 0Minor 1Partial 2Complete 3

Best Motor Lt arm π—Ëß¬°·¢π 90 Õß»“ 10 «‘π“∑’ No drift 0Drift 1Fall in 10 secs 2No effort against gra 3No movement 4

Best Motor Rt arm π—Ëß¬°·¢π 90 Õß»“ 10 «‘π“∑’ No drift 0Drift 1Fall in 10 secs 2No effort against gra 3No movement 4

Best Motor Lt leg πÕπ¬°¢“ 45 Õß»“ 5 «‘π“∑’ No drift 0Drift 1Fall in 5 secs 2No effort against gra 3No movement 4

Best Motor Rt leg πÕπ¬°¢“ 45 Õß»“ 5 «‘π“∑’ No drift 0Drift 1Fall in 5 secs 2No effort against gra 3No movement 4

Limb Ataxia Absent 0Upper or lower limb 1Upper & lower limbs 2

Sensory Normal 0Partial loss 1Dense loss 2

Neglect No neglect 0Sensory or visual 1Sensory & visual 2

Dysarthria Normal articulation 0Mild to moderate 1Severe 2

Best language Aphasia No aphasia 0Mild to moderate 1Severe 2Mute 3

Total


§≥–·æ∑¬»“ µ√å ®ÿÃ“≈ß°√≥å¡À“«‘∑¬“≈—¬

ON ADMISSION

™◊ËÕ............................ °ÿ≈............................ HN............................

BARTHEL INDEX

WITH HELP INDEPENDENT

1. Feeding 5 10

2. Moving from wheelchair to bed and return

(includes sitting up in bed) 5 or 10 15

3. Personal toilet (wash face, comb hair, shave, clean teeth) 0 5

4. Getting on and off toilet (handing clothes, wipe, flush) 5 10

5. Bathing self 0 5

6. Walking on level surface (if unable propel wheelchair) 10 15

* Score only if unable to walk 0* 5*

7. Ascend and descend stairs 5 10

8. Dressing (includes tying shoes, fastening fasteners) 5 10

9. Controlling bowel 5 10

10. Controlling bladder 5 10

Total score

RANKIN SCALE

No symptoms at all 0

No significant disability despite symptoms: able carry outall usual duties and activities. 1

Slight disability: unable to carry out all previous activitiesbut able to look after own affairs without assistance. 2

Moderate disability: requiring some help; but able to walkwithout assistance. 3

Moderately severe disability: unable to walk withoutassistance and unable to attend to own bodily needs withoutassistance. 4

Severe disability: bedridden, incontinent, and requiring constantnursing care and attention 5


§≥–·æ∑¬»“ µ√å ®ÿÃ“≈ß°√≥å¡À“«‘∑¬“≈—¬

™◊ËÕ........................ °ÿ≈..................... Õ“¬ÿ............... HN....................................

Stroke Discharge Summary Sheet

Date of admission .................................................................. Date of discharge .....................................................................

Final Diagnosis Hemorrhagic stroke type............................

Ischemic Stroke

Vessel: Anterior circulation: ACA/MCA

Posterior circulation: PCA/VB/AICA/PICA/SCA

Cause Emboli : cardiac Type Total anterior circulation infarct

Emboli : artery Partial anterior circulation infarct

Emboli : unknown Posterior circulation infarct

Large vessel thrombosis Lacunar

Lacunar stroke : type........................................

Others...............................................................

Risk of stroke HT AF DM Smoking Alc Dyslipid Others......................................

Complication: Intracerebral hemorrhage Brain edema Others.............................................................

Other diagnosis

1. .......................................................................................................

2. ....................................................................................................... CT

3. .......................................................................................................

Investigations

Lab: Hct.............. WBC............. PMN.............% L.............% Eo...........% B..............% Plt............. ESR.........................mm/hr

VDRL.......... FPG........... BUN........... Cr.......... Chol........... TG........... HDL........... LDL................ Stool occ bl............

CT scan.......................................................................................... EKG...............................................................................................

MRI not done done scheduled on.........................................................................................................................

MRI brain result....................................................................................................................................................................................

MRA brain result....................................................................................................................................................................................

MRA neck result....................................................................................................................................................................................

CDUS not done done result.............................................................................................................................................

Echocardiogram not done done result..................................................................................................................

Condition on discharge BP...................... mmHg

Result : improved stable worse dead cause............................................................................................

NIHSS on admission................................................ NIHSS on discharge.........................................................................................

Barthel Index............................................................. Rankin Scale....................................................................................................

Hospital meds.........................................................................................................................................................................................

Discharge meds......................................................................................................................................................................................

·æ∑¬åºŸâµ√«®.................................................................


§≥–·æ∑¬»“ µ√å ®ÿÃ“≈ß°√≥å¡À“«‘∑¬“≈—¬

ON DISCHARGE

™◊ËÕ...................................................... °ÿ≈................................................. HN............................

BARTHEL INDEX

WITH HELP INDEPENDENT

1. Feeding 5 10

2. Moving from wheelchair to bed and return

(includes sitting up in bed) 5 or 10 15

3. Personal toilet (wash face, comb hair, shave, clean teeth) 0 5

4. Getting on and off toilet (handing clothes, wipe, flush) 5 10

5. Bathing self 0 5

6. Walking on level surface (if unable propel wheelchair) 10 15

* Score only if unable to walk 0* 5*

7. Ascend and descend stairs 5 10

8. Dressing (includes tying shoes, fastening fasteners) 5 10

9. Controlling bowel 5 10

10. Controlling bladder 5 10

Total score

RANKIN SCALE

No symptoms at all 0

No significant disability despite symptoms: able carry outall usual duties and activities. 1

Slight disability: unable to carry out all previous activitiesbut able to look after own affairs without assistance. 2

Moderate disability: requiring some help; but able to walkwithout assistance. 3

Moderately severe disability: unable to walk withoutassistance and unable to attend to own bodily needs withoutassistance. 4

Severe disability: bedridden, incontinent, and requiring constantnursing care and attention 5




§≥–·æ∑¬»“ µ√å ‚√ßæ¬“∫“≈√“¡“∏‘∫¥’

¡À“«‘∑¬“≈—¬¡À‘¥≈


™◊ËÕ..............................................................................................

H.N...........................................................................................

Õ“¬ÿ................................................... ·ºàπ∑’Ë..........................

DateHour

Admit to Stroke Unit/ICUDx : ................................................................Vitals : Q 4 hours, I/OActivity : Bed rest

Head flat (< 30)Fall precautionAspiration precaution

Diet : NPO until cleared by M.D.orswallowing assessment

Medications:-

- Paracetamol 500 mg po/NGprn pain of fever Q 4 hours

- MOM 30 ml po/NG prnconstipation QD

Sign.........................code...........................

DateHour

DateHour

§≥–·æ∑¬»“ µ√å‚√ßæ¬“∫“≈√“¡“∏‘∫¥’ ¡À“«‘∑¬“≈—¬¡À‘¥≈

RAMATHIBODI HOSPITAL

Department Division Ward

Attending Staff Resident

DOCTORûS ORDER SHEET

Orders for 1 day only Orders for Continuation OFF

CBC, PT/INR, PTTBUN/Cr, Electrolytes, glucoseCapillary blood glucose0.9% NSS..................ml/h IV dripO2 nasal cannula 2 LPMCT brain without contrastNotify neurology resident on call12-lead EKGChest X-rayPlease check

Foley catheter placement NG tube placement if at high risk of aspiration tPA and post-tPA orders

NPO except medsObtain another IV line (hepLock)Keep SBP < 185 and DBP < 110 mmHgMay give Nicardipine IV dripObtain Actilyse (t-PA)

(Do not mix until told to do so)Total dose =..................mg (0.9 mg/kg, max 90 mg)

- 10% of total dose in 1 min- the remaining in 60 min

Record BP as follows:-Q 15 mins 2 hoursQ 30 mins 6 hoursQ 1 hour 16 hoursQ 4 hours if stable

Record neuro-signs (GCS) Q 1 hour 24 hoursNotify acute stroke on call Neurology resident if BP > 180/110 mmHgor decline in Neuro status or decrease in GCSNo arterial punctureNo aspirin, aspirin/dipyridamole (Aggrenox®),ticlopidine (Ticlid®), clopidogrel (Plavix®), cilostazole (Pletaal®)heparin, warfarin (Coumadin), Enoxaprarin (Clexane), Nadroparin (Fraxiparine)or any other antithrombotic for first 24 hrs. Post t-PA administrationCT scan after t-PA administration 24 hours

Sign..........................code..........................



§≥–·æ∑¬»“ µ√å»‘√‘√“™æ¬“∫“≈

¡À“«‘∑¬“≈—¬¡À‘¥≈

10. Consent form(Resident/Staff neurology)

§≥–·æ∑¬»“ µ√å»‘√‘√“™æ¬“∫“≈ ¡À“«‘∑¬“≈—¬¡À‘¥≈

Siriraj Acute Stroke Protocol

1. ‡«≈“¢≥–‡√‘Ë¡¡’Õ“°“√..........................

ºŸâ∫—π∑÷° ....................................

2. ¡“∂÷ß∑’Ë ER‡«≈“ .............................

ºŸâ∫—π∑÷° ..............................

3. æ¬“∫“≈§—¥°√Õß‡«≈“ ................................

ºŸâ∫—π∑÷° ................................

(ER nurse)

4. ·æ∑¬å‡«√ ER‡√‘Ë¡ —°ª√–«—µ‘/µ√«®√à“ß°“¬‡«≈“ ................................

ºŸâ∫—π∑÷° ................................

7. ‡®“– CBC, BS, electrolyte, BUN,Cr, Coagulogram, INR‡«≈“ ...............................

ºŸâ∫—π∑÷° ...............................

(ER physician)

6. Activate Siriraj acute stroke team‡«≈“ ......................................

ºŸâ∫—π∑÷° ......................................

(ER physician)

5. µ‘¥µàÕ√—ß ’·æ∑¬å (7308, 7309)‡«≈“ ...............................

ºŸâ∫—π∑÷° ...............................

(ER physician)

9. Non-contrast CT brain‡«≈“ ...............................

ºŸâ∫—π∑÷° ...............................

8. ‡«√‡ª≈ àßºŸâªÉ«¬‡æ◊ËÕµ√«® CT brain‡«≈“ ........................................

ºŸâ∫—π∑÷° ........................................

(ER nurse)

Cerebral infarct Cerebral hemorrhage Stroke mimics ◊∫§âπ‡æ‘Ë¡‡µ‘¡ À√◊Õ admitµ“¡§«“¡‡À¡“– ¡

æ‘®“√≥“„Àâ¬“„π°√≥’µàÕ‰ªπ’È ‰¡à„Àâ¬“‡æ√“–- ¡’Õ“°“√¿“¬„π 3 ™—Ë«‚¡ß- Õ“¬ÿ >18 ªï- º≈ CT ‰¡àæ∫‡≈◊Õ¥- º≈ Coagulogram ª°µ‘

11. Onset 0 - 90 π“∑’Dose 0.9 mg/kg „Àâ 10% iv bolus,90% iv drip in 1hr‡«≈“ ................................................

ºŸâ„Àâ ................................................

(Resident/Staff neurology on call)

11. Onset 91 - 150 π“∑’Dose 0.75 mg/kg „Àâ 10% iv bolus,90% iv drip in 1hr‡«≈“ ................................................

ºŸâ„Àâ ................................................


11. Onset 151 - 180 π“∑’Dose 0.60 mg/kg „Àâ 10% iv bolus,90% iv drip in 1hr‡«≈“ .................................................

ºŸâ„Àâ .................................................


12. ºŸâªÉ«¬ admit ∑’Ë Siriraj Acute StrokeUnit (8613, 8614)‡«≈“ ...............................

ºŸâ∫—π∑÷° ...............................

(Stroke unit nurse)

·®âß neurosurgeon ‡«√«à“ºŸâªÉ«¬‰¥â√—∫¬“thrombolysis admit ∑’Ë Word


* À¡“¬‡Àµÿ πÕ°‡«≈“√“™°“√„Àâ by pass ºŸâÕ”π«¬°“√πÕ°‡«≈“√“™°“√ ‚¥¬µ‘¥µàÕºŸâÕ”π«¬°“√‚√ßæ¬“∫“≈»‘√‘√“™ (». π.æ.ª√– ‘∑∏‘Ï «—≤π“¿“) ‚¥¬µ√ß

1. .............................................................................2. .............................................................................3. .............................................................................


§≥–·æ∑¬»“ µ√å»‘√‘√“™æ¬“∫“≈

Àπ—ß ◊Õ· ¥ß‡®µπ“¢Õ√—∫°“√√—°…“¿“«– ¡Õß¢“¥‡≈◊Õ¥‡©’¬∫æ≈—π

‚¥¬°“√„™â¬“≈–≈“¬≈‘Ë¡‡≈◊Õ¥

„ÀâºŸâªÉ«¬À√◊ÕºŸâ¡’Õ”π“®°√–∑”°“√·∑πºŸâªÉ«¬‡ªìπºŸâ°√Õ°¢âÕ§«“¡·≈–°“‡§√◊ËÕßÀ¡“¬/„π™àÕß

‚¥¬Àπ—ß ◊Õ©∫—∫π’È ¢â“æ‡®â“ π“¬/π“ß/π“ß “« ..................................................................Õ“¬ÿ................ ªï

∫—µ√ª√–®”µ—«ª√–™“™π ∫—µ√¢â“√“™°“√ ∫—µ√æπ—°ß“π√—∞«‘ “À°‘® ∫√‘…—∑ ‡≈¢∑’Ë.........................

—ß°—¥............................................................................„π∞“π–‡ªìπ ºŸâªÉ«¬ ºŸâ¡’Õ”π“®°√–∑”°“√·∑π

„π∞“π–........................¢ÕßºŸâªÉ«¬™◊ËÕ π“¬/π“ß/π“ß “«..................................................................................................

H.N. ................................................................................A.N. .......................................................................................

¢â“æ‡®â“‰¥â√—∫∑√“∫∂÷ß√“¬≈–‡Õ’¬¥¢Õß°“√√—°…“¿“«– ¡Õß¢“¥‡≈◊Õ¥‡©’¬∫æ≈—π‚¥¬°“√„Àâ¬“≈–≈“¬≈‘Ë¡‡≈◊Õ¥

∑“ßÀ≈Õ¥‡≈◊Õ¥¥”®“°·æ∑¬å¢Õß§≥–·æ∑¬»“ µ√å»‘√‘√“™æ¬“∫“≈ ¥—ßµàÕ‰ªπ’È

¢âÕ 1 °“√„Àâ¬“≈–≈“¬≈‘Ë¡‡≈◊Õ¥„πºŸâªÉ«¬¿“«– ¡Õß¢“¥‡≈◊Õ¥‡©’¬∫æ≈—π¿“¬„π 3 ™—Ë«‚¡ß®–∑”„ÀâºŸâªÉ«¬¡’

‚Õ°“ ∑’Ë®–øóôπµ—«®“°§«“¡æ‘°“√ Ÿß°«à“°≈ÿà¡∑’Ë‰¡à‰¥â√—∫¬“ª√–¡“≥ 30%

¢âÕ 2 ¢â“æ‡®â“‡¢â“„®¢âÕ∫àß™’È·≈–√“¬≈–‡Õ’¬¥¢Õß°“√√—°…“¥—ß°≈à“«¢â“ßµâπ √«¡∑—Èß√—∫∑√“∫∂÷ßº≈·∑√° âÕπ

¢Õß°“√„™â¬“π’È§◊Õ

2.1 ¿“«–‡≈◊Õ¥ÕÕ°„π ¡Õß·≈–‡≈◊Õ¥ÕÕ°„π∫√‘‡«≥µà“ß Ê ¢Õß√à“ß°“¬‚¥¬®–¡’Õ—µ√“‡ ’Ë¬ß¢Õß

¢âÕ·∑√°´âÕππ’Èª√–¡“≥ 7%

2.2 Õ—µ√“°“√·æâ¬“™π‘¥√ÿπ·√ß (Anaphylactic, Angioedema) ª√–¡“≥ 0.1%

ºŸâ„Àâ¢âÕ¡Ÿ≈°“√√—°…“

≈ß™◊ËÕ.............................................................. ≈ß™◊ËÕ.................................................................

(...........................................................) (..............................................................)

µ”·Àπàß......................................................... ºŸâªÉ«¬ / ºŸâ¡’Õ”π“®°√–∑”°“√·∑πºŸâªÉ«¬

≈ß™◊ËÕ..............................................................æ¬“π ≈ß™◊ËÕ.................................................................æ¬“π

(...........................................................) (..............................................................)

µ”·Àπàß......................................................... µ”·Àπàß...........................................................

«—π∑’Ë.............../................./................. ‡«≈“.............π.


BODY WEIGHT

(KG)

Dose t-PA (mg)

Onset 0 - 90 min. 91 - 150 min. 151 - 180 min.

0.9 (mg/kg) 0.75 (mg/kg) 0.6 (mg/kg)

61

62

63

64

65

66

67

68

69

70

71

72

73

74

75

76

77

78

79

80

54.9

55.8

56.7

57.6

58.5

59.4

60.3

61.2

62.1

63.0

63.9

64.8

65.7

66.6

67.5

68.4

69.3

70.2

71.1

72.0

45.75

46.50

47.25

48.00

48.75

49.50

50.25

51.00

51.75

52.50

53.25

54.00

54.75

55.50

56.25

57.00

57.75

58.50

59.25

60.00

36.6

37.2

37.8

38.4

39.0

39.6

40.2

40.8

41.4

42.0

42.6

43.2

43.8

44.4

45.0

45.6

46.2

46.8

47.4

48.0

§≥–·æ∑¬»“ µ√å»‘√‘√“™æ¬“∫“≈ ¡À“«‘∑¬“≈—¬¡À‘¥≈


§≥–·æ∑¬»“ µ√å»‘√‘√“™æ¬“∫“≈ ¡À“«‘∑¬“≈—¬¡À‘¥≈

Checklist for intravenous thrombolysis in acute strokeInitial assessment

Onset of stroke clearly established < 3 hours prior to presentation

Unequivocal diagnosis of stroke; no seizure at onset

Urgent blood work (Blood glucose, CBC, electrolyte, Coagulogram, INR)

Emergency non-contrast CT brain

Acute Stroke Team notified

Urgently request family members to be present

ECG

Consider insert urinary catheter and NG tube prior to thrombolysis

CT assessment

Non-contrast CT assessment within 3 hours of stroke

No signs of neoplasm, SAH or aneurysm

Final assessment

At least moderate deficit remaining (NIHSS > 4)

2nd canula inserted

BP below 185/110, may give a single dose of i.v. metoprolol or nicardipine if required

2.7 < blood sugar level < 22

Platelet count > 100,000/mm3, INR < 1.7, normal APTT

No suspicion of septic emboli, SAH or pregnancy at present time

No previous intracranial haemorrhage/SAH, cerebral neoplasm

No AMI, stroke or head trauma in previous 3 months

No history of haemorrhage in previous 30 days, that might lead to unmanageable haemorrhage with TPA

Patient or responsible person provide informed consent (specific information sheet and consent form for

rtPA)

Sticker ™◊ËÕºŸâªÉ«¬


Date

Time

1A Consciousness 0 = Alert1 = Sleepiness 2 = Stupor3 = Coma

1B Question 0 = Answers both questions1 = Answers only one question 2 = Answers neither question

1C Commands 0 = Performs both tasks1 = Performs only one task 2 = Performs neither task

2 Gaze 0 = Normal1 = Partial gaze plasy 2 = Total gaze palsy

3 Visual field 0 = No visual loss1 = Partial hemianopsia 2 = Total hemianopsia3 = Bilateral hemianopsia

4 Facial Palsy 0 = Without facial paralysis1 = Minor facial paralysis 2 = Partial facial paralysis3 = Complete facial paralysis

5 Arm Strength 0 = Normal1 = Drifts down after 10 seconds2 = Fall before 10 seconds3 = No effort against gravity4 = No movement9 = Limb amputated

6 Leg Strength 0 = Normal1 = Drifts down after 5 seconds2 = Fall before 5 seconds3 = No effort against gravity4 = No movement9 = Limb amputated

7 Ataxia 0 = Does not present ataxia1 = Ataxia in only one limb 2 = Ataxia in 2 limbs9 = Limb amputated

8 Sensory 0 = Without sensory alteration1 = Mild to moderate sensory loss 2 = Severe or complete sensory loss

9 Language 0 = Without language alteration1 = Mild to moderate aphasia 2 = Severe aphasia3 = Mute or global aphasia

10 Dysarthria 0 = Without dysarthria1 = Mild or moderate dysarthria 2 = Severe dysarthria or anarthria9 = Intubation

11 Inattention 0 = Without inattention1 = Mild inattention 2 = Severe inattention

Total

Signature

§≥–·æ∑¬»“ µ√å»‘√‘√“™æ¬“∫“≈ ¡À“«‘∑¬“≈—¬¡À‘¥≈

Left Left Left Left

Right Right Right Right

Left Left Left Left

Right Right Right Right


§≥–·æ∑¬»“ µ√å»‘√‘√“™æ¬“∫“≈ ¡À“«‘∑¬“≈—¬¡À‘¥≈

Inclusion and Exclusion Criteria of the National Institute of Neurological Disorders and Stroke

(NINDS) study*

Inclusion Criteria of NINDS

Ischemic stroke of defined onset < 3 hours

Deficit measurable on NIHSS

Baseline CT of the brain without evidence of hemorrhage

Exclusion Criteria of NINDS

A prior stroke within the last 3 months prior to presentation (PTP)

Major surgery within the last 14 days PTP

Serious head trauma within the last 3 months PTP

History of intracranial hemorrhage (ICH)

Systolic blood pressure (BP) > 185 mmHg or diastolic BP >110 mmHg or if aggressive treatment was required

to lower the BP to below these limits

Rapidly improving or minor symptoms

Symptoms suggestive of subarachnoid hemorrhage (SAH)

Gastrointestinal bleeding or urinary tract hemorrhage within the 3 weeks PTP

Arterial puncture at a non-compressible site within the last 7 days PTP

Seizure at the onset of symptoms

Anticoagulants or heparin within 48 hours before stroke onset or elevated PTT

(patial thromboplastin time), or elevated PT (prothrombin time) > 15 sec

Platelet count < 100,000/ml

Blood glucose < 50 mg/dL or above 400 mg/dL

*Tissue Plasminogen Activator for Acute Ischemic Stroke CT, computed tomography; NIHSS, National

Institutes of Health Stroke Scale; NINDS, National Institute of Neurological Disorders and Stroke

The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. N Engl J Med

333(24):1581 - 1587, 1995.





∂“∫—πª√– “∑«‘∑¬“

°√¡°“√·æ∑¬å °√–∑√«ß “∏“√≥ ÿ¢

∂“

∫—πª√–

“∑

«‘∑¬“

°√¡

°“√·

æ∑¬å

STRO

KE

FAST

TRAC

K C

ARE

MAP

DATE

TIM

E AT

ARRIV

AL

NAM

E A

GE

HN

AN

1.Co

ntinue

previou

s mon

itor of v

ital s

igns

and

neu

ro signs

q 1

5 min u

ntil

2 hrs then

q 3

0 min. f

or 6

hrs

then

60

min. f

or 1

6 hrs

2.If

susp

ect f

or in

tracran

ial h

emorrhag

e go

to I

CH

managem

ent

shee

t

3.If

SBP

> 18

5 or D

BP >

110

mmHg

, go

to e

levate

d B

P t

reatm

ent

shee

t

4.Ca

rdiac

mon

itorin

g (if

nee

ded)

5.Ch

eck

inpu

t & o

utpu

t

1.Af

ter 2

4 hrs CT

sca

n to e

xclude

intra

cran

ial h

emorrhag

e if

hemorrhag

epresen

t go

to I

CH

managem

ent

shee

t

1.Co

ntinue

rt-P

A infusio

n then

IV

NSS

at r

ate 6

0 cc

/hr

2.Ox

ygen

can

ula

(if

need

ed)

3.No

antiplat

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antico

agulan

t age

nt for 2

4 hrs po

st rt-

PA4.

Peptic

ulce

r prop

hylax

is(H

2-bloc

ker/

Proton

pum

p inhibitor)

5.Co

ntinue

pati

entûs

reg

ular m

edica

tion

prescribed

(if a

ppropriat

ed)

1.Ch

eck

blee

ding

& h

emato

ma fro

m p

unctu

re site

s, ch

eck

urine,

stool emesis

or o

thers for bloo

d2.

Notif

y ph

ysici

ans im

med

iately

for e

vide

nce

of*

blee

ding

* ne

urolog

ical d

eterio

ratio

n*

SBP

> 18

5 or <

100

mmHg

* DB

P >

105

or <

60

* pu

lse <

50/min

* resp

iratio

n >

24/m

in

1. R

ecord

TIM

E A

T O

NSE

T__

____

__2. C

heck

vita

l signs

onc

e & B

P q

15 m

in.

3. A

ssess NI

HSS

4. C

heck

inclu

sion

& e

xclusio

n crite

ria

1. S

tat b

lood

draw

for CB

C, P

T, a

PTT,

BS

2. S

tat n

on-con

trast

CT sca

n of b

rain

TIM

E A

T C

T S

CA

N__

____

_

1. IV

assess N

SS ke

ep a

t rate

40

cc/hr

2. N

o an

tiplat

elet &

antico

agulan

t age

nt3. A

void o

f urinary

cathete

rizati

on a

ndna

soga

stric

tube

inserti

on

1. A

ctiva

te str

oke

fast

track

path

way

2. R

ecord

vital

signs

onc

e & B

P q

15 m

in.

3. Immed

iately

follow

docto

rûs o

rder

1.Re

cord results

of C

T scan

& la

bs2.

Chec

k vital

signs

& n

euro signs

(in N

IHSS

she

et)3.

q 15

min. f

or 2

hrs

4.If

SBP

> 18

5 or D

BP >

110

mmHg

, go

toel

evate

d B

P t

reatm

ent

shee

t

5.Re

cord p

atien

t weig

ht in

kg

1. S

tat stool o

ccult b

lood

(be

d sid

e kit)

1. S

econ

d IV

assess : N

SS lo

ck in

opp

osite

arm

2. P

repa

re IV

rt-PA

(con

centratio

n 1

mg

: 1 c

c)3. T

otal

dose :_

___

mg

(0.9 m

g/kg

, max

dos

e 90

mg)

Adm

inis

ter __

__ m

g (10%

of t

otal

dose) I

V ov

er 1

min.

Adm

inis

ter

____

mg

(90%

of total

dos

e)IV

infusio

n ov

er 6

0 min.

TIM

E A

T N

EE

DL

E _

____

__4. T

rans

fer to ICU

TIM

E T

O I

CU__

____

__5.

Avoid

arter

ial p

unctu

res,

frequ

ent v

enou

s pu

nctures

and

urinary

cathete

rizati

on for 2

4hrs

post

rt-PA

6.No

antiplat

elet &

antico

agulan

t age

nt for 2

4 hrs

post

rt-PA

1.Re

cord v

ital s

igns

& n

euro signs

q 1

5 min. f

or2

hrs po

st rt-

PA2.

Notif

y ph

ysici

ans for SB

P >

185

& D

BP >

110

mmHg

Dep

art

men

t/E

mer

gen

cy d

epart

men

tE

mer

gen

cy d

epart

men

tIn

tensi

ve

care

unit

Asp

ect

of

(pre

lim

inary

evalu

ation)

(thro

mboly

tic

ther

apy)

care

Assessmen

t

Labs

& T

ests

Med

icatio

n &

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∂“∫—πª√– “∑«‘∑¬“ °√¡°“√·æ∑¬å

THROMBOLYSIS CHECK LISTName_______________________________ Age_____ HN_________ AN_________ Date:_______________

Attending staff______________________ Time: Symptom Onset ______ rtPA given:_______NIHSS_________

INCLUSION criteria (must all be YES)

* Age 18 years or older Yes No

* Time of onset well established to be less than 3 hours Yes No

* Clinical diagnosis of ischemic stroke causing a measurable neurological deficit Yes No

* CT without hemorrhage or significant edema Yes No

EXCLUSION criteria (must all be NO)

* SBP > 185 or DBP > 110 Yes No

* Symptoms rapidly improving or minor symptoms (NIHSS = 0 - 6) Yes No

* Coma or severe obtundation (or NIHSS > 25) Yes No

* Seizure at onset Yes No

* Symptoms of subarachnoid hemorrhage (diffuse headache, stiffness of neck) Yes No

* Prior stroke or head trauma within 3 months Yes No

* Major surgery within 14 days Yes No

* Prior intracranial hemorrhage Yes No

* GI hemorrhage or urinary tract hemorrhage within 21 days Yes No

* Arterial puncture at a noncompressible site or LP within 7 days Yes No

* Recent Myocardial infarction Yes No

* Patients receiving heparin within 48 hrs and with an elevated PTT Yes No

* PT >15 or INR > 1.7 Yes No

* Platelet count < 100,000 Yes No

* Plasma glucose < 50 or > 400 Yes No

* Hematocrit < 25% Yes No

* Pregnant (Note: menstruation is NOT a contraindication) Yes No

TREATMENT

Total dose to be given (0.9mg/kg)

Weight (kg): ____ x 0.9 mg = _____ mg (maximum 90 mg)

Give 10% bolus over 1 minute ___ mg (= ml)

Give remaining 90% constant infusion over 60 minutes ___ mg (= ml)

.................................................M.D.Physicianûs Signature


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Doctorûs orders

∂“∫—πª√– “∑«‘∑¬“

312 ∂ππ√“™«‘∂’ ‡¢µ√“™‡∑«’ °∑¡. 10400

DATE ONE DAY DATE CONTINUATION

- Check vital & neuroûs signs

after infusion

15 mins. for 2 hrs

then 30 mins. for 6 hrs

then 60 mins. until 24 hrs

- Maintain BP 185/110 mmHg,

if BP out of ranges please notify

- Avoid after infusion

insertion Foley catheter within 2 hrs

insertion NG tube within 24 hrs

entral venous access, arterial puncture &

intramuscular injection

- UA, Stool occult blood

If hemorrahage is suspected

1. Stop infusion of the thrombolytic drug.

2. Repeat CBC, platelet, INR, PTT, PT

(fibrinogen, D-dimer)

3. CT brain stat

4. Prepare for administration of

6 to 8 FFP

5. Notify neurosurgeon

q

q

q

- NPO except meds for

24 hrs

- Bed rest

- Record I/O

- Medication

1. H2 blocker/PPI

Prophylaxis



1a. Level of 0 = Alert and responsiveConsciousness 1 = Response to minor stimuli

2 = Response to painful stimuli3 = Reflex response or unresponse

1b. Questions 0 = Both correctask ptûs age 1 = One correctand month 2 = Neither correct

1c. Commands 0 = Both correctopen/close eyes 1 = One correctgrip/release hand 2 = Neither correct

2. Best Gaze 0 = Normalhorizontal EOM by 1 = Partial gaze palsyvoluntary or Dollûs 2 = Forced eye deviation

total paresis3. Visual Field 0 = No visual loss R/L

field of good eye 1 = Partial hemianopia,2 = Complete hemianopia3 = Bilateral hemianopia

4. Facial Palsy 0 = Normal R/Lcheck symmetry of 1 = Minor paralysis (flat NLF)grimace to pain. 2 = Partial paralysis (UMN)

3 = Complete paralysis (U & LMN)5. Motor Arm 0 = No drift R

arms outstretched 1 = Drift90*(sitting) or 2 = Some antigravity effort45*(supine) for 10 secs. 3 = No antigravity effort L

4 = No movement at allX = Unable to assess (amputation)

6. Motor Leg 0 = No drift Rraise leg to 30* 1 = Drift(supine) for 5 secs. 2 = Some antigravity effort

3 = No antigravity effort L4 = No movement at allX = Unable to assess (amputation)

7. Limb Ataxia 0 = No ataxia R/Lfinger to nose 1 = Ataxia in upper or lower ext.or heel to shin 2 = Ataxia in upper & lower ext.

X = Unable to assess (amputation)8. Sensory 0 = Normal R/L

only stroke-related loss 1 = Mild-mod unilateral loss2 = Total loss, Coma, bilateral loss

9. Best Language 0 = Normalname objects, 1 = Mild-mod aphasiaread sentences, 2 = Severe aphasiawriting 3 = Mute, global aphasia, coma

10. Dysarthria 0 = Normal1 = Mild-mod; slurred2 = Severe; unintelligible or muteX = Intubation

11. Extinction/Neglect 0 = Normalsimultaneous touch & 1 = Neglect to double simultaneousvisual field test stimulation in any modality

2 = Both neglect

TOTAL SCORE

∂“∫—πª√– “∑«‘∑¬“ °√¡°“√·æ∑¬å

NIHSS SCORE SHEET (1)

Patient Name________________________ Unit #______________ Date___/___/___ TOTAL______________

Date/Time of Stroke Onset_____________ Stroke Type___________ Examiner_________________________DATE/SCORE

NIHSS ITEM SCORE DEFINITIONS


¿“§ºπ«° 4

CT scan examples for early signs of cerebral ischemia12

√Ÿª∑’Ë 1 Hyperdense MCA sign (arrow).

√Ÿª∑’Ë 2 Loss of the anterior half of the insular ribbon (arrow).


√Ÿª∑’Ë 3 Loss of the insular ribbon on the right side (arrows)

and hypodensity of the basal ganglia (short arrows).

√Ÿª∑’Ë 4 Sulcal effacement right frontal lobe (arrow).


√Ÿª∑’Ë 5 Early signs of a > 2/3 MCA infarction.

This patient should not be treated with thrombolysis


¿“§ºπ«° 5

Stroke Unit13

Stroke unit ¡’À≈“¬§«“¡À¡“¬ ‚¥¬∑—Ë«‰ªÀ¡“¬∂÷ß ∫√‘‡«≥∑’Ë‡ªìπ —¥ à«π¥Ÿ·≈ºŸâªÉ«¬‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß

¡’°“√ª√– ¡ª√– “π°“√¥Ÿ·≈ºŸâªÉ«¬‚¥¬ À«‘™“™’æ ¡’·æ∑¬åºŸâ‡™’Ë¬«™“≠‡©æ“–∑“ß æ√âÕ¡∑—Èß¡’æ¬“∫“≈‡©æ“–∑“ß

·≈–∑’¡ À«‘™“™’æ∑’Ë¡’§«“¡√Ÿâ§«“¡ “¡“√∂„π°“√¥Ÿ·≈ºŸâªÉ«¬‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß πÕ°®“°π’È ¬—ßµâÕß¡’°“√ª√–™ÿ¡

ª√÷°…“À“√◊Õ√–À«à“ß∑’¡ À«‘™“™’æ ºŸâªÉ«¬·≈–≠“µ‘ Õ¬à“ß ¡Ë”‡ ¡Õ

≈—°…≥–¢Õß stroke unit “¡“√∂®”·π°‰¥â‡ªìπ 3 ≈—°…≥– §◊Õ

1. Acute stroke unit

2. Rehabilitation stroke unit

3. Combined stroke unit

®“°≈—°…≥–¢Õß stroke unit ¥—ß°≈à“«¢â“ßµâπ ‚√ßæ¬“∫“≈µà“ß Ê “¡“√∂®—¥ stroke unit „π≈—°…≥–„¥°Á‰¥â

‡æ◊ËÕ§«“¡§ÿâ¡§à“¢Õß°“√®—¥µ—Èß stroke unit §«√®—¥„Àâ¡’®”π«π‡µ’¬ß¢—ÈπµË” 4 ‡µ’¬ß æ¬“∫“≈ 1 §πµàÕºŸâªÉ«¬ 2 ‡µ’¬ß

√“¬°“√§√ÿ¿—≥±å ‡§√◊ËÕß¡◊Õ·æ∑¬å «— ¥ÿÕÿª°√≥å ”À√—∫ stroke unit

≈”¥—∫ √“¬°“√ ®”π«πÀπà«¬ ‡Àµÿº≈§«“¡®”‡ªìπ

¢Õß Stroke unit

1 ∑’ËπÕπ≈¡ 2 ”À√—∫ªŸ√ÕßºŸâªÉ«¬‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß∑’Ë‰¡à “¡“√∂

™à«¬‡À≈◊Õµ—«‡Õß‰¥â ªÑÕß°—π°“√‡°‘¥·º≈°¥∑—∫

2 Infusion pump 4 ‡æ◊ËÕ§«∫§ÿ¡°“√„Àâ “√πÈ”·≈–¬“∑“ßÀ≈Õ¥‡≈◊Õ¥¥”„Àâ·¡àπ¬”

ªÑÕß°—π§«“¡º‘¥æ≈“¥ ´÷ËßÕ“®‡ªìπÕ—πµ√“¬∂÷ß™’«‘µ‰¥â

3 Syringe pump 0 - 1 §«∫§ÿ¡°“√„Àâ “√πÈ”·≈–¬“„πª√‘¡“≥πâÕ¬

ªÑÕß°—π§«“¡º‘¥æ≈“¥„π°√≥’¬“∑’Ë¡’Õ—πµ√“¬ Ÿß

4 ‡§√◊ËÕß defibrillation 1 ‡æ◊ËÕ„™â„π°“√™à«¬™’«‘µºŸâªÉ«¬∑’Ë¡’°“√‡µâπÀ—«„®º‘¥ª°µ‘

5 ‡§√◊ËÕß§«∫§ÿ¡°“√„ÀâÕ“À“√‡À≈« 0 - 1 ‡æ◊ËÕ„™â„π°“√§«∫§ÿ¡°“√„ÀâÕ“À“√‡À≈«„πºŸâªÉ«¬∑’Ë¡’ªí≠À“

„π°“√¬àÕ¬Õ“À“√

6 Ambu bag 4 ‡æ◊ËÕ„™â„π°“√∫’∫Õ—¥≈¡‡¢â“ªÕ¥ºŸâªÉ«¬„π√–À«à“ß

™à«¬‡À≈◊Õ°“√À“¬„®À√◊Õ°“√¥Ÿ¥‡ ¡À–

7 ‡§√◊ËÕß«—¥πÈ”µ“≈„π‡≈◊Õ¥®“°ª≈“¬π‘È« 2 ‡æ◊ËÕµ√«®«—¥πÈ”µ“≈„π‡≈◊Õ¥®“°ª≈“¬‡µ’¬ßºŸâªÉ«¬

„π°√≥’‡√àß¥à«π

8 Pad slide 1 ”À√—∫‡§≈◊ËÕπ¬â“¬ºŸâªÉ«¬

9 Monitor 0 - 1 ‡æ◊ËÕµ‘¥µ“¡ —≠≠“≥™’æ

Health & Medicine

แนวทางรักษา stroke-fast-track 2007