NHS FORTH VALLEY Acute Stroke Guideline

26/03/2012 Date of First Issue 01/11/2011 Approved 26/03/2012 Current Issue Date 26/03/2014 Review Date Final: 2.08 Version Yes / No DD / MM / YYYY EQIA Dr Anthony Byrne Author / Contact Group Committee – Drug & Therapeutics Committee Final Approval This document can, on request, be made available in alternative formats

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Consultation and Change Record
Contributing Authors:

Dr. L. Fielden, Dr. A. Byrne, Dr. A. Grant, Dr. A. McKenzie, Mr. J. McCall

Consultation Process: Distribution: Change Record

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Author

Change

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FOREWORD This guideline is intended to summarize treatment of acute stroke during the initial phases of diagnosis, investigation and management (i.e. the first few hours to days). They are to support non-specialist staff prior to the patient being admitted to the Stroke Unit. More comprehensive guidelines exist and can be accessed online e.g. SIGN guideline 108, NICE. This guidance is not intended to serve as a standard of medical care or be applicable in every situation. Decisions regarding the treatment of individual patients must be made by the clinician in light of that patient’s presenting clinical condition and with reference to current good medical practice. Subarachnoid haemorrhage, subdural and extradural haemorrhage are not dealt with in this document as they do not fall under the remit of stroke disease. National Guidelines for further reference. Scottish Intercollegiate Guidelines Network (SIGN) • “SIGN 108: Management of patients with stroke or TIA: assessment, investigation, immediate management and secondary prevention.” December 2008. URL - http://www.sign.ac.uk/pdf/sign108.pdf National Institute for Clinical Excellence (NICE) • “Stroke: National clinical guideline for diagnosis and initial management of acute stroke and transient ischaemic attack (TIA).” July 2008. URL - http://guidance.nice.org.uk/nicemedia/live/12018/41363/41363.pdf Where reference is made to drug therapy, further information on indications, cautions, contra-indications, side-effects and dosing can be obtained from the British National Formulary (BNF).

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Section 1: Acute Management of suspected Stroke 1.4) Version 2. a possible infective source should be considered. CRP. cholesterol.1. however. Intracerebral events may induce pyrexia. If nil by mouth and type I diabetic. If the neurological deficit resolves rapidly.g. Avoid dextrose in the early post-stroke phase to avoid iatrogenic hyperglycaemia. If GCS <13 consider emergency CT brain scan (see 1. the neurological deficit is more likely hypoglycaemia induced rather than due to stroke. Reassess the neurological deficit once blood glucose is corrected. LFT. Time. In patients at risk of hypercapnic respiratory failure the target is 88-92%. Take cultures. Perform 12 lead ECG. Assess blood pressure and pulse. Consider simple airway opening manoeuvres. EXCLUDE HYPOGLYCAEMIA AS THE CAUSE OF NEUROLOGICAL DEFICIT Check rapid blood glucose with finger-prick testing. Note the presence or absence of delirium if possible (e. 20-1).5oC commence regular paracetamol. Assess Glasgow Coma Scale. airways suction and insertion of an oropharyngeal or nasopharyngeal airway. If below 4. glucose. Monarch.0 mmol -1 give repeated doses of 50ml 10% glucose solution until corrected. Year. Request Chest X-ray Request a CT brain scan (see section 1.08 13th January 2012 UNCONTROLLED WHEN PRINTED Page 4 of 17 . Assess oxygen saturation and respiratory rate. If IV access cannot be obtained and central venous access is inappropriate.4). Avoid wide fluctuations in blood pressure. Place. If temperature exceeds >37. then subcutaneous fluids can be used to maintain plasma osmolality.6). Calculate an Abbreviated Mental Test (AMT) (Age. in particular looking for the presence or absence of atrial fibrillation. ESR & clotting screen. Monitor temperature. Airway obstruction is usually due to reduced conscious level or aspiration in this setting. Tracheal intubation if clinically appropriate. 1. In such patients obtain an arterial blood gas on oxygen therapy (NB: Do not perform arterial puncture if considering thrombolysis). Maintain oxygen saturations 94%-98%. Recall address.1 Acute Assessment Maintain airway. PM. commence insulin sliding scale (see section 2. WW1. CAM score or 4AT).2 • • • • Immediate investigations Obtain blood for FBC. identify source and commence antibiotics as appropriate (adapted from SIGN) Airway Breathing Circulation Disability D (Dextrose) Exposure Cognitive Function Full clinical assessment: History & Examination. U & E. Recognise 2 people. Commence IV fluids in hypovolaemic or drowsy patients and in those nil by mouth.

If unable to swallow. food or medication (NICE). After initial workup in the Emergency Department. a CT brain should be requested for the following morning by the admitting doctor. neck stiffness or fever Severe headache at onset of stroke symptoms For all other stroke patients: • • • • Efforts should be made to scan the patient on the day of the admission if this can be done in-hours. If aspirin allergic/intolerant: Give a loading dose of clopidogrel 300mg then continue clopidogrel 75mg daily. The patient remains at risk of aspiration. keep Nil By Mouth. as soon as possible. If presenting out-of-hours and no ‘immediate indication’ (as above). Record test as ‘failed’. Acute Admissions Unit or Clinical Assessment Unit patients with stroke or transient ischaemic attack (who require admission) should be transferred to the Stroke Unit as per guidance in the Operational Service Guidelines. note this.4 CT Brain imaging Antiplatelet agents/Anticoagulants should be withheld while awaiting brain imaging. 1. • • • • Prescribe aspirin 300mg stat immediately. regardless of outcome.1. The requesting of a CT scan should be confirmed in the patient’s case notes to avoid duplicate requesting. Version 2.5 Immediate Management Post-Imaging If brain imaging has excluded an intracerebral haemorrhage or complicating structural CNS lesion (e. • If the patient is not sufficiently alert to cooperate.g. abscess). tumour. The result of the scan should be recorded in the patient’s case notes. commence intravenous fluids and arrange early Speech & Language Therapy Assessment. prescribe rectally or by enteral tube. (SIGN) Aspirin 300mg should be prescribed for 14 days on the drug prescription sheet. It is the responsibility of the person requesting the CT brain to ensure the report is reviewed and acted upon e.08 13th January 2012 UNCONTROLLED WHEN PRINTED Page 5 of 17 . administering aspirin 300mg or neurosurgical discussion. where level of consciousness diminished rather than lone dysphasia) Unexplained progressive or fluctuating symptoms Papilloedema. Indications for Immediate Scanning:• • • • • • • Potential candidate for thrombolytic therapy (refer immediately to thrombolysis protocol) On anticoagulant therapy Known bleeding tendency Reduced level of consciousness (GCS <13.g. • The swallow test result must be recorded in the medical notes.3 • Swallow Screen An appropriately trained member of staff should perform a water swallow test on the day of admission prior to any oral fluid. 1. If failed.

0. The administration of anticoagulants is contraindicated during the first 24 hours after IV thrombolytic therapy. If unable to take clopidogrel for long term therapy. Antiplatelet therapy as in 2.1 should be used in the interim. • • • • • Version 2. but should be deferred for two weeks after onset in those with major stroke (SIGN. Patients with ischaemic stroke and symptomatic proximal deep vein thrombosis or pulmonary embolism should receive anticoagulation treatment in preference to treatment with aspirin unless there are other contraindications to anticoagulation (NICE). or change to lansoprazole if PPI specifically required or an H2 antagonist e. anticoagulation with warfarin can be introduced early in patients with minor stroke or TIA (SIGN). For patients in atrial fibrillation or with paroxysmal atrial fibrillation following stroke.1. anticoagulation treatment should be stopped for 1 week and aspirin 300 mg substituted (NICE). These agents should be used in line with NHS Forth Valley formulary guidelines. New anticoagulant drugs are becoming available (direct thrombin inhibitors e.0-3. NICE). If both aspirin and clopidogrel intolerant. There is evidence that omeprazole/esomeprazole may reduce the efficacy of clopidogrel: • • stop PPI if no longer indicated and no ongoing gastric protection required. Target INR is 2. Patients initially prescribed clopidogrel (300mg loading dose then 75mg daily) should continue on the clopidogrel. dabigatran or factor Xa inhibitors e. Anticoagulation is not recommended for preventing recurrent stroke in patients with noncardioembolic ischaemic stroke. (NICE update 2010). 2. Treatment options include a caval filter or anticoagulation.08 13th January 2012 UNCONTROLLED WHEN PRINTED Page 6 of 17 .1 Pharmacological Therapy 2. dipyridamole retard 200mg BD as a single agent can be prescribed.Section 2: Ischaemic Stroke Management 2. Each patient should be considered on an individual basis.1. NICE).1. Review any proton pump inhibitor (PPI) therapy. ranitidine. In people with prosthetic heart valves who have disabling cerebral infarction and who are at significant risk of haemorrhagic transformation.g. People with haemorrhagic stroke and symptomatic deep vein thrombosis or pulmonary embolism should have treatment to prevent the development of further pulmonary emboli. rivaroxaban). Such patients should be discussed with the cardiologist at the earliest opportunity.1 Antiplatelet therapy • • • Patients prescribed aspirin 300mg should continue on this for 14 days then change to clopidogrel 75mg for long term secondary prevention. aspirin 75mg PLUS dipyridamole retard 200mg BD is the preferred option.2 Anticoagulant therapy (warfarin or heparin) • • • Anticoagulant therapy should not be used routinely in the acute ischaemic stroke setting (SIGN.g.g.

3 Thromboprophylaxis • • • The administration of anticoagulants is contraindicated during the first 24 hours after thrombolytic therapy.1. Decisions need to be made on an individual patient basis.1. Version 2. Anti-embolic stockings are not recommended for thromboprophylaxis after stroke (CLOTS-1 and CLOTS-2 trials). however. malignant disease). unless there is good evidence that the patient has not been complying with anti-hypertensive medication pre-admission.g.08 13th January 2012 UNCONTROLLED WHEN PRINTED Page 7 of 17 . Regularly review the need for thromboprophylaxis (both the need to commence therapy or to discontinue therapy when no longer appropriate). dehydration or significant co-morbidities e. Avoid fluctuations in blood pressure • If able to swallow and no other contra-indication continue any usual blood pressure medication. • 2. There can be difficulty with treatment as those who are immobile due to large cerebral infarcts are at risk of VTE but are also at highest risk of haemorrhagic transformation of the infarct.2. Consider a thromboprophylactic dose of low molecular weight heparin if: • • • • haemorrhagic stroke excluded AND risk of haemorrhagic transformation or bleeding into another site is assessed to be low AND the patient is at high risk of VTE (such as major restriction of mobility.4 Antihypertensive therapy (acute phase) Do not lower blood pressure routinely in acute stroke (SIGN) • There is no evidence of benefit in treating hypertension in ischaemic stroke acutely and there is some evidence suggesting potential harm. previous history of venous thromboembolism. Consider lowering BP acutely only with the following serious concomitant medical issues (NICE) • Hypertensive encephalopathy • Hypertensive nephropathy • Hypertensive cardiac failure/myocardial infarction • Aortic dissection • Pre-eclampsia or eclampsia • Intracerebral haemorrhage with systolic blood pressure ≥ 200 mmHg or • The patient may be considered for blood pressure lowering medication if a potential candidate for thrombolysis and BP is >185/110. this is at the discretion of the on-call stroke specialist.

• Routine use of intravenous insulin regimens to lower blood glucose in patients with ‘moderate’ hyperglycaemia after acute stroke is not recommended as there is no trial evidence yet of benefit and a significant demonstrated risk of inducing hypoglycaemia.6 Hyperglycaemia/Diabetes treatment Hyperglycaemia in stroke • Diabetic patients on insulin who are unable to swallow (or in whom there is concern about ability to maintain adequate oral intake) should be commenced on an IV sliding scale insulin regimen.5 Statins • • • • • A statin should be prescribed to patients who have had an ischaemic stroke. • Hypoglycaemia should be managed as per the usual local protocol. SIGN recommends using simvastatin 40mg or atorvastatin 80mg based on the Heart Protection Study (HPS) and SPARCL trial respectively.1. • Advice should be sought from the diabetic specialist team if there is continued concern about glycaemic control. Following clinical risk assessment by a stroke consultant atorvastatin 80mg may be recommended. Patients with ischaemic stroke on prior statin therapy should continue treatment. Version 2.0mmol/l should be further assessed to exclude or confirm a diagnosis of impaired glucose tolerance or diabetes. Cholesterol level should still be checked on admission.08 13th January 2012 UNCONTROLLED WHEN PRINTED Page 8 of 17 . if necessary. The insulin dosing for the sliding scale may have to be adjusted to avoid glucose levels below this.1. • Care should be taken not to cause hypoglycaemia with such regimes and a glucose of 7mmol/l is acceptable as the minimum level. irrespective of cholesterol level. via a nasogastric tube. Statin therapy following haemorrhagic stroke is not recommended routinely unless the risk of further ischaemic vascular events outweighs the risk of further haemorrhage. • A random glucose >6. Hypoglycaemia in stroke • Hypoglycaemia should be avoided and a blood glucose minimum of 7mmol/l is acceptable. Patients not currently prescribed a statin would usually receive simvastatin 40mg.2. 2.

3 Echocardiogram • • Echocardiography is not recommended for all patients with ischaemic stroke (SIGN). • 2. Echocardiogram should be considered for patients o where clinical findings or baseline investigations (e.g.1 Further brain imaging • • • Consider if there is an otherwise UNEXPLAINED DETERIORATION in the patient’s condition (to exclude hydrocephalus. • • • • 2. a repeat echo may not be appropriate.08 13th January 2012 UNCONTROLLED WHEN PRINTED Page 9 of 17 . If a patient has had a recent echocardiogram prior to their stroke. 2. presence of murmurs etc). Hypertension without ECG abnormality is not an indication for echocardiogram. Clinical deterioration following stroke may be related to intercurrent infection so this must be considered. This should only be requested after discussion with a cardiologist.4 Cardiac Rhythm Monitoring • • Cardiac rhythm monitoring (24/48/72 hour ECG tapes) may be appropriate to investigate for paroxysmal atrial fibrillation in patients with sinus rhythm on admission ECG. ECG findings. Enter as much information on the request card as possible to allow appropriate vetting of the request (e.2 Carotid artery imaging • Request urgent carotid duplex scan for all patients with non-disabling ischaemic stroke syndrome or TIA in the carotid territory who are potential candidates for carotid surgery (SIGN). Further imaging with CT angiogram. Routine follow up scanning is required after THROMBOLYTIC THERAPY for acute ischaemic stroke. haemorrhagic transformation of infarct) and when repeat imaging will influence further management. Version 2. The routine use of echocardiography with contrast media for further evaluation of patients following stroke or TIA is not recommended. Emergency scanning following thrombolysis should be done if there is a neurological deterioration raising suspicion of intracerebral haemorrhage. See thrombolysis protocols.g.2. abnormal ECG) suggest cardiac disease.2.2 Further investigation 2.2. This should usually be performed around 24 hours from treatment but can be done at an appropriate time earlier or later if treated out-of-hours. o with cryptogenic stroke.2. This should be requested on discussion with a consultant.2. MRI or MR angiogram may be required and should be discussed with a consultant.

Discuss with the on-call haematologist the appropriate treatment to give.1 Initial Management Following brain imaging confirming intracerebral haemorrhage • • • All antiplatelets/anticoagulants should be discontinued. • Patients anticoagulated solely due to atrial fibrillation who have a cerebral haemorrhage should usually have their anticoagulation fully reversed. particularly where neurosurgery has indicated they may accept the patient in the event of a clinical deterioration. Intravenous labetolol or glyceryl trinirate may be options. Subarachnoid haemorrhage and subdural and extradural haemorrhage are managed differently from primary intracerebral haemorrhage and are not covered in this guidance. Evidence in this area is inconclusive.08 13th January 2012 UNCONTROLLED WHEN PRINTED Page 10 of 17 . While routine surgical evacuation by craniotomy is not recommended for supratentorial primary intracerebral haematoma. Clinical Observation • Regular clinical observation should be made including neuro-obs and Glasgow Coma Scale. early neurosurgical discussion may still be required in individual circumstances. If there is doubt about appropriateness. A baseline full blood count and clotting screen is required (if not already done). Further CT imaging may be appropriate. This will usually be a combination of prothrombin complex and intravenous vitamin K. Statin Therapy • Statin therapy after haemorrhagic stroke is not recommended routinely unless the risk of further ischaemic vascular events outweighs the risk of further haemorrhage (SIGN). particularly those who need long term anticoagulation due to the valve. This may include younger patients with haemorrhage and subsequent pressure effects or those with very superficial haemorrhage.Section 3: Primary Intracerebral Haemorrhage 3. then discussion should take place in order that patients do not miss out on appropriate intervention. (NICE). Version 2. The haematoma seen on the CT is a “snapshot” image and will often continue to expand following the CT scan. Patients with Prosthetic Heart Valves • Patients with cerebral haemorrhage and a prosthetic heart valve should also be discussed with cardiology. Blood Pressure Management • Consider acute management of hypertension in intracerebral haemorrhage if systolic blood pressure >200mmHg. Clotting levels in those receiving anticoagulation treatment (and have an elevated INR) should be returned to normal as soon as possible. • A deterioration may indicate haematoma expansion or a re-bleed. This should be done at least hourly for the first 24-48 hours. Lowering by no more than 20% in the first 24 hours may be advisable.

Attending staff should remain alert to the possibility of aspiration after placement.radiological evidence of pneumonia • Aspiration is a risk of stroke and associated with poor outcome. • Risk reduction . The swallow test result must be recorded in the medical notes. (see flow chart below). regardless of outcome. SIGN) • Treat for aspiration pneumonia as per the local antibiotic guidelines. • The presence of a nasogastric tube does not prevent aspiration of saliva or reflux of NG feed and aspiration. Early placement of a nasogastric feeding tube should be considered in patients identified as unable to take adequate food or medication due to a low conscious level and/or the presence of dysphagia (SIGN).08 13th January 2012 UNCONTROLLED WHEN PRINTED Page 11 of 17 .Section 4: Post-stroke Dysphagia 4. If the patient is drowsy and unable to sit upright for 15 minutes. it is NOT SAFE to carry out a Water Swallow Test.1 Screening for Swallowing Difficulties and Referral to SLT. Oropharyngeal dysphagia can result in serious complications such as aspiration pneumonia. 4. food or medication (NICE).sit up and mobilise as soon as possible (NICE.0 • • • • Swallowing Impairment An early swallow screen should be performed by an appropriately trained member of staff on the day of admission prior to any oral fluid. dehydration and missed medication. This would usually be a decision made once the patient is in the Stroke Unit Aspiration +/. • • • document decision not to screen and why patient should remain Nil by Mouth with IV hydration monitor conscious level Attempt to re-screen every 12 hours Version 2. undernutrition.

Record observations below. 66591 (01324 566591) This checklist is not designed to screen patients who have complex intra-oral or head and neck surgery. Water Swallow Test . Fourth Test + 36 HRS. Observe closely and record results below. YES NO Third Test + 24 HRS. water to patient and observe drinking.08 13th January 2012 UNCONTROLLED WHEN PRINTED Page 12 of 17 . YES NO YES Fourth Test + 36 HRS. NO First Test YES NO If the answer is NO throughout this section continue to Part 2. Maintain Nil By Mouth and repeat full Water Swallow Test every 12 hours over 2 days. In those cases please use existing ward protocols or refer directly to SLT. (Review Date May 2006) Version 2. or tracheostomy.Water Swallow Test . one at a time.Part 1 Give patient 3 x 5 ml teaspoons of water. Does the patient show signs of any of the following? • • • • coughing choking (increased) breathlessness change in voice quality (hoarse and/or wet/gurgly) First Test Second Test + 12 HRS. YES NO YES NO YES NO YES NO Results Staff signature: Staff signature: Staff signature: Staff signature: Outcome of Water Swallow Tests PASS ( NO throughout Part I and II) FAIL ( YES at any time) Ward/ Date Ward/ Date Ward/ Date Ward/ Date Patients PASSING the Water Swallow Test should progress to oral feeding under observation as per flow chart overleaf Patients FAILING the Water Swallow Test should be re-tested as per the chart overleaf or be referred on to SLT as appropriate To make a referral to SLT please phone: Speech & Language Therapy Dept.. Third Test + 24 HRS. If the answer is YES at any time STOP screening. Forth Valley Royal Hospital: Ext.Part 2 Give glass with 50 ml. Does the patient show signs of any of the following? • • • • coughing choking (increased) breathlessness change in voice quality (hoarse and/or wet/gurgly) Second Test + 12 HRS.

• Patient has a known swallow problem (e.change on the sound “ah”? . YES   Give 1 x 5 ml teaspoon of cold water • Does the patient:. • Refer to dietitian if still NBM after 48hrs. choke. requiring modified diet) but is reported to be experiencing new problems.choke? . • Patient is reporting oropharyngeal swallowing difficulties (food “sticking” in mouth or throat.become hoarse or “wet”? • Repeat twice (total = x 3 times) • Record results on checklist NO • • • • • Keep Nil By Mouth. experience voice changes as above.Guidelines for Referral to Speech and Language Therapy (SLT) for Assessment of Oropharyngeal Swallowing Function. • Patient has rapid and/or poorly co-ordinated respiration (may be on ventilation) and is experiencing swallowing difficulties.cough? .08 13th January 2012 UNCONTROLLED WHEN PRINTED Page 13 of 17 .g. reports difficulties..change on the sound “ah”? . refer to SLT • Consider putting patient Nil By Mouth. Refer to dietitian. Version 2. • Repeat screening on a 12 hourly basis.fail to swallow? . water to patient and observe drinking • Does the patient:. Consider intravenous hydration.become (more) breathless? • Does the voice quality . Can the patient: • be seated upright (in bed or chair?) • remain alert and awake for at least 15 minutes? • Keep Nil By Mouth. NO • Implement and maintain full oral hygiene • Consider intravenous hydration.choke? . Repeat screening on 12 hourly basis Give glass with 50 ml. or develops a moist chest. for example). YES Is the mouth clean? Begin and maintain full oral hygiene.become hoarse or “wet”? • Record results on checklist NO YES   checklist overleaf Refer to SLT on completion of • Commence oral feeding – free diet and fluids • Carefully supervise first meal and observe eating/drinking over 2 days • Ensure patient is fully upright and alert when eating/drinking • If patient is noted to cough. particularly if chest infection develops The above guidelines do not apply to the following groups of patients who may be referred directly to SLT: • Patient is reported to have one or more of the following – a history of more than one otherwise unexplained chest infection aspiration on barium swallow or other similar radiological procedure evidence of aspiration (suspected infiltrate) on plain chest x-ray. Maintain full oral hygiene.become (more) breathless? • Does the voice quality .cough? .

Take History and Perform Examination 2. CXR for all who are admitted. 3.08 13th January 2012 UNCONTROLLED WHEN PRINTED Page 14 of 17 .) will be started after clinic review TIA TRIAGE MOBILE – 01324 567691 PAGE 1684 Patients with stroke. If patient drives against advice.2% 5. Validation and refinement of scores to predict very early stroke risk after transient ischaemic attack. seizures & dizziness should be admitted or referred to other clinics as appropriate 3. random glucose.369:283-92 2. FBC. all smokers and all with another clear indication (unless a CXR has recently been performed).transient episodes of focal cerebral dysfunction or transient monocular dysfunction during which symptoms last less than 24 hours and are presumed to be of vascular origin. random cholesterol.dvla. TIA or amaurosis fugax must not drive for at least one month4 Document that advice given. anti-hypertensives etc. and anyone with continuing neurological signs when first assessed should be assumed to have had a stroke. No = 0 Score 0 to 3 4 to 5 6 to 7 Risk Group Low Medium High 2 days 1. significant abnormality found on basic tests. SIGN 108. Other Information Immediate Secondary Prevention Drug Regime Aspirin 300mg STAT followed by 75mg daily (If true aspirin intolerance.1% 8.pdf Version 2.0% 4.1% Risk of Recurrence at Interval 7 days 1. Lancet 2007. Are symptoms/signs still present? • YES – Admit & treat as stroke • NO .8% Other Factors considered High Risk: y More than 1 event in 7 days y Atrial Fibrillation yOn anticoagulants y Prosthetic Heart Valve y TIA plus neck pain suggesting arterial dissection 5.8% 17. Action Plan “Office Hours” .gov. 10 to 59 min =1. under 60 years = 0 BP Systolic BP>140 or Diastolic BP>90=1. DVLA guidelines can be found online at http://www.Continue risk assessment 4. Other patients will be assessed at clinic and a chest x-ray performed if necessary. Johnston SC et al. leg or a contiguous combination Dysphasia y Visual Field Defect y Diplopia y Does the patient have vascular risk factors? Stroke – a clinical syndrome of rapidly developing symptoms and/or signs of focal neurological dysfunction lasting more than 24 hours with no apparent cause other than of vascular origin TIA .Section 4. Clopidogrel 300mg STAT followed by 75mg daily) Drugs to be dispensed from the Emergency Department or Clinical Assessment Unit Other drug therapy (other antiplatelets.uk/media/pdf/medical/aagv1.1600h to 0900h AND all day Saturday & Sunday ECG CXR3 ABCD2 score ≥ 4 or Other High Risk Factor ADMIT & arrange tests below Complete referral & leave at A&E reception Bloods2 ECG CXR3 CT Brain scan – next day Carotid Doppler & Echo (if indicated per protocol) – next day Start appropriate secondary prevention Bloods2 ECG CXR3 Complete referral form & leave at ED reception Start appropriate secondary prevention Give Driving Advice (see below) Advise call 999 if further symptoms pending review If diagnostic doubt. Patients with LOSS OF CONSCIOUSNESS should NOT be referred to this clinic Blackouts. ESR.Section 5: Transient Ischaemic Attack (TIA) The symptoms of a TIA usually resolve within minutes or a few hours at most. then use clinical judgement & admission may be appropriate ABCD2 score < 4 and no High Risk Factors 6.9% 11. 4. will not be covered by insurance company 1. or significant co-morbidity. <10 min = 0 Diabetes Yes = 1.0900h to 1600h Monday to Friday Complete Referral Form Bloods2 Contact TIA MOBILE 01324 567691 “Out of Hours” . faints. Other blood tests as clinically indicated. arm.7% 90 days 3.1% 9. other values=0 Unilateral weakness (face/arm/leg) = 2 OR Speech disturbance only = 1 OR Other impairment = 0 >60 min = 2. Risk Assessment ABCD2 Score1 – Age / Blood pressure / Clinical symptoms / Duration / Diabetes Age Clinical Duration 60 years or over = 1. Is this likely to be a vascular event? • • • Was the event of sudden onset? y Are the symptoms focal (attributable to a single vascular territory)? Unilateral weakness and/or sensory disturbance of face. 1. statins.5 – U&E’s.

coning and death. Clinical symptoms are very variable and non-specific.3 Cerebral Venous Sinus Thrombosis (CVT) Cerebral venous thrombosis is a rare cause of stroke. It may be advisable for patients to be monitored in a neurological centre with immediate access to neurosurgical decompressive facilities for 48 hours following onset. Events can proceed rapidly with rapid and catastrophic deterioration. The aetiology is often multifactorial and underlying thrombophilias are found in 22% of patients (SIGN). surgical decompression by hemicraniectomy can significantly reduce mortality if performed within 48 hours of stroke onset (SIGN).2 • Posterior Circulation Infarct or Haemorrhage Patients presenting with a significant posterior circulation stroke should be discussed with a senior and may merit discussion with the Stroke team at Edinburgh Western General Hospital regarding temporary transfer even if there is no immediate neurosurgical issue at time of presentation. • • • • 6. accounting for 0.0) for 6-12 months is recommended (SIGN) • • Version 2.1 • • Special circumstances Malignant MCA syndrome Following proximal middle cerebral artery (MCA) occlusion. even if signs of hydrocephalus are not yet evident. Edinburgh Western General Hospital.Section 6: 6. Long term treatment with warfarin (INR range 2. Close observation of such patients is required including neuro-observation (including Glasgow Coma Scale) at least hourly for the first 48 hours. • • Patients with CVT should be discussed with a stroke specialist either locally or at the Western General Hospital. CT appearances can be subtly different and other imaging such as MR or CT venography may be required.0-3. Edinburgh. subsequent massive oedema of infarcted tissue can result in a progressive increase in intracranial pressure. Diagnosing cerebral venous thrombosis is difficult and CVT are often assumed to be ischaemic infarcts. • • 6. For individuals aged up to 60 years who suffer an acute MCA territory ischaemic stroke complicated by massive cerebral oedema. Intravenous mannitol and/or corticosteroids have no effect on outcome and are not recommended.5% of all strokes per annum. Local oedema within the posterior fossa following significant cerebellar infarction with local mass effect or mass effect from haemorrhage can result in occlusion of the 4th ventricle and obstructive hydrocephalus with coning. Anticoagulation appears to be safe following cerebral venous thrombosis (despite the presence of associated secondary haemorrhage on scanning) and may be associated with an improvement in mortality and outcome (SIGN) Treatment with IV unfractionated heparin or low molecular weight heparin followed by warfarin should be considered in patients with cerebral venous sinus thrombosis (SIGN. NICE).08 13th January 2012 UNCONTROLLED WHEN PRINTED Page 15 of 17 . Basilar artery occlusion can also cause significant morbidity and mortality. Patients ≤60 yr showing neurological deterioration after major MCA infarction should be discussed with the neurosurgical team at the Department of Surgical Neurosciences.

5% of all strokes and 5-22% of strokes in young people (<45 years). The incidence of carotid artery dissection is two to three per 100.4 Extra-cranial Cervical Arterial Dissection Extracranial cervical arterial dissection is an uncommon cause of stroke. accounting for 2.08 13th January 2012 UNCONTROLLED WHEN PRINTED Page 16 of 17 . It is important to be aware of the possibility of intracranial extension of the dissection resulting in subarachnoid haemorrhage. NICE). Aetiologies include chiropractic neck manipulations & other neck trauma and arteriopathies such as fibromuscular dysplasia and cystic medial necrosis. • • The most likely cause of stroke in cervical artery dissection is embolism from the dissection flap.000 per year. • Version 2. (SIGN) In patients with extracranial cervical arterial dissection consider treatment with either anticoagulation for three to six months or antiplatelet agents (SIGN. This diagnosis should be excluded in the usual way if symptoms are suggestive prior to initiating treatment with antiplatelets or anticoagulation.6.

arm and leg. or a sensorimotor stroke (basal ganglia or internal capsule) OR ƒ Ataxic hemiparesis (cerebellar-type ataxia with ipsilateral pyramidal signs – internal capsule or pons) OR ƒ Dysarthria plus clumsy hand OR ƒ Acute onset movement disorders (hemichorea. hemiballismus – basal ganglia) Partial Anterior Circulation Stroke (PACS) Lacunar stroke (LACS) ƒ Lacunar syndromes should not affect higher cortical function Posterior Circulation Stroke (POCS) Include ƒ ƒ ƒ ƒ ƒ Isolated homonymous hemianopia Isolated cerebellar stroke Disorders of conjugate eye movement Cranial nerve deficit with contralateral motor or sensory deficit Bilateral motor/sensory symptoms Version 2. single limb. dysphasia.sensory deficit of at least 2 out of 3 of face.g.08 13th January 2012 UNCONTROLLED WHEN PRINTED Page 17 of 17 . hand only. arm and leg ƒ Homonymous visual field defect ƒ Higher cortical dysfunction e.g.Appendix 1: Oxford Classification of Stroke Total Anterior Circulation Stroke (TACS) -carries poorer prognosis All of the below: ƒ Weakness +/. Pure motor (commonest) or pure sensory deficit affecting contiguously 2 out of 3 of face. dyspraxia ƒ 2 out of 3 criteria from TACS criteria OR ƒ Isolated dysphasia or other cortical dysfunction OR ƒ Motor/sensory deficit more restricted than a LACS e.

arrival and treatment and clinical information on symptoms and severity is used for audit purposes to ensure safety and effectiveness of service. International Stroke Thrombolysis Register). Safe Implementation of Thrombolysis in Stroke. Please fill out the paperwork as completely as possible. This protocol is for guidance only and is not intended to serve as a standard of medical care or be applicable in every situation. Much of the information. The pathway attempts to identify patients who are appropriate for treatment and facilitate treatment in as short a time interval as possible. such as timing of symptoms.1. These are a national audit (NHS Quality Improvement Scotland) and an international audit (SITS-ISTR.5 October 2012 . The information is difficult to obtain retrospectively. This document is intended to guide a clinician to administer intravenous thrombolysis for acute ischaemic stroke. and comparison with other centres. Page 1 of 7 Version 2.Name: DoB: Address: CHI: CLINICAL GUIDANCE & DOCUMENTATION FOR THROMBOLYSIS IN ACUTE ISCHAEMIC STROKE This should be filed as part of the patient’s case record. but without delay to treatment. Decisions regarding the treatment of individual patients must be made by the clinician in light of that patient’s presenting clinical condition and with reference to current good medical practice. Additional guidance is available through the South Scotland Telestroke Project – see associated protocols.

Other bloods should be sent as clinically indicated. Send blood for FBC. pulse. DO NOT perform arterial puncture. coagulation screen. INITIAL ASSESSMENT & ACTIONS 1(a) CLINICAL SUSPICION DoB: CHI: Immediate clinical assessment indicates that this patient has symptoms suggestive of a stroke. Where possible. Alert the Stroke Team (Ext 67691) and/or the on-call medical middle-grade doctor that there is a patient potentially for stroke thrombolysis. ROSIER Scale Has there been loss of consciousness or syncope? Has there been seizure activity [see also exclusion criteria] Is there a NEW ACUTE onset [or on waking from sleep] 1. 3.5 October 2012 . Contact “Flow Co-ordinator” and inform of potential need for Critical Care bed. Contact Duty CT radiologist/radiographer and request an immediate CT Brain scan.5 hours – see page 7). A CXR is not usually required before treatment and should not delay proceedings. the greater the potential benefit and the lower the haemorrhagic risk from thrombolysis Page 2 of 7 File with Admission Documents Version 2. onset is taken as the last time they were seen without symptoms . thrombolytic therapy may be possible. respiratory rate 7. Speech disturbance 5.Name: 1. blood pressure. If within this time frame. In addition. Check BM – if low. take the following steps as rapidly as possible. Inform the laboratory that these are for a potential thrombolysis case as results are needed as an emergency before treatment can be administered. Assessment and imaging must be completed to allow the delivery of the initial dose within 3 hours (for selected cases within 4. It should be done at earliest convenience as the situation allows. Asymmetric facial weakness 2. 6.1. Unless absolutely indicated. Insert IV cannulae in both upper limbs 4. 1(c) IMMEDIATE ACTIONS If the patient fulfils the above criteria. Stroke is unlikely but not completely excluded if total score ≤0) 1(b) TIME CRITERIA A definite time of onset must be known. treat urgently and reassess neurology. Check temperature. Review Exclusion Criteria 9. use the telestroke protocols for contacts during “out-of-hours” periods. 5. Perform ECG 8. 10. Visual field defect Total Score:______ Yes (-1)  Yes (-1)  Yes (+1)  Yes (+1)  Yes (+1)  Yes (+1)  Yes (+1)  No (0)  No (0)  No (0)  No (0)  No (0)  No (0)  No (0)  (Range –2 to +5. Critical Care medical staff should also be informed when necessary (if treatment proceeds). For patients waking from sleep with symptoms or being found with symptoms. TIME IS BRAIN The shorter the time to brain reperfusion. tasks should be undertaken simultaneously by members of the attending staff to minimise delay. Asymmetric arm weakness 3. (a) Time of Symptom Onset: (b) Time of Arrival (c) Time of Initial Assessment Date: ___ / ___ / ___ Time: ___ : ___ hrs Date: ___ / ___ / ___ Time: ___ : ___ hrs Date: ___ / ___ / ___ Time: ___ : ___ hrs Time Difference (a) to (b) (a) to (c) ___ h _____ m ___ h _____ m If the patient has been transferred to hospital rapidly. TRIAGE. continue through the following steps. 2. glucose and U&E. Asymmetric leg weakness 4. 1.

treatment may also be administered in selected patients out with this age range.5 October 2012 .g. If there is significant doubt as to whether the patient is appropriate for thrombolysis. including haemodialysis or peritoneal dialysis Alcohol or drug intoxication. Many of the above contra-indications are relative and after discussion with a stroke physician experienced in thrombolytic therapy. the default position is BEST USUAL CARE and do not give rt-PA Page 3 of 7 File with Admission Documents Version 2. ulcerative GI disease Patient already dependent with activities of daily living prior to this stroke event Other life-threatening illness (e.g. clopidogrel.4 On heparin (unless APTT within normal laboratory limits) Treatment with Low Molecular Weight Heparin or Heparinoid Treatment with a direct thrombin inhibitor Other known defect in clotting function/bleeding diathesis Yes No Not Known          Platelet count < 100. although this is outside the current European labelling (ESO 2008 guideline – Class III. aspirin. pancreatitis.0 or >22 mmol/l Neurological symptoms rapidly improving. spinal or cranial surgery.Name: 2. Level C). urinary. respiratory or menstrual bleeding in the last 21 days Arterial puncture at a non-compressible site in the last 10 days Patient is female and of childbearing potential (unless it is certain that pregnancy not possible) or less than 10 days post-partum Severe liver disease (hepatic failure. or history of significant drug abuse Other pathology for which thrombolysis may present a significant haemorrhagic risk e. However. dipyridamole) Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No No No No No No No No No No No No Not Known Not Known Not Known Not Known Not Known Not Known Not Known Not Known Not Known Not Known Not Known Not Known Not Known Not Known Not Known Not Known Not Known Not Known Not Known Baseline BM = BM <3. cirrhosis. CNS neoplasm. advanced cancer) likely to lead to death within a few months Treatment with thrombolytic agent within the last 14 days Or History of           AGE – Actilyse (rt-PA) is licensed for use in ischaemic stroke for patients aged 18 to 80 years. EXCLUSION CRITERIA CHECKLIST DoB: CHI: CONTRA-INDICATIONS.000 or known defect in platelet function (patients on antiplatelet agents are eligible e. lumbar puncture or thoracocentesis) or significant trauma (e. warfarin) and INR≥1.g. varices etc. Such treatment is at the discretion of the attending physician.e. a transient ischaemic attack) Bacterial Endocarditis or Pericarditis NIH Stroke Scale <5 (mild neurological deficit) or >25 (see page 6) Previous stroke plus diabetes Previous intracranial haemorrhage. No or Not Known as appropriate  History suggestive of subarachnoid haemorrhage (even if CT normal) Yes No Not Known  Seizure at stroke onset Yes No Not Known   BP Systolic <90mmHg or >185mmHg or Diastolic <40mmHg or >110mmHg Defect in coagulation Baseline BP = / Yes No Not Known On oral anticoagulant (e. treatment may proceed despite their presence.g. or haemorrhagic retinopathy Another stroke or head injury in the last 3 months Surgery (including liver or renal biopsy. major fall at time of stroke) within previous 14 days GI. considered likely to resolve completely within the next few hours (i. POTENTIAL CONTRA-INDICATIONS AND CAUTIONS Circle Yes.1. CNS vascular malformation.) Severe renal disease.g.

g./Prof. _______________________ at ____________________Hospital (face-to-face / by telephone / by telemedicine link*). then discussion should take place with their next of kin where possible.5*) hours Large hypodensity on CT scan suggesting large infarct Answer to ALL of the above must be “No” to proceed with thrombolytic therapy Scan reported by: ______________________________________ Reported in: CT scan Radiology Dept.g.1. DISCUSSION WITH STROKE PHYSICIAN EXPERIENCED IN THROMBOLYTIC THERAPY This patient meets the above criteria for thrombolysis for acute ischaemic stroke. tumour.Name: 3. 5.    Consent obtained from patient Assent from next-of-kin for an patient who cannot consent Not possible to obtain either consent or assent    6. vascular malformation or abscess) Evidence of well-established acute infarct likely to be older than 3 (4. proceed to the Administration Protocol If NO. * Or an appropriately trained & experienced stroke physician is in attendance Signed: Print: Tick appropriate box (* Delete as appropriate) 5. 4. CONDITIONS 1.  Via teleradiology  Performed Reported Date: ___ / ___ / ___ Time: ___ : ___ hrs Date: ___ / ___ / ___ Time: ___ : ___ hrs These times are included in Designation: Consultant / SpR the SITS-ISTR audit 4. Agreement was reached that this patient is eligible for thrombolytic therapy. Circle Yes or No as appropriate Treatment will be given within 3 (4½*) hours of definite symptom onset Yes No INITIAL Exclusion checklist has been completed with no contra-indications present or Yes No INITIAL relative contra-indications which have been discussed and accepted Brain imaging criteria have been met Yes No INITIAL Discussion has taken place with a stroke physician experienced in Yes No INITIAL thrombolytic therapy or such a physician in attendance Consent/assent has been obtained Yes No INITIAL Critical Care Bed is or will be available Yes No INITIAL Tick appropriate box Yes  No  Designation: Time: 7. The CT brain images were / were not viewed (in SRI / via teleradiology*) by this consultant. CONSENT / ASSENT Discussion of potential risks and benefits should take place with the patient and/or next of kin. or when there is no way to discuss with their next of kin in a timely manner. 3. Consent should be obtained from a capable patient (either verbal or written). If a patient is unable to give informed consent (e.5 October 2012 . IMAGING CRITERIA     DoB: CHI: Circle Yes or No as appropriate Yes No INITIAL Yes Yes Yes No No No INITIAL INITIAL INITIAL Evidence of intracranial haemorrhage Evidence of structural CNS lesion which can mimic stroke (e. due to dysphasia). and discussion took place with Dr. document reason & proceed with BEST USUAL CARE Page 4 of 7 File with Admission Documents Version 2. 2. 6. CONCLUSION Is the patient to receive thrombolytic therapy? Signed: Print: Date: If YES. In such a case. treatment is administered as an emergency treatment under the Adults With Incapacity Act 2000.

with an EWS chart. following the “Nursing Protocol” for stroke thrombolysis During the first 24 hours.9 = _____mg See Dosage Table  Administration is by a bolus IV injection (over 1 to 2 minutes) of 10% of the total dose.5 October 2012 .1.Name: ADMINISTRATION PROTOCOL DELIVERY OF THROMBOLYSIS    NIHSS Score: _____ Actual Weight  / Estimated Weight  DoB: CHI: See Dosage Table Ensure rt-PA prescribed on drug Kardex INITIAL _____kg INITIAL INITIAL Total rt-PA dose – 0. the following procedures/treatments should be avoided: Intra-muscular injections Heparin / LMWH / Anticoagulants A repeat CT Brain scan should be performed 24 to 36 hours from treatment   FOR MANAGEMENT OF COMPLICATIONS – SEE APPROPRIATE INSTRUCTION CARD BASELINE BLOOD RESULTS (not all are necessary before treatment) Na K Cl Urea Creatinine Glucose Hb WCC Platelets MCV Cholesterol CRP APTT APTT control PT PT control INR AST ALT Bil T Prot Alb Alk Phos ADDITIONAL NOTES Signed: Page 5 of 7 File with Admission Documents Print: Date: Version 2.9mg/kg body weight to a maximum dose of 90mg Dose= weight(kg) _____ x 0. followed by an IV infusion of the remaining 90% over 1 hour Bolus Dose (10%): _____mg Infusion Dose (90%): _____mg INITIAL   Bolus Dose Delivered at: Infusion Started at: Time: ___ : ___ hr on Date: ___ / ___ / ___ Time: ___ : ___ hr on Date: ___ / ___ / ___ INITIAL INITIAL OBSERVATION & FURTHER PROCEDURES   During infusion and for first 12 hours patient should have high dependency monitoring and nursing. the following procedures/treatments should be avoided: Urinary Catherterisation Central Venous Access Arterial Puncture NG Tube Insertion Aspirin or other anti-platelets During the first 48 hours.

joint fused or amputated 0 = Normal. limb falls 4 = No movement UN – Untestable. 10. asymmetry on smiling) 2 = Partial paralysis(total or near total paralysis of lower face) 3 = Complete paralysis of one or both sides (absence of facial movement in the upper and lower face) 1c. limb falls 4 = No movement UN – Untestable. reflex movements only 0 = Answers both questions correctly 1 = Answers one question correctly 2 = Answers neither question correctly 0 = Performs both tasks correctly 1 = Performs one task correctly 2 = Performs neither task correctly 0 = Normal 1 = Partial gaze palsy 2 = Forced Deviation not overcome by oculocephalic manoeuvre 0 = Normal 1 = Partial Hemianopia 2 = Complete Hemianopia 3 = Bilateral Hemianopia (blind including cortical blindness) 0 = Normal 1 = Minor paralysis (flattened nasolabial fold. joint fused or amputated 0 = No ataxia or paralysed/comatose/does not understand 1 = Present in one limb 2 = Present in two limbs UN = Untestable only if amputation or joint fusion 0 = Normal. Best Language 0 = No aphasia 1 = Mild to moderate aphasia.1.no useable speech or auditory comprehension 0 = Normal 1 = Mild to moderate dysarthria. Level of Consciousness 1b. slurring of words. Motor Function – Leg R L 7. no sensory loss 1 = Mild to moderate sensory loss: aware of touch 2 = Severe to total sensory loss L 6. Motor Function Arm 0 = Normal. keenly responsive 1 = Not alert. leg holds 30 degree position for 5 seconds 1 = Drift.Name: NIH Stroke Scale – Serial Recordings DoB: PreTreatment CHI: 2 hour 24 hour 7 day† Date Time 1a. Extinction & Inattention 0 = No abnormality 1 = Inattention or extinction to bilateral simultaneous stimulation in one sensory modality 2 = Profound hemi-inattention to more than one modality Total Score Assessors Initials * Time intervals as per SITS audit. but rousable by minor stimulation 2 = Not alert. global aphasia. requires repeated stimulation to attend 3 = Unresponsive. Page 6 of 7 File with Admission Documents † 7 days post-treatment or discharge from hospital. Sensory 9. Interval refers to time from completion of infusion. LOC Commands Open & close eyes and grip & release with non-paretic hand 2. leg falls by end of 5 second period but does not hit bed 2 = Some effort against gravity 3 = No effort against gravity.5 October 2012 . LOC Questions Ask patient the month and their age 0 = Alert. Limb Ataxia Finger/nose & heel/shin both sides. loss of fluency or comprehension 2 = Severe aphasia. fragmented communication 3 = Mute. limb holds 90 (or 45) degrees for 10 seconds without drift 1 = Drift. Version 2. Visual Fields 4. Ataxia disproportionate to weakness only 8. Facial Palsy 5. limb holds 90 (or 45) degrees but drifts down before full 10 seconds but does not hit bed or other support R 2 = Some effort against gravity 3 = No effort against gravity. Dysarthria at worst can be understood with some difficulty 2 = Severe dysarthria unintelligible or unable to speak (out of proportion to aphasia) UN = Untestable due to intubation or other physical barrier 11. Best Gaze Horizontal eye movements only 3.

02 to 1.5 hour study” (SITS-ISTR 3 to 4. regardless of the INR Patients with a baseline NIHSS>25 Patients with a history of both previous stroke and diabetes    Onset to treatment time should be minimised.01 to 1. 3.40:2945-2948 ESO.008]. Lancet 2004.5 hours from onset.372:1303-1309 del Zoppo GJ et al. The mortality between treatment and placebo groups did not differ significantly . 47% were treated 3. Symptomatic intracranial haemorrhage was more common in patients treated with thrombolysis .34.26 to 77.5%) [odds ratio 2. 1  Patients with acute ischaemic stroke who are eligible for treatment with rt-PA within 3 hours should be treated as recommended in existing guidelines. Tissue plasminogen activator for acute ischemic stroke. Hacke W et al.38. Background Information . N Engl J Med.5 hours. Lancet. The trial excluded patients older than 80 years. The use of rt-PA in the 3 to 4. prospective.76. those with a baseline NIHSS>25. 2009. The frequency of the primary efficacy outcome in ECASS-3 (defined as modified Rankin Scale score of 0 to 1 at 90 days after treatment) was significantly greater with rt-PA (52.16.34.5 hours after acute ischaemic stroke.52. 4. falling to 14 when treated between 3 and 4.5 hours after acute ischaemic stroke (SITS-ISTR): an observational study.4%) and 1 patient with placebo (0. 1.ac. Expansion of the time window for treatment of acute ischaemic stroke with intravenous tissue plasminogen activator. risk ratio 1. This has been consistently 3 shown in other analyses .363:768-74 Wahlgren N et al. SITS Investigators. p=0. 95% CI 1.4%) than with placebo (45. ISBN 978 1 905813 40 7. Page 7 of 7 Hacke W et al. The number needed to treat (NNT) to gain one more favourable outcome is 2 with treatment within 90 minutes. inclusion & exclusion criteria were similar to those in the American Heart Association Stroke Council 2007 guidelines for thrombolysis within 3 hours.eso-stroke. falling to 7 when treated within 3 hours.9%) and 14 patients given placebo (3.1. 7. 95% CI 1. Median time was 3 hours 59 minutes. Although a longer time window for treatment with rt-PA has been formally tested. URL http://www. it was diagnosed in 10 patients treated with rt-PA (2.333:1581–1587.5 hour) .2%) [OR 1.7% compared to 8.5 to 4 hours and 39% were treated 4 to 4. Recommendations taking this information into account are as follows.org/pdf/ESO%20Guidelines_update_Jan_2009. ECASS and NINDS rt-PA stroke trials.68).5 October 2012 .85. N Engl J Med.sign.359:1317-1329 The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Management of patients with Stroke or TIA.04]. Thrombolysis with alteplase 3 to 4. 5. By the NINDS definition. delays in evaluation and initiation of therapy should be avoided because the opportunity for improvement is greater with earlier treatment. placebo-controlled trial examining the efficacy and safety of thrombolysis with rt-PA in acute ischaemic stroke administered between 3 and 4. the European Stroke Organisation (ESO) . By ECASS-3 definition. 10% were treated 3 to 3. those taking oral anticoagulants (regardless of INR value). along with analysis of the “Safe Implementation of Thrombolysis in Stroke – International Stroke Treatment 4 Registry 3 to 4.pdf Scottish Intercollegiate Guidelines Network. Association of outcome with early stroke treatment: pooled analysis of ATLANTIS.32. A favourable outcome was more common in patients treated with thrombolysis than placebo . Guidelines for Management of Ischaemic Stroke and Transient Ischaemic Attack 2008. www. 418 to the treatment group and 403 to the placebo group. p=0.Criteria for Extended Time Window Thrombolytic Therapy (3 to 4½ hours from onset) Following the ECASS-3 study . and those with a history of stroke and diabetes mellitus. 95% CI 1. Treatment with rt-PA should be administered to eligible patients who can be treated in the time period 3 to 4.25 to 4. 1995.5 hours. 90-day mortality in the group treated with rt-PA was 7. The eligibility criteria for treatment in this period are similar to those treated at earlier period with the additional exclusion criteria: o o o o Patients older than 80 years Patients taking oral anticoagulants. 2.uk File with Admission Documents Version 2. Otherwise. Treatment Benefit is strongly time dependent.5 hour time window remains unlicensed (September 2011) All treatments should continue to be supervised by a physician appropriately trained and experienced in the delivery of thrombolysis for acute ischaemic stroke. The trial used the same dosing regimen as described above.5 hours of definite symptom onset. randomised. p=0.5 hours. benefits have been seen in selected patients treated beyond the previous 3 hour time window for thrombolytic therapy.2%) 2 [odds ratio 9. 6. and other studies has lead to recommendations from the 5 6 American Heart Association / American Stroke Association (AHA/ASA) . 2008. symptomatic intracranial haemorrhage was diagnosed in 33 patients treated with rt-PA (7.4% in the placebo group (p=0. 7 and the Scottish Intercollegiate Guideline Network (SIGN) which can be summarised as above.006]. This study.The ECASS-3 study1 was a multicentre. Stroke. 2008. December 2008. 95% CI 1. 821 patients were enrolled. Thrombolysis with alteplase 3-4.

 Set the Syringe driver to the appropriate infusion rate and start the infusion as soon as possible after the bolus has been given  If a second syringe is needed (patients 64kg and above).  Draw up the first Infusion Dose in a 50ml syringe.  Dissolve the drug using the solution within the pack.  Swap syringes as soon as the first has gone through.  Remember that haemorrhage and oral/lingual angioedema can occur hours after the treatment has been completed.Haemorrhage .  If during the infusion there is suspicion of an adverse reaction then stop the infusion immediately e.Anaphylaxis . How to administer  Open the actilyse vials only when the decision has been made to treat the patient.  If two bottles of Actilyse are needed. insert in the syringe driver and prime the infusion line.Oral/lingual angioedema  Follow the appropriate algorithm to treat the adverse reaction. giving set etc.THROMBOLYSIS FOR ACUTE ISCHAEMIC STROKE How to administer rt-PA Equipment      Actilyse – Two 50mg bottles (only one needed if patient 54kg or less) Syringe for initial bolus – 5ml or 10ml syringe Syringes for infusion – Two 50ml luer-lock type Syringe driver capable of taking 50ml syringe Labels.g. and the other full 50ml bottle for the first infusion syringe. v 2.  If two vials needed. dissolve both bottles simultaneously to save time.01 FINAL March 2011 . .  Use the Dosing Chart to select the appropriate dose of Actilyse for the patient  Solution concentration should be 1mg/ml  Draw up the Bolus Dose a 5ml or 10ml syringe and administer intravenously over 2-3 minutes. have this drawn up and ready before the first syringe has finished. needles.  The infusion rate for the second syringe is the same as for the first. then it is easier to use one bottle for the Bolus dose and second Infusion syringe.

8 5.4 81.1 56.9 74.5 6.6 63.0 69.0 3.3 8.1 77.0 32.2 51.0 50.4 47. The above table has been checked by the Pharmacy Department and ratified as correct.0 50.5 5.4 47.1 4.1 6.6 41.0 N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A N/A 1.0 48.1 6. v 2.3 72.9 74.8 79.6 68.3 59.01 FINAL March 2011 .0 32.7 8.9 24.9 8.8 3.8 75.6 3.0 50.7 71.7 45.8 39.6 77.6 37.4 34.5 76.0 4.9 40.3 38.6 7.4 18.0 50.0 69.2 45.0 50.5 4.1 43.1 43.4 5.6 5.3 38.8 9.1 43.8 4.4 52.0 50.0 19.0 50.0 48.4 61.7 7.7 58.3 6.0 50.9 61.0 * Infusion rate is the same for both the first and second syringes.3 38.9 6.7 45.5 76.5 8.4 34.0 7.0 50.8 57.3 4.0 50.7 71.8 7.9 5.0 46.8 66.0 50.5 42.2 81.0 50.4 68.1 8.0 50.4 34.0 50.0 50.5 42.4 88.0 35.1 56. 1mg/ml concentration) Infusion Rate* 1st Syringe 2nd Syringe (ml/hr) 40 42 44 46 48 50 52 54 56 58 60 62 64 66 68 70 72 74 76 78 80 82 84 86 88 90 92 94 96 98 100+ 36.6 50.4 68.2 64.7 45.4 31.3 59.0 82.4 79.7 21.2 54.0 50.0 35.3 22.0 64.5 55.0 73.9 40.0 50.7 4.7 58.5 26.0 48.3 72.0 55.8 66.0 5.2 50.2 51.4 70.2 5.8 53.6 59.2 64.0 35.5 42.2 14.3 9.8 53.9 11.5 55.0 32.6 86.8 16.0 37.6 8.8 84.8 48.4 7.6 37.6 50.6 13.2 90.6 50.2 7.9 61.4 47.THROMBOLYSIS FOR ACUTE ISCHAEMIC STROKE rt-PA Dosage Table Weight kg st lb 6 4 6 8 6 13 7 3 7 8 7 12 8 2 8 7 8 11 9 2 9 6 9 11 10 1 10 5 10 10 11 0 11 5 11 9 11 13 12 4 12 8 12 13 13 3 13 8 13 12 14 2 14 7 14 11 15 2 15 6 15 10 Total Dose (mg) Bolus Dose (mg) Infusion Dose (mg) Infusion Administration (50ml Syringes.4 43.4 81.1 77.7 6.8 66.6 50.8 29.2 63.6 37.6 63.2 72.1 27.8 79.9 40.0 50.

passing a nasogastric tube (for 24 hours).02 FINAL March 2011 . clotting screen and These results can enable an abnormality to be Group & Save detected and early treatment initiated Refer to the appropriate protocol for extracranial or intracranial haemorrhage Adapted from Lothian University Hospitals NHS Trust Nursing Protocol for the IST-3 trial v1. Refer to the doctor in charge before commencing any anticoagulant therapy. drip stand. Document and report any unusual observations Following administration of the treatment. cardiac monitor and manual sphygmomanometer Record a full set of baseline neurological observations and vital signs. O2 saturation monitor. report. review. Do not give aspirin until post treatment CT scan results are available Avoid: urinary catheterisation (until at least 30 minutes after infusion has finished). therefore it is essential that they are monitored closely and emergency equipment needs to be accessible. To ensure that every effort can be made to prevent serious bleeding or other complications IM injections can cause bleeding at the injection site in patients who have received thrombolytic therapy Anticoagulants are contraindicated in patients who have received thrombolysis due to the increased risk of bleeding Carrying out these procedures can cause bleeding Should haemorrhage be diagnosed please send samples for urgent FBC. Patients receiving thrombolysis can deteriorate quickly. Manual BP cuffs are recommended since mechanical cuffs. Check with medical staff if this is required RATIONALE The patient needs close monitoring for a minimum of 24 hours. vital signs and GCS need to be monitored as follows:  Every 15 minutes for 2 hours (using a manual BP cuff)  Every 30 minutes for the next 6 hours  Hourly for a further 6 hours  4 hourly for the next 36 hours If there is any cause for concern. suction. Baseline observations are necessary and are useful in detecting any deterioration during or post treatment Close observation of vital signs and the GCS is essential to detect any deterioration in the patient’s condition as early as possible.THROMBOLYSIS FOR ACUTE ISCHAEMIC STROKE NURSING PROTOCOL ACTION Ensure that the bed space is appropriately equipped with oxygen. document and increase observation frequency accordingly Immediately report any signs of bleeding or deterioration in the patients condition to the senior nurse and the medical team looking after the patient Avoid giving IM injections for 48 hours from time of treatment administration Avoid giving heparin or warfarin. when used frequently in patients receiving thrombolytics. Deterioration may be due to an intracranial or extracranial haemorrhage. can cause severe bruising and bleeding.

treat with PR or PO paracetamol 1g 4 hourly. sometimes photophobia  Rising BP and falling pulse To maintain adequate cerebral perfusion pressure to perfuse the brain. urticaria. vomiting. According to NHS Forth Valley policy all drugs should be prescribed Early intervention can limit complications If unsure seek help REMEMBER “TIME IS BRAIN” Adapted from Lothian University Hospitals NHS Trust Nursing Protocol for the IST-3 trial v1. angioedema. treatment If temperature is elevated above 370C. bronchospasm. but reduce the risk of intracerebral bleeding due to hypertension To diagnose if there has been a further intracranial event and seek urgent assistance Early detection and intervention can minimise In the event of a sudden drop in GCS or change complications. and hypotension Stop rt-PA infusion obtain immediate medical assistance Ensure thrombolytic drug is prescribed on drug chart Increased temperature is detrimental to recovery in patients who have suffered brain attacks Anaphylaxis is a rare but life-threatening complication. Report any sustained pyrexia Consider an anaphylactoid reaction if the patient develops rash. An urgent CT scan can be in vital signs an urgent medical review is arranged to help detect complications of essential.THROMBOLYSIS FOR ACUTE ISCHAEMIC STROKE – NURSING PROTOCOL ACTION RATIONALE Blood pressure is to be maintained between 110/60 and 240/120mmHg If BP outside these parameters call the appropriate doctor.02 FINAL March 2011 . Signs of raised intracranial pressure or intracranial bleeding:  unequal pupils  sudden drop in GCS  onset of drowsiness  onset of nausea.

a CT brain scan should be requested the day after treatment. patient will likely be ready to step down to ward-level care after 24 hours Outcomes following thrombolysis Comparing treatment with thrombolysis to “best usual therapy” (aspirin and supportive care) in an appropriate population of patients with acute ischaemic stroke:     There is a 1-in-10 greater chance of living independently after treatment with thrombolysis (50% compared to 41%) There is no excess of deaths following thrombolysis (18% for both groups) There is a higher risk of intracranial haemorrhage following thrombolysis (approx. IMMEDIATELY CONTACT THE RESPONSIBLE MEDICAL TEAM Post – treatment interventions  In the 24 hours post treatment avoid the following to minimise the risk of haemorrhage:  Urinary catheterisation  Nasogastric tube  Central venous cannulation  Arterial puncture The procedures may be necessary but should be discussed with medical team Avoid intra-muscular injections for 48 hours Avoid anticoagulant therapy Do not give aspirin until post-treatment CT results available Consider paracetamol for pyrexia     Unless there are problems which require emergency brain imaging (see below). 1-in-20 compared to 1-in-100) There is also a small risk of extracranial haemorrhage or allergic reaction Appropriately selected patients are more likely to benefit from thrombolysis than to come to harm Adapted from Lothian University Hospitals NHS Trust Protocol v1.01 FINAL March 2011 . This would normally be during working hours at a time most approximate to 24 hours post-treatment. If progress is uncomplicated.THROMBOLYSIS FOR ACUTE ISCHAEMIC STROKE Nursing Pathway Summary Preparation for patient arrival  Minimum Equipment required:  Supplementary Oxygen  Manual sphygmomanometer   O2 Saturation Monitor Syringe pump   Suction Drip stands On arrival of patient  Record basic observations on chart  GCS  Pulse  Blood pressure  O2 saturation Thrombolytic Therapy  Where thrombolytic therapy has not been given:  Initial bolus of thrombolytic to be given over 1-2 minutes by doctor  Remainder of treatment to be given over 1 hour via syringe driver Observation of Vital Signs & GCS     Every 15 minutes for 2 hours Every 30 minutes for next 6 hours Every hour for a further 6 hours Every 4 hours for next 36 hours IF THERE ARE ANY SIGNS OF BLEEDING OR THE PATIENT DETERIORATES IN ANY WAY.

Exposure High flow oxygen Adrenaline 1:1000 solution 0. look for other causes of the deterioration see appropriate protocol Potential Complication – Anaphylaxis  Suspect if patient develops  Rash  Angioedema   Urticaria Hypotension   Bronchospasm Shock       Stop rt-PA infusion Urgent medical assessment – Airway.HROMBOLYSIS FOR ACUTE ISCHAEMIC STROKE – NURSING SUMMARY THROMBOLYSIS FOR ACUTE ISCHAEMIC STROKE – NURSING SUMMARY Potential Complication – Extracranial Haemorrhage  Potential bleeding sites include (list not exhaustive):  Arterial & venous puncture sites  GI tract  Urinary tract  Retroperitoneum  Occult injuries sustained if fell/collapsed at onset of stroke Suspect if  Clinical signs of hypovolaemic shock – tachycardia. APTT.01 FINAL March 2011 . fall in blood pressure. Breathing. Edinburgh If no intracranial haemorrhage is found on CT (or insufficient to explain symptoms). peripheral shutdown  Evidence of blood loss such as melaena or haematuria Stop rt-PA infusion immediately Use mechanical compression to control bleeding if possible Check coagulation screen (PT. cryoprecipitate and platelets may be necessary. Disability. fibrinogen) and full blood count Send blood for “Group & Save” Support circulation with intravenous fluids if necessary Discuss case & test results with haematologist Correct fibrinolytic state as advised If intracranial bleeding confirmed. IV Fluid challenge. Salbutamol nebs Adapted from Lothian University Hospitals NHS Trust Protocol v1.5ml IM (repeat if necessary) Antihistamine – Chlorphenamine 10-20mg IV slowly Hydrocortisone 100-200mg IV slowly. tranexamic acid 1g IV over 15 minutes repeated every 8 hours as necessary1 Delay any surgery until the fibrinolytic state is corrected see appropriate protocol see appropriate protocol           Potential Complication – Intracranial Haemorrhage  Suspect if  Neurological deterioration  Seizure   New Headache Nausea or vomiting  Fall in conscious level          Stop rt-PA infusion immediately Arrange an urgent CT brain scan Check coagulation screen (PT.g. depending on result of coagulation screen and advice of haematologist For severe life-threatening haemorrhage. Circulation. discuss possibility of evacuating haematoma with neurosurgeons at Western General Hospital. a fibrinolytic inhibitor should be given immediately e. fibrinogen) and full blood count Send blood for “Group & Save” or cross-match depending on the situation Support circulation with intravenous fluids or blood transfusion as appropriate Discuss case & test results with haematologist Transfusion of fresh frozen plasma. APTT.

theatres.4 References 1. 1990 Aug. Boehringer Ingelheim1 suggest that in potentially dangerous haemorrhage. Reid AW. transfusion of cryoprecipitate. Clozel JP. Banken L. this is now an unlicensed use for aprotinin and it is not stocked in Forth Valley. the fibrinolytic therapy must be discontinued.03 FINAL September 2011 . 1995. Summary of product characteristics for Alteplase 2. Clozel et al2 looked into the use of aprotinin as an antidote for rt-PA.6:273-285 Adapted from Lothian University Hospitals NHS Trust Protocol v1. Pessin MS.THROMBOLYSIS FOR ACUTE ISCHAEMIC STROKE Management of Suspected Intracranial Haemorrhage Suspect intracranial haemorrhage if:   Neurological deterioration Seizure   New Headache Nausea or vomiting  Fall in conscious level Standard Management           Stop rt-PA infusion immediately Arrange an urgent CT brain scan Check coagulation screen (PT. Hypofibrinogenemia was not a uniform finding. In their small animal study they found that aprotinin immediately stopped thrombolysis. discuss possibility of evacuating haematoma with neurosurgeons at Western General Hospital. APTT. J Am Coll Cardiol. but the duration of this effect was dose dependent. 1992 Apr. Ludlam CA. The British Society of Haematology produced a consensus report in 1995 on guidelines for the use of thrombolysis. In those who fail to respond.g. but the benefits are unclear. Intracranial haemorrhage after coronary thrombolysis with tissue plasminogen activator. 3. Blood Coagulation and Fibrinolysis. tranexamic acid) are sometimes used. Edinburgh If no intracranial haemorrhage is found on CT (or insufficient to explain symptoms). For severe life threatening bleeding they suggest a fibrinolytic inhibitor such as aprotinin (see above) or tranexamic acid and replacement of clotting factors depending upon the results of a coagulation screen. Guidelines for the use of thrombolytic therapy. A study looking into intracranial haemorrhage after coronary thrombolysis3 found that the exact mechanisms behind the haemorrhage were unclear. Lowe GDO. Boehringer Ingelheim. Critical Care Unit. Their advice is that most patients can then be managed with volume replacement. ward 6. However. It is rarely necessary to replace the clotting factors because of the short half-life of the drug and the minimal effect on the systemic coagulation factors. Aprotinin: an antidote for recombinant tissue-type plasminogen activator (rt-PA) active in vivo. Roux S.92(4):384-90 4. Am J Med. in particular cerebral haemorrhage. Antifibrinolytics (e. ward 7 & the emergency drug cupboard in FVRH Other Information The manufacturers of rt-PA.16(2):507-10. Fox KAA. look for other causes of the deterioration Blood products are supplied by the Blood Transfusion laboratory once sanctioned by a haematologist. Bennet B. Their patients had received rt-PA and heparin and it was suggested that excessive prolongation of the APTT and elevated fibrin degradation products may have contributed to the occurrence of intracranial haemorrhage. fibrinogen) and full blood count Send blood for “Group & Save” Support circulation with intravenous fluids if necessary Discuss case & test results with haematologist Correct fibrinolytic state as advised If intracranial bleeding confirmed. Tranexamic acid is stored in cupboards in the Emergency Department. fresh frozen plasma and platelets should be considered: seek the advice of your local haematologist. Zivin JA et al. Kase CS.

but the benefits are unclear. Intracranial haemorrhage after coronary thrombolysis with tissue plasminogen activator. fall in blood pressure. Guidelines for the use of thrombolytic therapy. a fibrinolytic inhibitor should be given immediately e. Pessin MS. but the following points are a guide to managing such a patient in a safe and appropriate way. 1990 Aug.92(4):384-90 4.2 References 1.   Other Information Major bleeding is an infrequent but important complication of giving thrombolysis for acute ischaemic stroke. ward 6. Bennet B. Blood Coagulation and Fibrinolysis.g. Their patients had received rt-PA and heparin and it was suggested that excessive prolongation of the APTT and elevated fibrin degradation products may have contributed to the occurrence of intracranial haemorrhage. It is rarely necessary to replace the clotting factors because of the short half-life of the drug and the minimal effect on the systemic coagulation factors. Roux S. tranexamic acid 1g IV over 15 minutes repeated every 8 hours as necessary1 Delay any surgery until the fibrinolytic state is corrected Blood products are supplied by the Blood Transfusion laboratory once sanctioned by a haematologist. depending on result of coagulation screen and advice of haematologist For severe life-threatening haemorrhage. A study looking into intracranial haemorrhage after coronary thrombolysis4 found that the exact mechanisms behind the haemorrhage were unclear. Boehringer Ingelheim2 suggest that in potentially dangerous extracranial haemorrhage. Adapted from Lothian University Hospitals NHS Trust Protocol v1. Ludlam CA. There are no definitive guidelines on the management of thrombolysis related bleeding. Their advice is that most patients can then be managed with volume replacement. Tranexamic acid is stored in drug cupboards in the Emergency Department. peripheral shutdown etc. Critical Care Unit. 2.6:273-285 Boehringer Ingelheim.16(2):507-10. Summary of product characteristics for Alteplase Clozel JP.THROMBOLYSIS FOR ACUTE ISCHAEMIC STROKE Management of Suspected Extracranial Haemorrhage Suspect extracranial haemorrhage if:   Clinical signs of hypovolaemic shock – tachycardia. but the duration of this effect was dose dependent. In those who fail to respond. However. fresh frozen plasma and platelets should be considered. The British Society of Haematology produced a consensus report in 1995 on guidelines for the use of thrombolysis. theatres. Hypofibrinogenemia was not a uniform finding. APTT. transfusion of cryoprecipitate. fibrinogen) and full blood count Send blood for “Group & Save” or cross-match depending on the situation Support circulation with intravenous fluids or blood transfusion as appropriate Discuss case & test results with haematologist Transfusion of fresh frozen plasma. In their small animal study they found that aprotinin immediately stopped thrombolysis. J Am Coll Cardiol. For severe life threatening bleeding they suggest a fibrinolytic inhibitor such as aprotinin (see above) or tranexamic acid and replacement of clotting factors depending upon the results of a coagulation screen. The manufacturer. Antifibrinolytics can be used. cryoprecipitate and platelets may be necessary. Am J Med. Lowe GDO. 1995. Evidence of blood loss such as melaena or haematuria Standard Management         Stop rt-PA infusion immediately Use mechanical compression to control bleeding if possible Check coagulation screen (PT.03 FINAL September 2011 . Banken L. Zivin JA et al. 3. this is now an unlicensed use for aprotinin and it is not stocked in Forth Valley. Aprotinin: an antidote for recombinant tissue-type plasminogen activator (rt-PA) active in vivo. the fibrinolytic therapy must be discontinued. Reid AW. Fox KAA. Kase CS. 1992 Apr. Clozel et al3 looked into the use of aprotinin as an antidote for rt-PA. ward 7 & the emergency drug cupboard in FVRH.

wheeze. SpO2 < 92%. cyanosis. Stridor Rapid breathing. low blood pressure. Therefore give adrenaline as per usual protocol TONGUE ANGIOEDEMA See additional notes over page Antihistamine CHLORPHENAMINE 10-20mg slow IV IN ADDITION For all severe or recurrent reactions and patients with asthma give HYDROCORTISONE 200mg slow IV IV Fluid Challenge 500 to 1000ml Nebulised SALBUTAMOL may be used as an adjunctive measure if bronchospasm is severe and does not respond to other treatment Airway: Breathing: Circulation: 1. Life Threatening Problems Swelling. Breathing. Circulation.02 FINAL March 2011 . clammy. Disability.look for: 60 East • Acute onset of illness West 1 • Life-threatening Airway40 and/or Breathing and/or Circulation problems North • Any usually skin changes 20 0 1st Qtr 2nd Qtr for 3rd Qtr 4th Qtr Lie patient flat. faintness.5ml (500 micrograms) IM Repeat in 5 minutes if no clinical improvement 2. Call Help High Flow Oxygen Monitor Blood Pressure ECG O2 Saturation ADRENALINE 1:1000 solution 2 0. Hoarseness. Risk from anaphylaxis outweighs risk of haemorrhage from IM injection. fatigue. Exposure Diagnosis . confusion Pale. drowsy/coma Page 1 of 2 v2. 2008 Treatment Algorithm for Anaphylactic Reactions Suspected Anaphylactic Reaction STOP rt-PA INFUSION 100 80 Airway.THROMBOLYSIS FOR ACUTE ISCHAEMIC STROKE Management of Suspected Anaphylactic Reaction Suspect anaphylactic reaction if:  Consider if any of the following develop:  Rash  Urticaria  Angioedema  Hypotension Treat as severe if:  Airway compromise    Bronchospasm Shock  Clinical signs of shock Adapted from Resuscitation Council UK Guidance.

et al. transient hemifacial swelling starting in the tongue. life-threatening airway compromise requiring anaesthetic intervention is rare – 0. If not already in attendance.8% of all patients receiving rt-PA1.2. 2. Canadian Medical Association Journal 2005. 60: 1525-1527 Hill MD. Hill MD.FACIAL / TONGUE ANGIOEDEMA Background:       Angioedema of the tongue has been reported in occurring in patients receiving rt-PA Cases series report a frequency of 1. Journal of Neurology 2005. and resolves within 24hours1 Angioedema can develop hours after the rt-PA infusion is completed Combined observational data suggest severe. Thrombolysis for acute ischemic stroke: results of the Canadian Alteplase for Stroke Effectiveness Study. Hemi-orolingual angioedema and ACE inhibition after alteplase treatment of stroke. 252:1167-1170 Page 2 of 2 v2.3 or 13% of those developing angioedema Risk factors for developing angioedema are current use of ACE-inhibitors and involvement of the insular/frontal cortex in the acute stroke Treatment:     If ANY features of angioedema occur STOP THE INFUSION IMMEDIATLEY (if not already completed). although there are specific risks associated with stroke and thrombolytic therapy o Airway haemorrhage due to trauma from intubation and thrombolysis o A drop in blood pressure due to rapid sequence induction may reduce cerebral perfusion pressure and increase the volume of ischaemic brain However. et al for the Canadian Alteplase for Stroke Effectiveness Study (CASES) Investigators.3% to 5%1.5ml of 1:1000 solution) o Risks associated with anaphylaxis outweigh the risks of haemorrhage related to IM injection during or after thrombolytic therapy Advanced airway management may be necessary if airway is significantly compromised. Life threatening orolingual angioedema during thrombolysis in acute ischemic stroke. usually contralateral to the ischaemic hemisphere.2 to 0.2 (more frequently than in myocardial infarction) It usually manifests as mild. Neurology 2003. hypoxia due to airway compromise/loss will increase the risk of poor outcome Ongoing treatment o Once stabilised transfer to HDU or ITU as appropriate (following stroke thrombolysis the patient will normally be treated in HDU for first 24 hours).02 FINAL March 2011 . et al. 3. o Chlorphenamine 10mg IV tds o Hydrocortisone 100mg IV tds o Nebulised Adrenaline as required      1. fast-page on-call MEDICAL MIDDLE GRADE Contact on-call ANAESTHETIST Commence treatment for anaphylaxis as above o High Flow oxygen o Chlorphenamine 10mg IV o Hydrocortisone 200mg IV Consider NEBULISED ADRENALINE (5ml of 1:1000 solution driven by 100% oxygen) o ENSURE EYE PROTECTION with goggles/wet swabs or paper towels o Can be repeated 2-3 hourly as required If no response to nebulised adrenaline within 5 minutes then give IM ADRENALINE 500micrograms (0. 172:1307-1312 Engelter ST.

CLOT-BUSTING TREATMENT FOR ACUTE STROKE PATIENT INFORMATION You/your relative has had a stroke because an artery supplying blood to the brain has been suddenly blocked by a clot.  1 in 10 reduced risk of being dependent (requiring help to walk or needing help with most bodily needs). and to harm. The injection must be started within 4½ hours of the start of the stroke (for some groups this is limited to within 3 hours). This treatment gives a better chance of recovering fully from a stroke. (50% compared to 41%) There is a higher chance of bleeding into the brain (1 in 20 with clot-busting compared to 1 in 100 without) or bleeding elsewhere immediately after the injection and a small risk of allergic reaction. The best treatment at present is to try unblocking this artery by injecting a “clot-busting” drug called Alteplase. or with only a slight disability). patients are more likely to benefit from Alteplase than come previous activities.  1 in 10 greater chance of independence (being able to carry out all But. Giving the treatment as soon as possible increases the chance of a good recovery and reduces the risk of problems because of the treatment. overall. The medical term for “clot-busting” is thrombolysis. Standard Standard Treatment Dependent 41% Clot-Buster Clot-Busting Treatment Dependent 32% Dead 18% Dead 18% Independent 41% Independent 50% Above graphs are for treatment started within 3 hours of the start of stroke symptoms A patient has a 1 in 10 greater chance of living independently after treatment with the clot busting drug. FV Acute Stroke Team March 2011 .

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