UNC Code Stroke Pathway (ED)

EMS Pre-Notification 0-10 Minutes 10-25 Minutes 25-45 Minutes 45+ Minutes

Priorities: Activate Code Stroke, Priorities: Rapid Triage, Brief Exam, Priorities: Labs Drawn & Priorities: Determine treatment (IV/IA) eligibility, alteplase Priorities: Post-alteplase monitoring if given
Register Patient & Enter Orders Sent, Full History & NIHSS administered within 45-60 minutes if candidate
Transport to CT Scan & transfer to NIR or inpatient unit
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 Obtain name & DOB from  Verify Blood Glucose result obtained  Maintain BP <185/110  Maintain BP <185/110  Manage overall care  Maintain BP <180/1053 or <160/90 if on
EMS from EMS (if <60mg/dL go directly to  Implement nicardipine
assigned room for treatment) Hemorrhagic Stroke  Continue cardiac monitoring If Alteplase Candidate:  Monitor for post-alteplase complications4
 If last known normal (LKN) is 
 Vital Signs: BP & HR  Begin mixing alteplase when advised
<6 hours, page (or delegate
Brief Neuro Exam within 1st 15min pathway if necessary  Manage Overall Care
 Continue Cardiac Monitoring
ED MD

If no pre-notification received: (based on CT results)  Neuro assessment by NEU MD – DO NOT administer

Charge RN to page) Code  Strict NPO until order is placed 2 If tPA Administered:
 Verify LKN: If <6 hours, page (or delegate  Manage Overall Care
Stroke (123-7003). Include  Facilitate EKG (should not  When alteplase ordered, complete  Continue post-alteplase Neuro assessment and VS
Charge RN to page) Code Stroke (123-  Brief POC update to
ETA, age and LKN
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delay alteplase administration) protocol
7003). Include ETA, age and LKN1 patient/caregiver independent double AND waste
 Obtain 2nd IV if treatment  Hang 50mL’s NSS at same rate when alteplase vial
 Order STAT Labs: CBC, Chem-  Order STAT Labs: CBC, Chem-7, PT, excess
PATIENT ARRIVES
empty to complete VTBI
7, PT, PTT/INR, Cardiac PTT/INR, Cardiac Enzymes  Transport to assigned candidate  Remove bolus into syringe
 Monitor for post-alteplase complications4
Enzymes  Order STAT EKG Reason: CODE STROKE room  Administer bolus and infusion per
If IA Candidate:  Nursing Bedside Dysphagia Screen—if passed may
 Order STAT Head CT without Contrast  Verify /initiate IV
 Order STAT EKG Reason: order & protocol
administer meds and notify LIP to enter diet order; if
access  Prepare for transport to
CODE STROKE
Reason: CODE STROKE  Implement post-alteplase Neuro failed STRICT NPO
 Draw Labs CTA (if not already done)
assessment and VS protocol:
 Order STAT Head CT without  Rapid Triage  Transfer to ICU when bed available (unless IA
PATIENT ARRIVES

 Send Labs with ‘Code and NIR

o Q 15min x 2 hrs
Contrast Reason: CODE  Obtain Vital Signs from EMS monitor candidate)
Stroke Alert’ paper to
 Notify ED MD for BP >185/105 o Q 30min x 6hrs If tPA not administered:
STROKE #888
 ID band placed on patient** o Q 1 hr x 16 hrs  Nursing Bedside Dysphagia Screen—if passed may
 
ED RN

Notify HUC of Code Stroke Obtain POC Glucose

 Obtain Blood Glucose (if not done by administer meds and notify LIP to enter diet order; if
orders  Full set of Vitals
EMS) & notify ED MD of results failed STRICT NPO
 Neuro Assessment  Review Lab Results *
 Contact ED Registration for  Transport to CT Scan on EMS stretcher  Transfer to bed when available
 Cardiac Monitoring *Note: BG is only test necessary to review before alteplase if not on
STAT registration (Note: If no In addition, if no pre-notification received: If IA Candidate:
 Strict NPO anticoagulation and no history of blood dyscrasias
name/DOB available, patient  Contact ED Registration for STAT  Review alteplase eligibility
Transport to NIR, handoff to NSICU/anesthesia at
 Obtain patient weight bedside
should be registered as a registration (see notes)
*Note: If no name/DOB available, patient If Alteplase Candidate: If NOT Alteplase Candidate:
Disaster Patient)
should be registered as a DISASTER PATIENT  Notify ED RN to remove  Enter place patient in bed order if If tPA given:
 Verify weigh stretcher  Complete NIHSS
**Note: Registration SHOULD NOT delay CT alteplase and begin mixing 2 applicable
 Enter post-alteplase and admission orders
available in assigned room  Obtain History from
Scan, patient may be registered after CT scan  Review risks/benefits/  Write consult note/ H&P using
 Obtain Stroke Binder Patient/Caregiver using orderset
in emergencies alternatives with pt/caregiver template
 Consult with  Write admission note/H&P using template
 Consider Stroke Trials
NEU MD

& provide education sheet

 Obtain history from EMS en route to CT Radiologist for final If tPA not given:
 Communicate POC to ED  Communicate POC to patient/family
 Initial CT Scan Read interpretation of CT
 ASA 300mg PR (if nursing bedside screen
MD/RN and ED Staff
 If hemorrhage on CT, implement Scan if necessary
 Receive ‘Code Stroke’ Page  Use ED PROV STROKE orderset If IA Candidate: failed)
Hemorrhagic Stroke Pathway  Initiate UNC Acute
to order tPA  Activate Code IA Stroke, obtain CTA*  ASA 325mg PO (if nursing bedside screen
 Respond to ED Triage Desk to In addition, if no pre-notification received: Ischemic Stroke
 Notify RN when order is placed (if not previously done) passed)
meet patient  Receive ‘Code Stroke’ Page and Treatment Guidelines
& verify dose with RN If IA Candidate:
 Order CTA if needed if pt is a respond directly to ED/CT Scan, (based on CT results &
 Consult NSICU & enter place
possible Code IA Stroke* determine need for CTA* exam)  Assist with transport to NIR
patient in bed order

Updated 9.2016 * When CTA is ordered, place cerebral angiogram order and initiate Code IA Stroke physician workflow. Page “Possible Code IA Stroke” to 123-9099 according to Code IA physician workflow
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See Failsafe Pager Process on Reverse 2 See Code Stroke Communication Flow for Alteplase Administration on Reverse 3
See BP Management for Alteplase Patients on Reverse 4
See Serious Complications on reverse
 UNC Code Stroke Pathway (Additional Information)
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Code Stroke Failsafe (for Pager/Directory Downtime)
 If no response to bedside within 10 minutes, use failsafe pager 123-7003
 If no response, use overhead page
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Code Stroke Communication Flow for Alteplase (tPA) Administration in the ED:
1) NEU Resident makes decision for Alteplase Administration
2) NEU Resident verbally communicates to ED RN: “please remove Alteplase from Pyxis via Override and to begin mixing the medication” (*see note)
3) NEU Resident holds risk/benefits/alternatives discussion with patient/family. (If patient/family declines, stop here. Vials should be saved for pharmacist/stroke coordinator to process reimbursement).
4) NEU Resident places order in EPIC to administer Alteplase bolus and infusion
5) ED RN x 2 completes independent double check. ED RN links medication in EPIC and begins bolus, followed by infusion
* Note: If Alteplase is not started to be mixed within 10 minutes, NEU Resident should escalate and notify ED Charge Nurse who should provide immediate assistance. If no results, NEU resident
will escalate to ED attending for assistance with resources.
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Post-Alteplase BP Management Guidelines: Guidelines For IV Infiltration During Alteplase Infusion:
Patient Who DOES Require Antihypertensive Medication(s) Pre-Alteplase:  Change infusion to alternate IV site for continuation of drug
-If patient is treated pre-alteplase with an anti-hypertensive, a Nicardipine drip will be ordered by NEU MD when the  It is not necessary to re-dose drug
alteplase order is placed
 Treat infiltrated site locally with elevation and warm compress
-Goal BP for Nicardipine titration will be <160/90 mmHg. Titrate q 5-15 minutes until goal BP is reached.
-Order for notify LIP if BP is >180/105 should still remain and this should be treated as an emergency  Document in EMR

Patient Who DOES NOT Require Antihypertensive Medication Pre-Alteplase:

-NEU MD will order PRN antihypertensives for BP >180/105 mmHg when Alteplase order is placed.
-RN to notify LIP after 1st PRN dose of antihypertensive is administered.
-LIP will order a Nicardipine drip after 1st PRN antihypertensive dose
-Goal BP for Nicardipine titration will be <160/90 mmHg. Titrate q 5-15 minutes until goal BP is reached.
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Post-Alteplase (tPA) Serious Complication Management Guidelines:
Decline in Neuro Exam, Suspicion of Intracranial Hemorrhage:
 Stop Alteplase (tPA) if infusing, Notify Neurology STAT, STAT Non-Contrast Head CT
Angioedema:
 Stop Alteplase (tPA) if infusing, Notify Neurology STAT, follow UNC ED Allergic Reaction Protocol
Other Serious Hemorrhage:
 Stop Alteplase (tPA) if infusing, Notify Neurology STAT, prepare for diagnostic tests to evaluate (dependent on location)
Resources
Nursing Neuro Checks: Refer to Comprehensive Neurologic Assessment for the Adult Patient (NURS 0145)
Hemorrhagic Stroke Pathway: Under Clinical Documents on EM Website (http://www.med.unc.edu/emergmed/resources-links/clinical-documents)
Anticoagulation Reversal in the ED: Under Clinical Documents on EM Website (http://www.med.unc.edu/emergmed/resources-links/clinical-documents)