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Acute Stroke Protocol
1. IDENTIFY POTENTIAL STROKE:
Symptoms (within 6 hours of confirmed onset):
- Aphasia - expressive
- Aphasia - receptive
- Aphasia - global
- Ataxia
- Diplopia
- Dysarthria
- Hemianopsia
- Hemiparesis
- Quadriparesis
- Visual field disturbances
2. INITIAL TREATMENT/TRIAGE:
- Document time of onset of symptoms.
- Attach patient to monitor. Set BP to record every 15 minutes.
- Fingerstick glucose.
- O2 at 2L/cannula. Increase flow as indicated.
- IV's 0.9 NS/ @KVO (not D5W).
- Start two (2) large bore IV's (18 gauge at least). Place in Anticubital or higher, avoid jugular or subclavian lines.
- Draw labs: CBC, Chem 7, Pt/PTT(INR), CPK, Troponin, Drug Toxicology Screen
- Perform baseline neurological examination (brief)
- Order EKG
- Order portable chest X-Ray
- ER Attending: Call the Transfer Center 877 236-4828 (admit2U) or 587-8980. Ask to speak to Brain Attack attending on call.
Tell the operator: the patient's name, age, time of onset, your name and call back number.
- Weigh the patient
- Foley Catheter
- Obtain non-contrast head CT
3. DETERMINE CANDIDACY FOR INTRAVENOUS THROMBOLYTICS:
Inclusion Criteria:
- Age 18 years or older
- Clinical diagnosis of ischemic stroke causing a measurable neurologic deficit
- Time of symptom onset well established to be <180 minutes before treatment would begin
Exclusion Criteria:
- Evidence of intracranial hemorrhage on pretreatment computed tomography (CT)
- Only minor or rapidly resolving stroke symptoms
- Clinical presentation suggestive of subarachnoid hemorrhage
- Active internal bleeding
- Known bleeding diathesis, including but not limited to:
- Platelet count < 100 x10 9 /liter (<100,000/mm3 ).
- Patient has received heparin within 48 hours and has an elevated a
PTT (>upper limit of normal for laboratory)
- Current use of oral anticoagulants and an elevated INR > 1.5 seconds
- Within 3 months of any intracranial operation, serious head trauma, or previous stroke
- Major surgery within last 14 days
- History of gastrointestinal or urinary tract hemorrhage within 21 days
- Recent arterial puncture at noncompressible site
- Recent lumbar puncture
- On repeated measurements, systolic blood pressure >185 mm Hg or diastolic blood pressure >110 mm Hg at the time treatment is to begin, or patient requires continuous intravenous antihypertensive treatment to reduce blood pressure to within these limits
- May use Labetalol or hydralazine intermittent iv doses to maintain these limits
- History of intracranial hemorrhage
- Abnormal blood glucose level (<50 or >400 mg/dl)
- Post-myocardial infarction pericarditis
- Patient observed to have seizure at the same time as the onset of stroke symptoms occurred
- Known arteriovenous malformation or aneurysm or neoplasm
4. ADMINISTRATION OF T-PA:
- If patient meets inclusion & exclusion criteria, discuss risks and benefits with patient and family (see sample Risk/Benefit Information form)
- Dosage of t-PA = 0.9 mg/kg up to a maximum of 90 mg. (see dosing sheet).
- (10% of total dose) given as a bolus over 1 minute.
- Remainder of dose is administered over one hour (using an infusion pump & buretrol). Do not hang entire t-PA vial.
- To give remaining t-PA that is left in tubing; when infusion pump beeps, inject 50 cc 0.9NS into the t-PA infusion bag and restart pump.
- Vital signs with neurological checks are to be performed and documented before the initiation of t-PA therapy and every 15 minutes thereafter. Keep SBP < 185 and DBP <110. Use of any antihypertensive is acceptable.
- If the patient experiences a sudden decline in neurological status, or new onset of hemorrhage (GI/GU, etc.) STOP the infusion of t-PA and notify the Attending Physician immediately.
5. TRANSFER:
- Obtain specific instructions regarding appropriate type of transport and exact destination from the Brain Attack Attending
- Specify to paramedics BP to be taken every 15 minutes. If SBP > 185 and/or DBP> 110 give Labetalol 5-10 mg IV Q 10 minutes until effective (total dose 150 mg)
- Notify University ED if significant change in status.
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