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Administering Thrombolysis Early Management

Administering Thrombolysis Early Management. Angela Roots Stroke Practice Facilitator Angela.Roots@nhs.net. What have we learnt so far?. What we have learnt so far. Why thrombolyse Inclusion/exclusion Family Medical history/pre-morbid state LAS decision making Assessment (NIHSS)

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Administering Thrombolysis Early Management

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  1. Administering ThrombolysisEarly Management Angela Roots Stroke Practice Facilitator Angela.Roots@nhs.net

  2. What have we learnt so far?

  3. What we have learnt so far... • Why thrombolyse • Inclusion/exclusion • Family • Medical history/pre-morbid state • LAS • decision making • Assessment (NIHSS) • Scans • Time

  4. On arrival • LAS phone ahead • Bleep system activated • Stroke team waiting in ED • History from LAS & family • Admit patient, portable monitoring, CT Scan

  5. What next? • Consent • IV access • Observations • Pre-empting risk • Dose • Administration • Communication

  6. Consent • Up to 4.5 hours • Post 4.5 hours • Pt aphasic / confused / mental health problems • Family disagrees • What would you do??

  7. IV access • 2 cannulas • Minimise and monitor puncture sites • Ask for assistance after 3 failed attempts

  8. Observationshypertensive • If DBP>110mmHg or SBP >180 mmHg: • IV labetalol10 -20 mg over 1 minute, repeated after 10 minutes till response Max. total dose 300 mg/24 hours (HR>60bpm) • IV GTN (0.5-10mg/hour) and use same target parameters • What is your local policy?

  9. Observationshypertensive • Higher risk of bleed • Avoid rapid drop in blood pressure • Monitor heart rate • Headache

  10. Observations • Blood Sugar levels • ?cause of neurological deficit • INR • Main laboratory • CoaguCheck

  11. Plan ahead, what are the risks? • Bleeding • Puncture sites • Wounds • GI • Cathlabs • Deterioration • Anaphylaxis • Overnight cover • Staffing skill mix • Ceiling of care

  12. Dose • 0.9mg/kg • Weight required • Estimated vs actual • 90mg maximum dose

  13. Estimate the weight 52kg 89.6kg

  14. Dose and administration 10% total dose given as a bolus over 2 minutes then remainder via infusion pump over 1 hour

  15. Dose and administration • Keep dose calculation chart handy • Ensure clear prescription of total dose or bolus then infusion to avoid confusion once bolus administered • Avoid double concentration 1mg/1ml

  16. Dose and administration • Often need more than 1 vial of drug so 2 syringes to be completed • Monitor for extravasation carefully • Keep check on infusion pump rate during the hour • Ensure the infusion tubing is flushed slowly at completion to ensure the 2ml in the infusion tubing is administered

  17. Dose and administration • Before you give the drug; • Stop, stand back, reassess • Signs of improvement?

  18. Location • ED Resus area • Bolus in CT scanning department (fully monitored) • HASU ? What do you think?

  19. Communication • Patient, family, carers • Ward • Staffing capacity • Skill mix • Cardiac monitored bed • Bed manager/ site nurse practitioner

  20. So do you think we should thrombolyse? Yes! Lets go, time is brain!!!

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