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Administering Thrombolysis-early management

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Administering Thrombolysis-early management

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    1. Administering Thrombolysis-early management

    2. Pathogenesis of ischaemic stroke

    3. Stroke

    4. Stroke Strategy

    5. What needs to be in place Protocols with paramedics (FAST) ROSIER assessment & Tpa protocol National Institutes of Health Stroke Scale (NIHSS) (all stroke team trained) Protocol with radiology 24hr HASU bleep / rota Agreement with bed management / monitored beds Identified Trained nurses (rt-PA & HASU skills) Protocols of care, Tpa guidelines / BP Guidelines

    6. Thrombolysis pathway: summary

    7. On arrival Red phone ahead Bleep system activated (stroke Dr, nurse, imaging, bed manager) Team waiting in ED History from LAS & family Admit pt, portable monitoring, clear CT Mobile box to CT

    8. What next? Take a moment to stand back and think. Dont over complicate things Diagnosis stroke? Time of onset known and less than 4.5 hours? Plain CT less than 33% MCA territory, or >25% mismatch on PCT? No ICH, SAH or AVM? No major surgery or significant bleed <14 days? Not on anticoagulants or known bleeding disease? BP less than 185/110? If not, reduce with labetalol Possibility of pregnancy? Screening required Administer tPA

    9. THROMBOLYSIS PATHWAY

    10. ECASS III Ischaemic stroke 3-4.5h. 18-80 years 0.9mg/kg t-PA vs placebo: 90 day mRS 0-1 52.4% vs 45.2% Corrected OR 1.42 (95% CI 1.02, 1.98) p=0.04 sICH (any bleed =4 NIHSS points) 2.4% vs 0.2% p=0.008 7.9% vs 3.5% p=0.006 (NINDS definition of sICH) Mortality 7.7% vs 8.4% p=0.68 ECASS investigators, NEJM 2008

    11. THROMBOLYSIS PATHWAY: ELIGIBILITY Onset more than 6 hours ago? Yes? No? Symptoms rapidly improving? Yes? No? History of intracranial haemorrhage or head injury? Yes? No? Known arteriovenous malformations or aneurysms? Yes? No? Major surgery or trauma in the last 14 days? Yes? No? Any history of active bleeding, liver disease or varices? Yes? No? Recent lumbar puncture or arterial puncture? Yes? No? Could the patient be pregnant? Yes? No? *SBP > 185 mmHg or DBP >110 mmHg? Yes? No? INR >1.5 or Platelets < 100,000/dl? Yes? No? Glucose < 3.0 mmols/l? Yes? No? Evidence of haemorrhage on CT scan? Yes? No? Early infarct signs suggest >6 hour from stroke onset Yes? No?

    12. Infusion guideline

    13. Overview Recombinant tissue plasminogen activator (r-tPA) has been proven to be an effective treatment if given within 3 hours of stroke onset. However, the best results are attained with earlier administration within 90 minutes Nonetheless, the vast majority of acute stroke patients do not receive thrombolysis in time. This is primarily because of late presentation to hospital and delays in assessment and investigation.

    14. Aims of thrombolytic treatment To break up the occluding thrombus or embolus To restore perfusion to reversibly ischaemic brain To reduce the volume of brain tissue irreversibly damaged

    15. consent Up to 3 hours Post 3 hours Pt aphasic / confused / mental health problems Family disagrees What would you do??

    16. Bleeding risk 1% natural risk in ischaemic stroke 5% with active treatment within 3 hours Increases with delay from time of onset 11-12% between 3-6 hours

    17. Thrombolysis in 3 hours

    18. Main trials NINDS parts 1 and 2: 624 patients ECASS: 0-360 minutes: 620 patients ECASS II: 0-360 minutes: 793 patients ATLANTIS A: 0-360 minutes: 142 patients ATLANTIS B: 0/180-300 mins: 613 patients IST 3 (6hrs) current DIAS 4 (9hrs) current

    19. location ED Resus area Bolus in CT scanning department (fully monitored) HASU ? What do you think?

    20. Prior to Tpa if pt hypertensive If DBP>110mmHg or SBP >180 mmHg: labetalol 10 -20 mg iv over 1 minutes, repeated after 10 minutes till response then labetalol infusion (2-8mg/min): titrate to BP S 150-180; D 90-110 Max. total dose 300mg/24 hours (HR>60bpm) If no response or contra-indications to labetalol, give iv GTN (0.5-10mg/hour) and use same target parameters

    21. ADMINISTRATION of tPA: Total dose: 0.9mg/kg of estimated weight (maximum dose 90mg) Bolus dose: 10% of total over 2 minutes, 90% as infusion over 60 minutes

    22. HASU nursing skills Encompasses 4 main elements: 2.9WTE/bed with 80:20 skill mix Thrombolysis provision and management Hyper-acute maintenance of normal physiology and detection of deterioration Hyper-acute complication prevention Early assessment and rehabilitation

    23. Aims of monitoring a patient in the Acute Stroke Phase To detect any deterioration in the patients condition and prevent complications that will impede their recovery Conscious level GCS -Detect swelling Detect stroke extension Oxygen saturations & Respiratory Rate Temperature Heart rhythm & Rate Blood pressure Blood glucose Hydration & Nutrition Infection Venous Thrombosis

    24. Post Thrombolysis care GCS, TPR, and BP every 15 min for 2 hours, every 30 minutes for 6 hours, then every hour for 18 hours Hourly observation for acute neurological deterioration: changes in consciousness levels, new headache bradycardia, acute hypertension nausea/vomiting seizures Hourly observations for bleeding: Tachycardia and/or hypotension fall in haemoglobin evidence of melaena/haematuria Hourly observations of angioedema: Breathlessness, chest or throat tightness, tingling lips or tongue, itching Tongue or facial swelling, audible wheeze, increased respiration, stridor, desaturation

    25. GCS The Glasgow Coma Scale EYE OPENING SCORES 1-4 Score 4 = Spontaneously 3 = To speech 2 = To pain 1 = No response VERBAL RESPONSE SCORES 1-5 Score 5 = Orientated 4 = Confused 3 = Inappropriate words 2 = Incomprehensible sounds 1 = No response BEST MOTOR RESPONSE SCORES 1-6 Score 6 = Obeys commands 5 = Localises to pain 4 = Flexes and withdraws from pain 3 = Abnormal flexion 2 = Extension 1 = No response

    26. JA, 66 years old, HT, DM 10:25 Collapsed getting out of car 10:30 Slurred speech, left sided weakness 11:55 Arrival at KCH (1:30 post onset) 12:05 CT scan

    27. Management of suspected bleeding Use mechanical control where possible compression venous/arterial puncture sites Urgent CT scan to exclude ICH Blood for aPTT, INR, FBC, Group and Save Call stroke team Consider cryoprecipitate 6-8 units if significant fall in Hb or ICH If platelets low give platelets 6-8 units Discuss with neurosurgeons/haematology on-call Consultant if appropriate

    28. Management of neurological deterioration Likely cause will be ICH or cerebral oedema Arrange urgent CT scan: If haemorrhage, treat as bleed If cerebral oedema and: Age <65 years infarct/hypodensity of > 50% of MCA territory &/or effacement of sulci over > 50% of MCA territory &/or compression of lateral ventricle &/or anteroseptal midline shift Urgent referral to neurosurgeons Contact stroke consultant for advice

    29. Management of Anaphylaxis Rare reported in 1.5% Stop infusion if still in progress ABC management: Protect airway and maintain adequate oxygenation Administer adrenaline, chlorphenamine and hydrocortisone as for anaphylaxis Volume replacement to maintain systolic BP >110 mm Hg Consider further steroids / antihistamines May require intubation urgently via crash call

    30. Hypersensitivity to TpA

    31. Thrombolysis care plan Problem statement This patient has been admitted to the stroke unit following a stroke. They have undergone Thrombolysis treatment. Potential for a reduced GCS & hemorrhages either cerebrally or systemically. Goals at 24 hours For patient to make a safe recovery and for early identification and treatment of potential complications. Regular Neurological observations Any deterioration in neurological status or change in observations report to medical team Observe for signs of bleeding acute headache, nausea or vomiting Refrain from any invasive procedures for 24hours Ensure patients temperature kept between 36c 37c

    32. IA Thrombolysis The ability to deliver IA tPA extends the possible acute-therapy window from 3 hours to 612 hours for selected patients (Adams et al., 2003). The IA route for tPA is a treatment consideration when rapid recanalization is desired. IA tPA must be given within 6 hours of onset of anterior stroke symptomatology and within 12 hours of onset of posterior circulation stroke symptoms. PROACT trials, 1 & 11

    33. Intra-arterial Thrombolysis Benefits Increased effectiveness Increased safety Longer time window Limitations Neuroradiology access Training and expertise Costs

    34. The future Alternative agents Tenecteplase Longer time lines IST 3: 3-6 hours DIAS 3: 3-9 hours Bridging therapies IMS III: IV vs IV+interventional/IA Collateral flow augmentation Catheter-based Neuroflow

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