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thrombolysiscvamx
Table of Contents
ED Mx of stroke with possible thrombolytic Rx
see also:
ED triage of the patient with possible stroke
- if patient is clearly not suitable for thrombolysis in stroke (eg. on warfarin) then see ED Mx of stroke.
- if patient may be suitable for thrombolysis in stroke such as onset of stroke symptoms within 4.5 hours without seizures, then continue on.
- triage as ATS triage 2 and transfer to a resuscitation cubicle
- contact stroke team ASAP and senior ED doctor
- keep patient nil orally
- URGENT CT BRAIN within 10-20 minutes of arrival in ED if possible
- non-contrast CT brain (with 1mm slice reconstructions)
- PLUS CTA from the aortic arch to brain vertex (and if possible CT perfusion scan) if:
- time of onset within six hours, with a longer window for suspected basilar occlusion, and,
- potentially treatable clinical deficit, and,
- risk benefit does not C/I contrast scan
- NB. no need to await CRN result if patient not known to have severe renal impairment
- CTA is OK if the patient is already on dialysis
- consider risk-benefit if eGFR < 30 mL/min
- consider risk-benefit if PH contrast allergy - consider giving a premed
- intravenous thrombolytic should be administered to all eligible patients in parallel with CTA/perfusion acquisition and endovascular clot retrieval (ECR) decision making to avoid delays
- tPA options:
- alteplase 0.9 mg/kg to max 90 mg, given 10% of dose IV infusion over 1 minute and remainder infused over 60min
- or, single bolus tenectaplase (TNK) 0.25mg/kg
- non-inferior to alteplase, easier to administer, possibly safer and less expensive
- CT angiogram confirms diagnosis in non-lacunar ischaemic stroke, increases appropriate use of tPA for mild/‘rapidly improving’ patients with occlusion, provides immediate knowledge of carotid stenosis and proximal vasculature, and provides critical information if considering transfer for ECR
- CTA also useful in intracerebral haemorrhage as it can demonstrate underlying vascular malformation requiring intervention and risk of ongoing haematoma enlargement – ‘spot sign’ ongoing contrast extravasation.
- CT perfusion scan improves sensitivity of Dx of stroke, shows extent of irreversible injury and the tissue at risk, and may reduce the incidence of futile ECR attempts.
- supplemental oxygen by mask (avoid nasal prongs as may cause bleeding) to keep SaO2 > 95%
- nurse patient 30-45deg elevation to minimise aspiration
- baseline obs including neuro obs and repeat every 15min
- bedside glucose level
- iv bung and send bloods for FBE, U&E, clotting, glucose
- if BP > 185/110 then GTN patch or consider iv metoprolol if no C/I
ED Mx after CT scan
- assess patient formerly for risk of bleeding
- complete thrombolysis checklist for inclusions and exclusions - see thrombolysis in stroke
- decide on Rx preferably within 30 minutes of arrival to ED
- decide upon:
- non-interventional Rx
- thrombolysis alone
- thrombolysis should be given within 4.5hrs of symptom onset
- endovascular clot retrieval (ECR) following thrombolysis
- ECR should be performed within 6 hours of symptom onset
- ECR eligibility criteria:
- ischaemic stroke with proven large vessel occlusion on CTA
- internal carotid artery (ICA)
- middle cerebral artery (MCA)
- M1 segment – between the carotid terminus and MCA bifurcation
- early M2 segment – after bifurcation but proximal within the Sylvian fissure
- basilar artery
- independent premorbid function (modified Rankin score 0–2)
- ability to start procedure within six hours of stroke onset – discretion for basilar artery occlusion and selected anterior circulation patients beyond six hours (CT perfusion is strongly recommended for these cases) as per current national/international guidelines
- intravenous thrombolysis commenced if eligible
- accessible to clot retrieval – assessment by neurointerventionist (requires remote picture archiving and communication system (PACS) access at all referral sites)
- in Victoria, this will require transfer to an ECR centre such as RMH, Monash, Alfred, StV's or Austin
- if not in one of these centres:
- if metropolitan hospital:
- initiate a direct call between the referring consultant (which may also involve the on-site registrar) and receiving consultant stroke physician (the ECR centres have stroke physician availability at all times)
- if Victorian Stroke Telemedicine (VST)-enabled hospital:
- the VST stroke neurologist will assist in identifying likely ECR candidates and advise on transport requirements.
- transfer to ECR centre via AV (not ARV unless unstable) preferably within 30min of decision to transfer being made
after decision to consider thrombolysis
- 12 lead ECG
- 2nd iv bung
- estimate body weight
- urinalysis to check for haematuria
- have rt-PA at hand but not drawn up
administer Alteplase (rt-PA)
- do not shake bottle whilst preparing but swirl it to dissolve the powder - each bottle contains 50mg and is dissolved in 50ml sterile water provided.
- total dose 0.9mg/kg to max 90mg
- give 10% of this dose as an iv bolus
- give remainder of this dose as iv infusion over 1 hour
- see also alteplase
rt-PA precautions for 1st 24hrs
- no administration of Heparin, Warfarin or any platelet agent for 24 hours following t-PA administration.
- strict maintenance of fluid balance chart
- avoid automatic BP cuffs as these will over-inflate and cause bruising - use manual BP cuffs
- avoid NGT or IDC in 1st 12 hours
- strict rest in bed first 12 hours
- falls management
- nil orally until speech assessment, preferably at 10-12hours after rt-PA
- avoid any invasive therapies during t-PA administration (including TED stockings)
- Do not use razor blade for shaving (electric razor only)
- monitor BP, vital signs and neuro obs every 15min for 1st 2hrs, then every 30min next 4 hours, then hrly next 4 hours then 2hrly
- if BP > 185/110, try GTN patch or iv metoprolol if no C/I
- if hypotensive, give NSaline carefully and check other medications that might be causing it as well as for evidence of bleeding.
- if GCS drops by 2 or more then this suggests possible intracranial bleed
- regular internal bleeding assessment:
- Assess for internal bleeding (tachycardia, hypotension, pallor, restlessness, lower back pain, muscle weakness/ numbness in lower extremities).
- Any signs or symptoms of internal bleeding to be reported to medical staff immediately.
- regular external bleeding assessment:
- Assess for external bleeding e.g. IV sites, gums (2/24 mouth care), urine (FWT 6/24 to check for blood) and faeces (FOB)
- repeat FBE, clotting at 6hrs, 12hrs and 24hrs taken from non-tPA bung after discarding 1st 5mls.
- rt-PA precautions may be ceased 24 hours post infusion.
if bleeding becomes evident
- cease rt-PA infusion
- Take blood for urgent fibrinogen level , type and cross match of four units of packed cells and prepare to give FFP
- If external bleeding , resuscitate patient with fluids, contact blood bank to arrange transfusion, apply pressure to the site if the site is compressible
- Further measures to correct coagulation will be taken in discussion with on call haematologist (may include cryoprecipitate, platelets, FFP)
- see thrombolytics
if possible intracranial bleed:
- Mx as for bleeding above
- urgent CT brain
- if intracranial bleed, consult with neurosurgery.
if angioedema occurs
- cease tPA infusion if running
- avoid im or iv adrenaline as this increases risk of intracranial bleed due to transient hypertension
- give nebulised 5 mg adrenaline in 5 mL normal saline if airway compromised
- give iv 100mg hydrocortisone + 12.5 mg IV promethazine
thrombolysiscvamx.txt · Last modified: 2023/09/10 05:55 by gary1