ED Mx of stroke with possible thrombolytic Rx

see also:

• stroke (CVA)
• ED Mx of stroke
• Western Health Acute Stroke Trials 2015 (pdf)
• Vic. ECR protocol 2016

• 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

• 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

• 12 lead ECG
• 2nd iv bung
• estimate body weight
• urinalysis to check for haematuria
• have rt-PA at hand but not drawn up

• 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

• 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.

• 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

• Mx as for bleeding above
• urgent CT brain
• if intracranial bleed, consult with neurosurgery.

• 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