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Stroke thrombolysis protocol
This document outlines a stroke management protocol to standardize and expedite treatment for acute ischemic stroke patients. It discusses the importance of minimizing delays from symptom onset to treatment administration given the time-sensitive nature of stroke. The protocol details steps in the pre-hospital, emergency department, and in-hospital phases including rapid neurological assessment, imaging, criteria evaluation, and intravenous thrombolysis administration if eligible, with a goal of completing the entire process within 60 minutes or less. Adhering closely to established guidelines and protocols is emphasized to optimize outcomes for stroke patients.
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Introduction of stroke management protocol by Dr. Ankit Gajjar, Consultant Intensivist.
Stroke is a leading cause of disability/mortality. Approx. 1.44-1.64 million new cases annually in India.
Despite thrombolysis breakthroughs, treatment applications in India remain low (<5-6% of eligible patients).
Ischemic stroke results from vascular occlusion. Causes include thrombotic and embolic events.
Untreated ischemic areas lose ~1.9 million neurons per minute. Reperfusion may save salvageable brain tissue.
Emphasizes urgency: neurons and synapses lost rapidly. Time-sensitive treatment crucial for outcomes.
Time-dependent benefits of thrombolytic drugs necessitate a protocol to minimize treatment delays.
The '8 D’s' of the Stroke Chain of Survival: Detection, Dispatch, Delivery, Door, Data, Decision, Drug, Disposition.
Role of community and healthcare providers in recognizing stroke symptoms for effective detection.
Importance of rapid dispatch and stroke alerts, mimicking emergency responses like heart attacks.
Emergency teams’ protocols for care en route, including identifying appropriate facilities and patient monitoring.
Coordination between emergency services and stroke teams for prompt treatment and communication.
Prioritizing patient assessments and allocation of resources upon arrival at the hospital.
Importance of clinical data, including blood pressure and imaging, in guiding treatment decisions.
Criteria for determining eligibility for thrombolysis based on clinical and time factors.
Specific criteria for treating patients with ischemic stroke using thrombolytic therapy.
Guidelines for additional characteristics influencing treatment eligibility within 3-4.5 hours of symptom onset.
NINDS recommendations on ideal emergency department response times for acute stroke management.
Description of Actilyse’s action in clot breakdown through binding to fibrin-associated plasminogen.
Specifics on tPA dosage, administration protocols, and monitoring requirements during treatment.
Instructions on reconstitution and administration of t-PA, emphasizing careful handling.
Highlight on maintaining protocol-based care and monitored treatment in stroke units post-intervention.
Stress on the necessity of ICU care after emergency treatment for stroke.
Need for timely management within NIH recommendations; even one hour delay can be critical.
NIH recommended timelines: DTN ≤60 min, detailing sequential steps from arrival to rt-PA administration.
Optimized timeline for preparing stroke patients for rt-PA treatment within strict time limits.
Introduction to the NIHSS scoring system for assessing stroke severity and care needs.
Clinical vignette illustrating decision-making in stroke treatment without imaging in an emergency.
Exemplifies a patient's timeline from symptom onset to ER presentation for thrombolysis consideration.
Discussion of contraindications for thrombolysis in a complex patient scenario with multiple risks.
Detailed protocol steps for emergency response and assessment for suspected stroke cases.
Overview of nursing roles in initial management steps, including relevant assessments and interventions.
Team structure and communication for stroke management, involving intensivists, radiologists, and nurses.
Flowchart for treatment decisions based on CT/MR timing criteria, assessing the patient's condition.
Emphasis on the necessity of obtaining informed consent from patients before treatment initiation.
Summary of critical actions for recognizing and responding to stroke symptoms swiftly.
Identifies frequent mistakes in stroke response, emphasizing the importance of timely transport and imaging.
Highlights actions to avoid in the pre-hospital setting that could delay stroke management.
Closing remarks emphasizing the importance of efficient stroke management protocols and teamwork.
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Similar to Stroke thrombolysis protocol
Stroke thrombolysis protocol
- 1. Stroke Management Protocol DR ANKITGAJJAR MD, IDCCM, EDIC CONSULTANT INTENSIVIST
- 3. Why protocol-ize thestroke treatment? • Stroke is the first leading cause of disability and 3rd leading cause of mortality • 1.44 – 1.64 mio cases of new acute stroke every year • 0.63 mio deaths • 63,98,000 DALYs lost due to stroke Neurology Asia 2006; 11(1-4). Stroke and its consequences in India are of epidemic nature However, treatment application is endemically low
- 4. Background • After publicationof the results of the National Institute of Neurological Disorders and Stroke (NINDS) study, the application of intravenous thrombolysis for ischemic stroke was launched and has now been in use for more than 17 years. • This breakthrough ended decades of therapeutic nihilism but we have to acknowledge the fact that despite recommendations, less than 5-6% of potentially eligible patients are currently being treated in India
- 5. Actilyse® • EmergencyPhysician Slide Kit Pathophysiology of ischemic stroke and TIA Gorelick. J Med 2009;2:1-8. An ischaemic stroke is the result of a vascular occlusion in the blood supply to an area of the brain, which results in cerebral ischemia lasting more than 60 min Causes of ischemia • Thrombotic • Embolic
- 6. Potential to ReverseNeurologic Impairment With Thrombolytic Reperfusion Saver. Stroke 2006;37:263-266. González. Am J Neuroradiol 2006;27:728-735. Donnan. Lancet Neurol 2002;1:417-425. An untreated patient loses approximately 1.9 million neurons every minute in the ischemic area Reperfusion offers the potential to reduce the extent of ischemic injury Ischaemic core (brain tissue destined to die) Penumbra (salvageable brain area)
- 7. Actilyse® • EmergencyPhysician Slide Kit
- 8. “Time is brain” Saver.Stroke 2006;37:263-266. Estimated Pace of Neural Circuitry Loss In Typical Large-Vessel Supratentorial Acute Ischaemic Stroke Neurons Lost Synapses Lost Myelinated Fibres Lost Accelerated Aging Per Stroke 1.2 billion 8.3 trillion 7140 km 36 y Per Hour 120 million 830 billion 714 km 3.6 y Per Minute 1.9 million 14 billion 12 km 3.1 wk Per Second 32,000 230 million 200 m 8.7 h Minutes Hours Days Inflammation Peri-infarct depolarisations Excitotoxicity Impact Apoptosis Time
- 9. • The benefitsof only approved drug for acute ischemic stroke are highly time dependant and therefore it is imperative to develop a system to minimize the delays in administration of alteplase • Hence the protocol-ization
- 10. Stroke Chain ofSurvival DETECTION DISPATCH DELIVERY DOOR DATA DECISION DRUG DISPOSITION Pre-Hospital Emergency Department 8 D’s of Stroke Chain of Survival
- 11. • At riskpopulation • Symptoms PATIENT • Family members • Colleagues COMMUNITY • Family physicians/GP • EMS HEALTH CARE PROVIDERS DETECTION
- 12. • Call Handlersawareness • Stroke alert displaysSUSPICION • Same as heart attack/trauma • Rapid dispatch/alerts HIGHEST PRIORITY • A,B,C • Symptoms • Exact time of onset • Blood Sugar • CINCINNATI STROKE SCALE • DO NOT REDUCE THE BP ON SCENE CARE DISPATCH
- 13. • A,B,C, care •Flat or 30 degree elevation • Oxygen ,IV access, Monitor • Draw and keep blood samples EN ROUTE CARE • NEAREST WITH MINIMUM FACILITY NOT NECESSARILY THE BEST • CT scan at least, neurophysician availability IDENTIFY APPROPRIATE CENTRE • EXACT TIME OF ONSET • GCS,GRBS • RISK FACTORS PRE ARRIVAL NOTIFICATION DELIVERY
- 14. Actilyse® • EmergencyPhysician Slide Kit Emergency services need to announce estimated time of arrival and alert stroke team Bypass administrative admission Stroke networks Pre- and in-hospital team co-ordination INTENSIVIST Emergency physician Neurologist Stroke Meeting Point Nurse Radiologist
- 15. • Triage teamalert • Bed allocation, nurse allocation RAPID & HIGHEST TRIAGE PRIORITY • TIME SINCE ONSET • ABCDE • RULE OUT TRAUMA/FEVER • BP, RBS, ECG • RBS must precede IV rtPA FOCUSSED HISTORY & ASSESSMENT • GCS,NIHSS (Preferred) • PUPILS • Lateralising deficits • Stroke profile, stroke team alert SPECIFIC NEUROLOGICAL ASSEESMENT INVESTIGATIONS DOOR
- 17. • Worsening orImproving, status quo • BP > or < 185/110 • Sugars • Time since onset < or > 4.5 hrs • INCLUSION/EXCLUSION CRITERIA CLINICAL • NECT(preferred) or MRI rule out ICH • Bleed-inform Neurosurgery • No bleed-Reassess patient, rule out other causes IMAGING • Platelets, coagulation profile • S. creatinine LABS DATA
- 18. • Time sinceonset < or > 4.5 hrsTIME SINCE ONSET • ALL YES • INCLUDE FAMILY ALSO!! INCLUSION CRITERIA • ALL NO EXCLUSION CRITERIA DECISION
- 19. INCLUSION CRITERIA • Diagnosisof ischemic stroke with mesurable neurological deficit • Onset of symptoms <3 hrs (selected cases <4.5 hrs) • Age > 18 yrs
- 20. Additional Inclusion andExclusion Characteristics of Patients With Acute Ischemic Stroke Who Could Be Treated With IV rtPA Within 3 to 4.5 Hours From Symptom Onset Jauch el al. Stroke. 2013 Mar;44(3):870-947
- 23. Actilyse® • EmergencyPhysician Slide Kit Bock. NINDS Stroke symposium proceedings 1996; Updated 2011. Door-to-MD 10 minutes Door-to-Stroke Team Notification Door-to-CT Scan 25 minutes Door-to-Needle Door-to-Admission 3 hours 15 minutes 60 minutes Emergency department response times NINDS recommendations
- 24. Actilyse® Hoylaerts et al.J Biol Chem1982;257:2912-2919. Actilyse®, rt-PA (alteplase), is a serine protease, similar to naturally occurring tissue plasminogen activator (t-PA) Mode of action With high affinity, Actilyse® binds to and activates plasminogen attached to the fibrin netting of a blood clot Plasminogen is converted to plasmin, which catalyses the breakdown of fibrin to its degradation products, resulting in break up of the clot The affinity for freely circulating plasminogen is low, so Actilyse® has highly effective local fibrinolytic effects and relatively few systemic effects
- 25. • DOSE-0.9mg/kg -10%as bolus rest as infusion over 60 mins (max 100 mg) • ADMINISTRATION-continuous • MONITORING- every 15 mins for 1st hour tPA • Labetalol-BP control only if >185/110 • No other anticoagulants/antiplatelet agents Other drugs • Foley’s, Ryle’s tube for first 24 hours Avoid procedures DRUG
- 26. t-PA administration • Apowder vial and a solvent vial (sterile water for injection) • Powder to be reconstituted with solvent and the resulting solution is 1mg/ml • DON’T SHAKE the solution vigorously. Only gentle swirl is sufficient • Body weight based total dose calculated and first 10% as a bolus over 1-2 minutes and remaining as an infusion over 60 minutes
- 27. • TPA-UNINTERRUPTED • MONITORING CONTINUUM OFCARE • Pre arrival notification • Protocol based care • Trained staff STROKE UNIT DISPOSITION
- 28.
- 29. All of theabove procedures to be finished in less than an hr as per NIH recommendation However, in today’s time even 1 hr seems quite long
- 30. Actilyse® • EmergencyPhysician Slide Kit NIH-recommended emergency department response times Bock. NINDS Stroke symposium proceedings 1996; Updated 2011. DTN ≤60 min: the “golden hour” for evaluating and treating acute stroke T=0 Suspected stroke patient arrives at stroke unit ≤10 min Initial physician evaluation (including patient history, lab work initiation, & NIHSS) ≤ 15 min Stroke team notified (including neurologic expertise) ≤ 25 min CT scan initiated ≤ 45 min CT & labs interpreted ≤ 60 min rt-PA given if patient is eligible IDEALLY performed pre-hospital
- 31. Preparing the Patientfor rt-PA in 30 min (Optimally 15 min) Vital parameters, sugar, INR 5min (3min) History, Labs, call CT 3min (2min) NIHSS 5min (2min) CT (with rt-PA at hand) To CT 5min (2min) CT 5min (4min) Reading 3min (1min) ICH ? Large and/or demarcated infarction ? Measure / Estimate weight 1min (0min) Prepare rt-PA, inject 3min (1min) Personal communication, Peter Schellinger, Jan 2011.
- 32.
- 34. A 60 yearold diabetic hypertensive male presents to ER with weakness of left arm and leg. He is conscious, alert and oriented and denies any headache, vomiting or seizures. Clinical examination is suggestive of a stroke. Most appropriate next step in the management? •Treat patient assuming that he has an ischemic stroke without any neurological imaging as he has no symptoms of a hemorrhagic stroke (such as headache and vomiting). •Perform a plain CT scan of brain •Request for MRI brain •Give aspirin
- 35. • Went tosleep at 10 pm previous night •Visited bathroom at 5:45 am, answered wife •Woke up at 7 am with left arm weakness •Comes to ER at 8:15 am ??Thrombolyse
- 36. • This patienthas a BP 200/110 ; has suffered a MI 6 months ago; had a CABG 3 months ago, is on Antiplatelets and also on warfarin for AF • This patient is not eligible for thrombolysis because • 1.BP is 200/110 • 2.CT Scan shows massive change • 3. Had recent MI and CABG • 4. Is on Antiplatelets and Warfarin Can Thrombolysis Be Done ?
- 37. Protocol • Patient cameto emergency or activated EMS • 1) Emergency RMO A,B,C Brief neurological examination History (time since onset and medication) Detail history (if candidate for thrombolysis) to rule out contraindication
- 38. • 2) Firstnurse Oxygen if required RBS IV Cannula (2) Blood samples (PT/INR/ APTT , PLT , Creat) 12 lead ECG
- 39. Protocol • 2) SecondNurse (Telephonic Nurse) INTENSIVIST On call physician or Neurophysician CT SCAN (Radiologist) Pharmacy
- 40. Suspected Acute IschemicStroke CT/MR <4.5hrs >4.5hrs IV tPA Candidate? Other Rx Trials Supportive Care CTA/CTP,MR A,PWI-DWI 0.9 mg/kg IV tPA CTA,MRA Large vessel Clot? Consider: IA lytics or devices Off –label IV tPA Visible Clot or Penumbra ?
- 41. • INFORMED CONSENTIS MUST
- 42. 42 Summary This is whatshould happen: Recognize the signs of stroke and TIA Rapid neuro exam (Cincinnati Stroke Scale or similar). Determine time of symptom onset (if possible). Provide rapid transport to an ED capable of caring for acute stroke (pre-notify). Perform finger-stick to assess serum glucose levels.
- 43. 43 Summary • Failure torecognize signs and symptoms of stroke/TIA • Failure to attempt to determine symptom onset. – Delay in transport. – Transporting a potential stroke patient to an ED not capable of treating acute ischemic stroke with fibrinolytic therapy.
- 44. 44 Summary: Pre-hospital UNACCEPTABLEActions • Attempts to treat hypertension in the field. • Failure to notify other departments • DON’T GIVE ASPIRIN BEFORE CT • DON’T WASTE TIME
- 45.