StrokeFast Track multidisciplinary approach

1. stroke unit : Care in stroke unit is recommended in national clinical guidelines

2.IV rt-PA for acute ischemic stroke within 4.5 hrsof onset

3.Aspirin administationin the first 48 hrsof onset

4.Early hemi-craniectomyin Large hemiphericinfarction

5.Mechanical Thrombecomyfor ischemic stroke has large vessel occlusion or severe stenosis

Standard treatment of acute ischemic stroke

Acute phase caring for Patients with acute stroke

Pre hospital

Stroke Awareness , Stroke Alert

Detection , Dispatch , Delivery

In hospital

Door , Data , DecisionDrug , Disposition

Standard treatment of acute ischemic stroke

8Ds

Pre-hospitalNursing Management with acute stroke patients

Primary Prevention

Stroke Awareness(Key Stroke Warning Sing)

Stroke Alert( How to take action : Fast Call 1669 )

Pre hospital Assessment

Guideline for the Early management of patients with acute ischemic stroke 2013 (AHA/ASA)

D s of stroke care (8Ds)

Stroke chain of Survival :8Ds

Pre-hospital

Detection

Dispatch

Delivery

Hospital

Door

Data

Decision

Drug

Disposition

DetectionPatient or bystander recognition of stroke signs and symptoms

Key Stroke Warning SignsSudden on set Focal deficitRisk factors

Pre - hospital

DispatchImmediate activation of 9-1-1 and priority EMS dispatch

DeliveryPrompt triage and transport to most appropriate stroke hospital and prehospitalnotification

Pre-hospital Management of AIS patients

1.Assess & manage ABC

2. Initiate cardiac monitoring

3.Supplement O2 to maintain O2 saturation >94%

4.Establish in IV route but do not give dextrose

Pre-hospital Management of AIS patients

5. Check patient s blood sugar

6.Determine the time of onset of symptom

7.Rapidly transport patient to nearest most appropriate hospital

8.Notify hospital of pending stroke patient arrival.

(ASA Guideline Stroke 2013)

HospitalManagement of acute ischemic stroke

Emergency Department Based Care

Action Time

Door to drug (rtPA

Hospital

Door Immediate ED triage to high-acuity area

DataPrompt ED evaluation, stroke team activation, laboratory studies, and brain imaging

ABCs

Diagnosis & differential diagnosis(sudden onset, Focal deficit, Risk factor)

General management( ABC ,Fever, BS , HT ,IV fluid ,treatment of underlying disease)

Acute specific treatment(Standard treatment of acute ischemic stroke)

Treatment of neurological complication

Management of acute ischemic stroke

Immediate general assessment

Assess ABCs, vital signsOxygen provisionObtain IV access, blood investigations

(CBC, Plt, coagulation profiles)Blood sugarObtain 12-lead ECGAlert neurology team

Review historyEstablish time of onset (< 3 hours ?)Physical examinationDetermine GCS/NIH stroke scaleUrgent non-contrast CT scanRead CT scanRule out trauma/other causes

CT scan is the most important diagnostic testDo without contrastIncreased density suggest bleedBe aware that SAH may present with normal CTMRI is NOT ROUTINE (not superior to CT)Though MRI detect early bleed & more sensitive

Determine whether ischemic or hemorrhagic stroke

Brain CT scan in Stroke !

Normal Abnormal

Ischemicstroke

Hypodense Hyperdense

Hemorrhagicstroke

20

NIHSS

score Stroke Severity0 No Stroke Symptoms

1-4 Minor Stroke5-15 Moderate Stroke

16-20Moderate to Severe Stroke

21-42 Severe Stroke

Inclusion criteria (Must all be YES)4.5

>18

CT brain

Exclusion criteria (Must all be no)

1. SBP 185, DBP 110

mmHg

2. CT brain > 1/3 cerebral

hemisphere

3. 3

4. SAH

5.

3

6. PT 15 sec

INR 1.7

Exclusion criteria (Must all be no)

7. heparin 48 PTT

8. Platelet < 100,000/mm3

9. ( Active Bleed)

10.

7

NIHSS < 4 Aphasia hemianopia

Exclusion criteria (Must all be no)

12. 14

13. 21

14. Todd

paralysis

15. recent MI 3

16. recent myocardial infarction 3

17. NIHSS > 25

Exclusion

3 4.5

warfarin

INR

80

stroke (DM with prior stroke)

DecisionDiagnosis and determination of most appropriate therapy; discussion with patient and family

Recombinant Tissue Plasminogen Activator

rt -

PA

DrugAdministration of appropriate drugs or other interventions

Favorable outcomes : 31-50% of patients treated with rtPA , as compared with 20-38% of patients given placebo.

The major risk of treatment was symptomatic brain hemorrhage : 6.4% of patients treated with rtPAand 0.6% of patients given placebo

Intravenous Thrombolysis

Thrombolysis

rt-PA 0.9mg /Kg

10% of total dose Bolus 1 mins

90% of total dose Infuse over 60 mins

Total maximum dose not more than 90mg

rt-PA

mg.

= mg ml.

rt-PA Administation

rt-PA Administation

Insert cannularsinto vials of sterile water

rt-PA Administation

Insert cannulas into vial containing rt-PA

rt-PA Administation

Turn connected vials upside down to empty sterile water into rt-PA vials

rt-PA Administation

Mix rt-PA solution by gently agitating vials Do not shake

rt-PA Administation

Initiate treatment with I.V. bolus dose fo10% over 1-2 minutes

rt-PA Administation

90% I.V infusion over 60 minutes

By infusion pump or syringpump

rt-PA

Do not mix rt-PAwith any other medications.

Do notuse IV tubing with infusion filters.

All patients must be on a cardiac monitor

rt-PA must be used within 8 hours of mixing when stored at room temperature or within 24 hours if refrigerated

Complications of ThrombolysisIntra -cerebral haemorrhage -1.7 %

(1 in 77 patients) 0.28 % fatal

SITS MOST 2007

Bleeding -minor bleeding is common (IV site)

Anaphylaxis - 1%

Ace inhibitors Frontal & insular lesions

Angiodoema 1.3 % Canadian study 1,135 pts

Major Hemorrhage 0.4 %

After rt-PA Administration

Closely monitoring & record V/S ,N/S

15 min for 2 hrs

30 min for 6 hrs

60 min until 24 hrs

Control Blood Pressure

- Keep SBP < 180 mmHg and DBP < 105 mmHg

Receive O2 cannnular2-4 LPM Keep O2 satuation 94%

Look for bleeding from puncture site , urine,stooletcMonitor sign & symptom of intracerebralhemoorhage( acute hypertension , severe headache, nausea, vomiting)

No anticoagulant, antiplatelet drugs 24 hrsafter rtPANo ABG / artery puncture.Avoid insertion of NG tube ,foleyscathwithin 30 min after drug administation

After rt-PA Administration

NPO except medication for 24 hrs

IV fluid administation

Bed rest 24 hrs

Measurement of blood glucose into dextrostrip keep sugar level < 180 ,>70 mg%

Take 12 lead ECG and then on ECG monitoring at least 24 hrs

Within 24 hrsafter on rt-PA repeat CT Brain

After rt-PA Administration

If Hemorrhage suspectedStop IV rt-PA infusion

Notify Neurologist

Start CT Brain

Blood for INR ,PT ,PTT, CBC, Blood clot for cross matching

Preparing FFP, Platelets count, fibrinogenPreparing the patient for OR emergency

After rt-PA Administration

DispositionTimely admission to stroke unit, intensive care unit, or transfer

Refer

Flow stroke fast track in CMNH

Referral Stroke Fast Track from 2

Step by step for rt-PA

Step 1 Screening at ER by Nurse

Step 2 Clinical Screening by doctor

Step 3 IV Thrombolysis

Step 4 Post Thrombolysis care

(24 hrs; > 24 hrs)

1 Screening at ER by Nurse

3 - 4.5 .stroke

fast track

Blood for Coagulogram, E lyte ,CBC, BS, BUN, Cr, DTX

CT Brain, EKG

2.Clinical Screening by doctor

Exclusion & Inclusion Criteria for IV Thrombolysis

Stroke assessment : Severity

NIHSS

Patient and Family Consent

rt-PA

Time of stroke onset: 270

Check Head CT obtained done

Check Lab done

Physician order set completed done

Contraindication checklist completed done

Patient and Family Consent completed done

.signature

3. IV rtPA

(Recombinant TissuePlasminogen Activator)

4.Post Thrombolysis care (in ER)

Stroke unit

64

Nutritionists Social

Workers

CaseManagers

Occupational

Therapists

NursesMediacal

Doctors

Physiotherapists

Neurologist

PharmacologistPatient

Neurosurgeon

Multidisciplinary team

No one health profession has sufficient skill, knowledge , and experiences to deliver high quality care for these complex tasks. Two meta-analyses of studies of team

Patient care needs arebest met by the

services of more than one health profession discipline provides support for multidisciplinary team care

(Alexander,Lichtensteinet al. 1996; Gibbon 1999)

stroke

Interdisciplinary or multidisciplinary teams are better able to coordinate and provide such services, resulting in better health care and patient outcomes.

(Strasser,Falconeret al.2005;Mukamel, Temkin-Greener et al.2006)

An interdisciplinary service is strongly related to improved patientsoutcomes such as functional status, quality of life, and long-term survival.

A specialized multidisciplinary team appeared to be less effective.(Mirjam Korner,2010)

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