Cerebrovascular accident (CVA) is the medical term for a stroke. A stroke is when blood flow to a part of your brain is stopped either by a blockage or the rupture of a blood vessel. There are important signs of a stroke that you should be aware of and watch out for.
Thrombolysis in acute ischaemic stroke results in a 30% likelihood of improved outcome vs a 2% risk of worse outcome.
Administration of thrombolytic therapy must be commenced within 4,5 hours of onset of symptoms so acute strokes must be managed in an expedient manner.
1. Ensure onset of symptoms (including time to examine, investigate and initiate treatment) is less than 1 ½ hours.
2. Conduct and document a full National Intitute of Health Stroke Society(NIHSS) scoring examination.
3. Consider thrombolysis if NIHSS score is 5-22.
4. Ensure senior staff are involved immediately.
5. Ensure there are no contraindications:
· Defect not rapidly improving,
· Onset time to thrombolysis >4 ½ hours,
· NIHSS > 22 (Obtund or comatose patient) or <5,
· Any symptoms or signs suggestive of subarachnoid haemorrhage,
· Previous intracranial haemorrhage, stroke or head injury within 90 days,
· Major surgery within 14 days,
· Gastrointestinal or urogenital bleeding within 21 days,
· INR > 1.4 in presence of oral anticoagulants,
· Platelet count <100 x ,
· IV heparin within preceding 48 hours & APTT elevated,
· Arterial puncture at non-compressible site within previous 7 days,
· Hypertension with BP > 185/110,
· Blood sugar <3 or >22 mmol/l,
· Seizure at onset of stroke.
6. Arrange for URGENT CT Brain to exclude haemorrhage or tumor
7. Obtain IV access x2.
8. Take pathology samples for FBC/ U&E’s/ LFT/ Coagulation profile & random blood sugar.
9. Commence immediate continuous cardiac monitoring, BP measurement and oxygen therapy,
10. Obtain 12 lead ECG.
11. Obtain or accurately estimate patient weight.
13. If there are NO CONTRAINDICATIONS and all the INDICATIONS are met commence thrombolysis with Alterplase:
· Recommend dose is 0.9 mg/kg (maximum 90 mg).
· 10% of the dose is administered as a bolus with the remaining 90% administered over 1 hour.
· Use two 50 mg vials and dilute to 100mls.
· Take calculated bolus volume and administer to patient.
· Add remaining drug to an emptied saline bag.
· Prime the line and set pump rate to administer remaining required volume over the next 1 hour
14.Be vigilant for:
· Symptomatic hypotension,
· Deterioration in neurological status,
15. Maintain Nil per oral.
18. DO NOT INSERT OR PERFORM ARTERIAL PUNCTURES.
19. Minimize unnecessary venepuncture