Post on 24-Jul-2019
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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