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STROKE SERVICE
STROKE ADMISSION - MANAGEMENT PROTOCOL
This protocol is derived from the best available evidence (where available) including SIGN guidelines .
History – In addition to the standard history, particular attention should be paid to the time of onset of the
event(s), any fluctuation in symptoms, and the patient’s perception of their deficit. Also ask about previous
stroke, TIA, and recent head injury or fall. Confirm current drugs, especially antiplatelet agents and
anticoagulants. Risk factors for vascular disease should be listed.
Examination – Consciousness should be assessed using the GCS. The CNS exam should identify motor and
sensory deficits, hemianopia, dysphasia and neglect. CVS exam should record pulse rhythm and BP.
Investigation
Immediate: All patients should have a CT scan: these should be requested for the next available session;
Urgent CT scans must be done in those on warfarin, and with progressing signs (see below)
Bloods: U&Es, Glucose (including immediate BM stick), Lipids, FBC, ESR. Coagulation screen should
be done if intra-cranial haemorrhage is suspected or the patient is on warfarin. Record basic bloods (U/E,
sugar, FBC) in medical notes.
Organise CT scan, cardiac echo if any suspicion of cardio-embolic stroke.
All patients must have a CXR and ECG.
First 2-3 days: Request carotid Doppler if carotid territory TIA (or CVA with good recovery).
Echo if recurrent TIA or CVA, cardiac murmurs, stroke with no obvious cause and multiple sites / arterial
territories on CT scan.
In young patients (<55) request thrombophilia screen, autoimmmune screen, and echo to exclude
structural cardiac defects.
Management
Standard medical clerking, plus stroke admission proforma.
1. Hypoxic patients (saturation <95%) should have Oxygen unless contraindicated.
Monitor
Temperature, Pulse, BP 4 hourly, plus Oxygen saturation at least 6 hourly,(preferably continuously).
For ECG monitor if arrythmia, medically unstable, hypotensive.
Start fluid chart.
Assess conscious level – if drowsy, perform 4 hourly Neuro obs / Coma Scale
2. Unless in heart failure, all patients should start I.V. saline 500ml / 4hours until biochemistry available,
then amend as necessary. Avoid dextrose if possible for the first day.
3. Patients who fail the bedside swallowing assessment must have IV fluids and nasogastric tube placed
as soon as possible. (See Swallowing Protocol)
4. Once haemorrhage is ruled out on CT, start aspirin at once. Patients already on aspirin should have
this stopped on admission, and resumed once haemorrhagic stroke is excluded. Rectal aspirin should be
used if the oral route is not available. To start aspirin, use 300mg/ day for the first 2 days, then 75mg.
5. Hypertensive patients should not have their blood pressure lowered in the acute setting unless
encephalopathy or aortic dissection are diagnosed. If in doubt, contact senior staff.
STROKE SERVICE
6. Hyperglycaemia – patients with a blood glucose >11 mmol/l, within twelve hours of admission
should be started on a glucose/insulin infusion to maintain glucose as close to 11mmol/l as
possible.
7. DVT prophylaxis – If leg paralysis, full length TED stockings should be used if tolerated; heparin is
not indicated unless there is co-existing DVT or PE.
8. Pyrexia – over 37 C must be treated at once by oral or rectal paracetamol 1gram q. 6 hours
9. Nursing Assessments – especially pressure area risks, fluid balance, weight. Avoid urinary
catheter unless critical for measuring urine output or to relieve retention.
10. Hypertension should not normally be treated early post stroke. If Blood pressure very high, (over
220 systolic 120 diastolic) check for hypertensive retinopathy, acute renal failure and inform
consultant staff. Labetalol infusion may be required – but very rarely.
11. Refer to Rehabilitation Staff for early review
Urgent CT scan if:
on warfarin:
severe headache,
papilloedema, neck stiffness or fever
fluctuating symptoms
STROKE SERVICE
ADMISSION / CLINIC FINDINGS
Clinic Patient
NAME
Hospital Number
Admission / Clinic Date
Date of Onset
Symptoms Resolved
Symptoms incompletely resolved
Symptoms lasted 1 – 3 days
Symptoms lasted < 24 hours
Symptoms lasted < 1 hour
Symptoms lasted < 20 minutes
Admission Ward
Carotid Bruit
Motor Signs
Sensory Signs
Hemianopia
Dysphasia
Neglect
Cerebellar signs
Brainstem signs
Unconscious
Dominant hand:
Presenting Complaint
Headache
Vomiting
Seizure
Motor Symptoms
Sensory Symptoms
Collapse
Coma Scale
Total
Eyes
(1 - 4)
Show affected area
Time of Onset
Visual Symptoms
Amaurosis
Diplopia
Vertigo
Ataxia
Fall
Plantar response: 
R
Height:
BP
Systolic
Diastolic
Weight:
Pulse Rate
Motor
(1 - 6)
Pulse Irregular
Verbal
(1 - 5)
Comments
Atrial Fibrillation
Barthel
(Pre Adm)
L
Stroke Type
LACI
PACI
TACI
POCI
BLEED
TIA
STROKE SERVICE
DISCHARGE DETAILS
WARD
NAME
Discharge Date
Hospital Number
Discharge to:
GP Surname
Functional Status
Mobility (DESCRIBE)
PEG
Catheter
Dressing (DESCRIBE)
Antiplatelet
Anti HBP
Continence
Speech
Visual Function
Neglect
Incontinent - Urine
Incontinent - Bowel
Aphasic - severe
Aphasic - mild
Hemianopia
Visually Impaired
Right
Left
Barthel at discharge
Bowel (2)
Bathing(1)
Bladder (2)
Transfers(3)
Grooming(1)
Mobility(3)
Toilet(2)
Dressing(2)
Feeding(2)
Stairs(2)
Total: (20)
Comments
Statin
Warfarin
DISCHARGE BP
Discharge Rankin (0-5)
Current Cholesterol:
STROKE SERVICE
Glasgow Coma Scale
Eye Opening
E
spontaneous
4

90% less than or equal to 8 are in coma
to speech
3

Greater than or equal to 9 not in coma
to pain
2

8 is the critical score
no response
1

Less than or equal to 8 at 6 hours - 50% die
Best Motor Response
M

9-11 = moderate severity

Greater than or equal to 12 = minor injury
To Verbal Command:
obeys
E + M + V = 3 to 15
6
To Painful Stimulus:
localizes pain
5
flexion-withdrawal
4
flexion-abnormal
3
extension
2
no response
1
Best Verbal Response
V
oriented and converses
5
disoriented and converses
4
inappropriate words
3
incomprehensible sounds
2
no response
1
RANKIN SCALE
0-
No symptoms.
1-
Minor symptoms do not interfere with lifestyle.
2-
Minor Handicap; symptoms lead to some restriction in lifestyle, but do not interfere with patients ability
to look after themselves.
3-
Moderate Handicap; symptoms significantly restrict lifestyle & prevent totally independent existence.
4-
Moderately severe handicap; symptoms clearly prevent independent existence, although does not
need constant care & attention.
5-
Severe handicap; totally dependent, requiring constant attention day and night.
STROKE SERVICE
BARTHEL INDEX
Name:
Hospital Number:
DATE
BOWELS
BLADDER
GROOMING
TOILET USE
FEEDING
TRANSFER
MOBILITY
DRESSING
STAIRS
BATHING
TOTAL
0 = Incontinent
1 = Occasional accident (I per week)
2 = Continent
0 = Incontinent or catheterised & unable to manage
1 = Occasional accident (max 1 x per 24 hours)
2 = Continent for over 7 days
0 = Needs help
1 = Independent face washing, hair, teeth, shaving
0 = Dependent
1 = Needs some help
2 = Independent on, off, dressing, cleaning
0= Dependant
1= Needs some help – spreading, cutting
2= Independent if food within reach
0 = Unable & no sitting balance
1= Needs major help
2 = Needs minor help
3 = Independent
0 = Unable
1 = Wheelchair independent indoors
2 = Walks with help / supervision
3 = Independent (may use aid)
0 = Dependent
1 = Needs some help
2 = Independent including fasteners
0 = Unable
1 = Needs some help or supervision
2 = Independent
0 = Dependent
1 = Independent in bath or shower
20
DATE
DATE
STROKE SERVICE
MINI MENTAL TEST SCORE – page1
NAME:
Hospital Number:
1. ORIENTATION
What is today's date?
What is the year?
What is the month?
What day is today?
Can you also tell me what season it is?
Can you also tell me the name of this hospital?
What floor are we on?
What is the name of a street nearby (or near your home)?
What town or city are we in?
What country are we in?
Score 0-10
2. IMMEDIATE RECALL
Ask subject to repeat these words. Allow 1 second per word, and up to 6 trials.
Ball
Flag
Tree
Number of trials
Score 0-3
3. ATTENTION AND CALCULATION
Begin with 100 and count backwards by 7 ( 93 ?86 ?79 ?72 ?65 )
OR spell the word "World" backwards (DLROW)
Score 0-5
4. RECALL
Can you recall the words I said before?
Ball
flag
tree
Score 0-3
5. LANGUAGE
What is this?
Watch
Pencil
Repeat after me "No ifs, ands or buts"
Score 0-3
6. PRAXIS
Take this paper in your right hand, 1 point
….fold it in half…. 1 point
….and put it on your knee" 1 point
Score 0-3
7. LANGUAGE READING COMPREHENSION
Do as this says: "Close your eyes"
Score 0- 1
8. PRAXIS (Continued)
Write a sentence
Copy intersecting pentagons
Score 0-2
TOTAL /30
STROKE SERVICE
MINI MENTAL TEST SCORE – page2
CLOSE YOUR EYES
Clock Drawing Test
– if required.
Put numbers, hands
to make 10 to 2.
STROKE SERVICE
TIA PATIENT PROTOCOL - Fast Track Clinic.
We aim to see patients within a week of referral. The service can be accessed by fax, e-mail
or telephone call.
Access is only to those with a sudden onset, new, focal neurological deficit lasting less than 1 hour,
and usually around 20 minutes. Recent new onset mild stroke patients who have not been admitted
can also be seen.
Symptoms should be negative i.e loss of power (i.e unable to move), loss of vision, or loss of
sensation (numbness). Usually the whole limb is involved, or face / arm / leg on one side.
Positive symptoms such as tingling or clumsiness of a limb which can still move, or positive visual
symptoms like flashing lights, wavy lines, or blurring are not likely to be stroke related.
Speech disturbance should be dysphasia or dysarthria. Visual symptoms should be amaurosis fugax
(defined as loss of vision in one eye,) or hemianopia. Exclusion criteria for the clinic are given below.
These patients should be referred in the usual most appropriate way.

Migraine

Syncope, presyncope

Funny turn (no focal symptoms / symptoms on both sides)

Isolated vertigo or “Dizziness”

“Blurred vision”

Epilepsy

Transient global amnesia / confusion

Drop attack

Multiple sclerosis

Hypoglycaemia

Very recent head injury

Intracranial tumour, extradural or subdural haematoma, subarachnoid haemorrhage.

Major co-existing problem of GI bleed or acute myocardial infarct.

An old stroke and no new stroke.
Please use the fax form, or provide a letter with a list of risk factors, significant past history, current medication,
blood pressure and any recent investigations. A/E referrals should have a copy of A/E card attached. Please
feel free to photocopy the fax form locally – Any updates will be sent directly to you.
Baseline investigations would be appreciated if possible:
FBC, ESR, U/E, LFT, Glucose, Lipids, blood pressure, and weight.
Dr. Lindsay Erwin, Lead Consultant, Stroke Service, RAH Paisley
Tel: 0141 314 6893 (secretary)
Fax: 0141 314 7298
E-mail:
[email protected]
May 2008
STROKE SERVICE
RAH
TIA CLINIC FAST TRACK REFERRAL FORM:
FAX To: 0141 314 7298
Tel: To: 0141 314 6893
There should be a history of sudden onset FOCAL neurological symptoms.
There must be at least one of (tick box)
Right
Speech disturbance
Left
Right
Loss of power in: face
sensory loss in:
Left
face
arm
arm
leg
leg
Hemianopia.
Transient Monocular Blindness
Duration of symptoms: <10min
Patient Demographics
< 1 hour
D.o.B
< 1h and >24h
GP details
Name
Name
Address
Address
Tel:
Hosp. No.
CHI No.
Please tick any risk factors below
Previous Stroke
Diabetes
Hypertension
>24h
Tel:/Fax
Referred by Dr.
Current Medication
Current BP
Smoking
Alcohol
Previous MI
Cholesterol
Atrial Fibrillation
Angina
Intermittent Claudication
Family History of Stroke
Other information / other symptoms: attach A/E card
ABCD2
STROKE SERVICE
ABCD 2 SCORE : TO STRATIFY URGENCY OF TIA REFERRALS
The ABCD2 score has been validated in individuals with TIA, and can give an indication of the
urgency of a review.
The score is:
AGE >60
Blood pressure elevation systolic >140 / diastolic >90
Clinical features:
unilateral weakness / speech disturbance alone
Duration of event >60 minutes / 10-59 minutes
Diabetes
1 point
1 point
2 points / 1 point
2 points / 1 point
1 point
We advise that those with a score of 3 or more should be seen at a fast track clinic as quickly as
possible, and those with a score of 5 or 6 considered for admission.
STROKE SERVICE
Clinical Classification of Stroke
LACS( Lacunar syndromes:)
No visual field defect
No new disturbance of higher cortical function
No sign of brainstem disturbance --- (maybe - may reclassify later)
Categories:
PMS - pure motor stroke
PSS - pure sensory stroke
SMS - sensorimotor stroke
To be acceptable as PMS, PSS, or SMS, deficit must involve 2 out of 3 areas of: face, arm , leg;
if the arm , whole limb, not just hand.
POCS (Posterior cerebral syndromes)
Any of:
Ipsilateral cranial nerve palsy(single or multiple) with contralateral motor and / or sensory deficit.
Bilateral motor and / or sensory deficit
Disorder of conjugate eye movement
Cerebellar dysfunction without ipsilateral long tract deficit (as seen in ataxic hemiparesis)
Isolated hemianopia or cortical blindness
If any disorder of cortical function + above, classify as POCS
TACS (Total anterior cerebral syndromes)
All of:
Hemiplegia contralateral to the cerebral lesion
Hemianopia contralateral to the cerebral lesion
New disturbance of higher function - (dysphasia, visuospatial disturbance)
PACS (Partial anterior syndromes)
Any of:
Motor / sensory deficit + hemianopia
Motor / sensory deficit + new higher dysfunction
New higher dysfunction + hemianopia
Pure motor / sensory deficit less extensive than LACS - e.g. monoparesis
New higher dysfunction alone (e.g aphasia)
Sources:
Patten : Neurological Differential Diagnosis 2nd edition : Springer ISBN3-540-19937-3
Warlow, Dennis et al Stroke - a practical guide to management (second edition)
Blackwell Science ISBN 0-632-05418-2
(See table on next page – Formulating the clinical findings.)
STROKE SERVICE
Formulating the clinical findings
1
unilateral weakness (and / or sensory deficit) affecting face.
2
unilateral weakness (and / or sensory deficit) affecting arm
3
unilateral weakness (and / or sensory deficit) affecting hand
4
unilateral weakness (and / or sensory deficit) affecting leg
5
unilateral weakness (and / or sensory deficit) affecting foot
6
Dysphasia, dyslexia, dysgraphia, (i.e. dominant hemisphere cortical)
7
Visuospatial disorder / inattention / neglect (i.e. non – dominant hemisphere)
8
Homonomous hemianopias/ or quadrantopia
9
Brainstem / cerebellar signs other than ataxic hemiparesis
10
Other deficit
TACS
1+2+3+4+5+6+7
LACS
1+2+3+4+5
POCS
8 OR 9 OR 8 +9
PACS
Other combinations excluding 9 and 10
OR 1+2+3
OR 2+3+4+5
STROKE SERVICE
SWALLOWING ASSESSMENT.
Dysphagia needs to be identified early to minimise the risk of aspiration pneumonia.
Signs of aspiration soon after eating
Longer term signs of aspiration may be:
Coughing and choking
A change in colour (grey)
A wet gurgly voice
Wheezing or gasping
Tachycardia
Pocketing of food in cheeks
Loss of food / liquid from the nose
Recurrent chest infections
Excess salivation
Refusal to eat
Pyrexial illness
Dehydratrion
WATER SWALLOW TESTING
Give the patient a teaspoonful of water x3
Any evidence of:
a) absent swallow
b) delayed swallow / cough (up to 2 minutes after swallow)
c) wet, gurgly voice
Day 1
Day 2
Day 1
Day 2
If yes to any of the above, keep nil by mouth
If No, continue
GIVE THE PATIENT A 50ml GLASS OF WATER TO DRINK
Any evidence of:
a) absent swallow
b) delayed swallow / cough (up to 2 minutes after swallow)
c) wet, gurgly voice
If yes, keep nil by mouth, continue IV fluids or plan tube feeding
If NO, start on a soft diet and observe. Refer to Speech Therapy staff.
Do not refer to Speech Therapy if drowsy or comatose.
STROKE SERVICE
Management of Hyperglycaemia (Blood sugar >11mmol/l)
Use a syringe pump driver.
Make up a solution of 50 units soluble insulin to a total of 50mls.
Ensure line is flushed with solution before connecting to the patient’s IV line.
Make sure formal blood glucose is over 11 mmol/l.
Blood glucose (mmol/l)
Insulin infusion rate (ml/hour)
< 5 mmol/l
0
5 – 9 mmol/l
1
9 – 13 mmol/l
2
13 – 17 mmol/l
3
17 - 21 mmol/l
4
> 21 mmol/l
5
Check blood glucose at least 2 hourly and adjust the rate as required.
Aim for a blood sugar between 5 – 10 mmol/l.
Management of severe hypertension / hypertensive emergency (after discussion with Consultant staff)
This is accepted to be a systolic of over 220 mmHg and diastolic of 121 – 140 mmHg.
Labetalol is the drug of choice unless there is severe left ventricular failure or major bronchospasm.
Give 20mg intravenously over 1 – 2 minutes.
Make up a solution of 1 mg/ml labetalol with normal saline or 5% dextrose. Use 200ml bag – discard
volume of labetalol ampoules to ensure accurate dosing.
Start an infusion by pump at 0.25 mg / minute (15ml / hour if 200ml bag) increasing every 15 minutes
to 2mg / minute. Maximum total dose is 200mg.
Diastolic should not be lowered below 100 – 110 mmHg.
STROKE SERVICE
How to use antiplatelet agents after stroke
If already on aspirin or antiplatelet drugs, stop after a new stroke until CT scan excludes a bleed.
If not on aspirin, wait until CT excludes a primary intracerebral bleed then immediately start aspirin
300 mg/day for 14 days, reducing to 75 mg/day thereafter. If the patient cannot swallow, give aspirin
300mg as a suppository for 3 days, then 150mg daily. Antiplatelet agents CAN be given to those with
haemorrhagic transformation within an infarct ; these signs are clearly different on CT from a primary
bleeds.
Dipyridamole retard 200 mg b.d should also be given, as long as the patient can tolerate it
(headaches are the main problem).
If the patient is aspirin intolerant due to asthma or allergy use Clopidogrel 75mg daily. If the patient
has a history of GI bleeding, aspirin should be used once any acute cause is resolved, but with
lansoprazole 30mg nocte as cover. If the patient is intolerant of aspirin and Clopidogrel, try
dipyridamole retard as above.
The combination of clopidogrel and aspirin though appropriate for acute coronary syndromes should
not normally be used in stroke patients, as there is an increased bleeding risk.
It may be prudent to use aspirin plus clopidogrel in “crescendo TIA” patients but normally this should
be discussed with a consultant.
Use of Aspirin / Antiplatelet agents in minor stroke / TIA
If the patient has a history of classical TIA – weakness or numbness in:
face/ arm / leg,
face / arm
arm /leg
or amaurosis fugax
lasting less than an hour, antiplatelet agents may be used until review at a TIA clinic or until CT
scanning. If already on aspirin, dipyridamole retard 200 mg b.d. may be added.
If signs persisted beyond an hour, organise CT scan and withhold antiplatelet agents.
If a patient presents with a recent past history of stroke, refer to stroke service and withhold
antiplatelet agents until CT scan or MRI.
If a patient presents with classical TIA’s recurring within 24 – 48 hours, admit and contact stroke unit.
If unable to get advice, contact vascular surgeons urgently if the patient is considered fit for (and
agrees to) potential carotid endarterectomy.
STROKE SERVICE
HYPERTENSION - General guidelines.
It is important to ensure good control of blood pressure as well as other vascular risk factors. The
guidelines published by the ESH / ESC are an excellent resume of current practice and are
appended.
How to use antihypertensive drugs post stroke
If the patient is known to be hypertensive, and is on treatment;
If BP control suboptimal i.e. > 140/90 aim for at least 130/80 (BHS Guideline for diabetic patients)
If not on ACE, and renal function satisfactory, add perindopril 2mg / day, increasing to 4mg after 2
weeks. Check U/E at day 3 and day 10.
If not on a diuretic, or ACE, add perindopril then bendrofluazide 2.5mg (or indapamide 2.5mg as per
PROGRESS trial)
If already on ACE inhibitor and diuretic, add either calcium antagonist or beta blocker depending on
contraindications. Exceptionally, centrally acting agents (monoxidine) or alpha blockers may be
required. Use the European Society of Hypertension Guidelines for general advice (appended).
If the patient was NOT known to be hypertensive, but BP remains over 140/90 two weeks post
stroke, start PROGRESS type medication as detailed below.
If the patient is normotensive
PROGRESS Protocol
Start perindopril 2mg + indapamide 2.5 mg or bendrofluazide 2.5mg, increasing to 4mg perindopril
after 2 weeks. Check U/E at day 3 and 10. Aim to get to this target dose, unless symptoms of
hypotension, systolic pressure below 110 mmHg.
CHOLESTEROL MANAGEMENT
In general, all patients who have had a stroke, TIA or other cardiovascular event should be
immediately considered for a statin. The target is 4mmol/l or a 25% decrease in total cholesterol.
Ezitimibe can be used if intolerant of statins.
Very frail patients who are thought to have a prognosis of less than 2 years for survival may not need
statin, especially if it would complicate the drug regime. We tend to use simvastatin 40 mg nocte,
switching to atorvastatin 40mg then 80mg if required for good control. Current evidence suggests
statins should not be stopped after a stroke as there is a risk of a poorer outcome.
STROKE SERVICE
ATRIAL FIBRILLATION
Warfarin reduces stroke by about 2/3 in those with AF. Patients must be selected on the basis of risk
– only high risk patients should have warfarin in view of the bleeding risks. One useful score is given
below. Warfarin should not normally be started in the first 2 weeks post stroke because of a risk of
intracranial bleeding
CHADS2 Score
The CHADS2 index has been shown to be an accurate predictor of stroke in patients with AF
(JAMA 2001:285:22864-70).
CHADS2 assigns 2 points to a history of CVA or TIA and 1 point to four other criteria:
 C
CHF
1
 H
Hypertension
1
 A
Age >75yrs
1
 D
Diabetes
1
 S2
Stroke/TIA
2
E.g. an 82 year old with hypertension and a PMH of TIA would have a CHADS 2 score of 4.
Absolute risk corresponds to score: -
CHADS2
score
0
1
2
3
4
5
6
Adjusted stroke rate per 100 patient years
(i.e. % annual risk)
1.9
2.8
4.0
5.9
8.5
12.5
18.2
A score of 2 or more would indicate benefit from warfarin, though each case should be considered
individually. Below this, antiplatelet agents are recommended.
STROKE SERVICE
LOW SLOW WARFARIN INDUCTION FOR ATRIAL FIBRILLATION.
Check baseline INR: if < 1.4, give 5mg warfarin for 4 days. Check INR at days 5 and 8,
dose according to schedule. If on Amiodarone, check INR at day 3 – if INR over 3.7
dose carefully without this table.
Day 5 INR
Dose for day 5 -7
Day 8 INR
< 1.7
1.8 - 2.4
2.5 - 3.0
> 3.0
-----------------------------------------------------------------------------< 1.7
1.8 - 2.4
1.8 - 2.2
4mg
2.5 - 3.0
3.1 - 3.5
> 3.5
-----------------------------------------------------------------------------< 1.7
1.8 - 2.4
2.3 - 2.7
3mg
2.5 - 3.0
3.1 - 3.5
> 3.5
-----------------------------------------------------------------------------< 1.7
1.8 - 2.4
2.8 - 3.2
2mg
2.5 - 3.0
3.1 - 3.5
> 3.5
-----------------------------------------------------------------------------< 1.7
1.8 - 2.4
3.3 - 3.7
1mg
2.5 - 3.0
3.1 - 3.5
> 3.5
-----------------------------------------------------------------------------< 2.0
> 3.7
0mg
2.0 - 2.9
3.0 - 3.5
< 1.7
5mg
From: Tait RC, Sefcick A
Dose from day 8
6mg
5mg
4mg
3mg for 4 days
5mg
4mg
3.5mg
3mg for 4 days
2.5mg for 4 days
4mg
3.5mg
3mg
2.5mg for 4 days
2mg for 4 days
3mg
2.5mg
2mg
1.5mg for 4 days
1mg for 4 days
2mg
1.5mg
1mg
0.5mg for 4 days
omit for 4 days
1.5mg for 4 days
1mg for 4 days
0.5mg for 4 days
STROKE SERVICE
British Journal of Haematology 1998; 101:450 - 454
RAH PROTOCOL FOR r TPA IN ACUTE STROKE
Indications
1) Acute new stroke, clearly defined onset time which allows TPA to be given within 4.5 hours
from the stroke
2) Significant neurological deficit
3) Non contrast CT shows no bleed or infarct
4) No exclusion criteria met.
Absolute contraindications
1)
2)
3)
4)
5)
6)
Mild deficit / rapidly improving deficit
Known CNS vascular malformation or tumour
Bacterial endocarditis
Haemorrhage on CT
Well defined infarct on CT
Time of onset unknown
Check all the following are true:
Age > 21 and < 80 years
Time of onset known
Systolic BP under 180 mmHg, diastolic under 110 mmHg
No stroke or serious head injury within 3 months
No Major surgery in last 2 weeks
No Minor surgery in last 10 days – includes organ biopsy, pleural tap, lumbar puncture
No arterial puncture at non compressible site ion last 7 days
No heparin or warfarin use in last 48 hours
No coagulation defect; platelet count > 100,000
No known bleeding diathesis or recent GI or urinary tract bleed in last 3 weeks
No seizure at onset
Glucose > 2.7mmol/l and < 22 mmol/l.
No Pregnancy or > 20 days post partum
Then:
Establish IV access.
Send blood for emergency FBC, U/E, Coagulation screen, blood group and cross match
Get patient’s weight.
CT brain urgently
IF NO BLEED OR RECENT INFARCT SEEN – AND NO CONTRAINDICATIONS
start rTPA
Dose is: 0.9mg/kg. Give 10% as a bolus, the rest over 1 hour.
MAXIMUM DOSE 90mg.
STROKE SERVICE
BLOOD PRESSURE MONITORING
Monitor BP during the first 24 hours;
Every 15 minutes for the first 2 hours
Every 30 minutes for the next 6 hours
Every 60 minutes until 24 hours
ELEVATED BLOOD PRESSURE
1) If systolic BP is 180 – 230 mmHg or if diastolic BP is 105 – 120 mmHg for 2 or more readings 5 –
10 minutes apart;
Give i.v. labetalol 10mg over 1 –2 minutes. The dose may be repeated or doubled every 10 – 20
minutes to a total dose of 150mg.
2) If systolic blood pressure is >230 mmHg or if diastolic is 120 – 140 mmHg, give i.v. labetalol 10mg
over 1 –2 minutes. The dose may be repeated or doubled every 10minutes up to a dose of 150mg.
Monitor blood pressure every 15 minutes during labetalol treatment and observe for developing
hypotension / worsening hypertension.
If no satisfactory response, will need intravenous sodium nitroprusside at a dose of
0.5 – 10 g/kg/minute with close monitoring of blood pressure.
3) If Diastolic blood pressure > 140 mmHg for two or more readings 5 – 10 minutes apart, infuse
nitroprusside as above.
Intravenous r-tPA within 3 hours after the onset of symptoms in patients with acute ischaemic stroke is a highly
effective evidence-based treatment (grade A evidence). The use of r-tPA is supported by results from randomised
controlled trials and meta-analyses. The risk of early fatal and symptomatic intracranial haemorrhage is increased, but
these hazards are offset by reduction in the proportion of patients being dead or dependent.
According to meta-analyses, for patients given r-tPA within 3 hours of ischaemic stroke approximately
1 out of 10 more will be independent (NNT).
1 of 14 will suffer symptomatic haemorrhage (NNH).
Overall, the net benefit of r-tPA given within 3 hours of onset will result in one more independent survivor for every
10 patients treated.
STROKE SERVICE
CAROTID DOPPLER SCANNING.
This should be reserved for those with carotid territory TIA’s or anterior circulation stroke with good
recovery. Potential symptoms would be transient monocular blindness, or loss of power or
sensation in a stroke distribution (LACS, PACS, TACS). Patients should be fit for (and agree to)
endarterectomy if necessary.
Exclusions are;
Dizziness, vertigo, poor balance, falls
Occipital lobe or cerebellar stroke
Asymptomatic carotid bruits (best medical therapy and vascular risk review still appropriate)
More than a year since last event.
All referrals are vetted by the radiologists in conjunction with the stroke consultant, and inappropriate
requests will be declined or have other imaging modalities recommended.
Lindsay Erwin, December 2008