Transcript D. Thrombolysis Protocol - Diana Day

Thrombolysis
East of England Forum
Diana Day
Consultant Nurse for Stroke
What is thrombolysis
Clot buster
 Lyse (breaks up) clots
 Drug is called Alteplase (rt-Pa)
 Aim to restore blood supply to the brain
in the early hours of stroke
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Global Good Outcome at Day 90 (mRS 0-1,
BI 95-100, NIHS 0-1) (N=2776)
SITS database 12/12/2007
http://www.acutestroke.org/index.php
SITS-MOST vs RCTs – mRS 3/12
13
RCT placebo
16
11
14
20
7
18
mRS 0
+10%
20
RCT active rt-PA
22
8
14
12
7
mRS 1
mRS 2
18
mRS 3
mRS 4
mRS 5
+4,8%
SITS-MOST
19
0%
20%
Recovered
Red colours: independent
Blue colours: dependent
Black colour: dead
19,9
15,9
40%
14,7
60%
mRS 6
13,9
5,3
11,4
80%
100%
Dead
Lancet 2007; 369: 275-282.
Time is brain
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Around1.9 million neurons lost a minute
Time to treat
Max 4.5 hours
Recognise
React
Respond
Target 2hrs
Refer
Treat
(30-45mins)
Act F.A .S.T
Recognise /React
Respond
Journey time 30 – 45mins
(60mins review)
Refer and Assess
Assess
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Pre alert stroke team
Event history
NIHSS,PMH, meds
Glucose / bloods
Treat with thrombolysis?
Telemedicine
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Providing regional
access to stroke
expertise out of
hours
Who can we treat?
Inclusion criteria
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Clinical S&S of definite acute stroke
Clear time of onset
Presentation within 4.5 hrs of acute onset
Haemorrhage excluded by CT scan
Age 18 and over
NIHSS less than 25
Consent discussion
Exclusion Criteria
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Increase bleeding risk
 Greater than 4.5hrs
 Rapidly improving or minor stroke symptoms
 Stroke or serious head injury 3 months
 Major surgery, obstetrical delivery, external heart
massage last 14 days,
 Seizure at onset of stroke
 Severe haemorrhage last 21/7
 History of central nervous damage
 Hypo / hyper glycaemia
 Warfarin (unless INR below 1.5)
 BP > 180/110mmHg (and other exclusions)
Potential for thrombolysis
Conditions
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Hyper Acute stroke unit
Under the care of stroke physician /neurologist
Care at level 2 (HDU)
Physiological monitoring
Nurses trained in thrombolysis & acute skills
Protocols & guidelines for care
Access to immediate imaging (24hrs)
Protocols of care
Staffing
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Nursing 1:1 – whilst thrombolysing
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1:2 – 1:4 first 24-48 hrs of care
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Competency based training
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NIHSS trained
Mimics
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Seizure
Migraine
Sub /extra dural
Tumour
MS
Hyperglycaemia
Non organic
Cerebral abscess
/infection
Unlikely to be stroke

Felt funny & shaking
 Visual disturbance
 Pins & needles
 Fluctuating
symptoms
Exclude stroke mimics
Vascular event sudden onset
 Maximal at onset
 Fits within vascular territory
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Case 1
72 yr old gentleman well this morning
 Went to his car at 8.30am
 Dropped his keys, and fell to the ground
 His wife noticed right sided weakness
 Unable to talk properly
 Rang 999
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Assessment – 10.02
He has PMH high blood pressure
 He is being investigated for AF
 No previous hospital admissions
 BP 179/95, P 114, sats 94%, glu
7.8mmols
 NIHSS 21 (aphasic, RSW fal, HH)
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Early CT scan : time 10:23
CT Perfusion
Cerebral Blood Flow
Time to peak
Infusion Alteplase
0.9mg/kg/body weight, up to max of
90mg.
 Diluted with sterile water to 1mg/ml
 10% of infusion as bolus
 90% as infusion using syringe pump over
1 hour.
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Post Thrombolysis
Potential complications
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Haemorrhage
Intracerebral
 Systemic
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Reperfusion hypotension
 Improvement then deterioration
 Nausea / vomiting
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Haemorrhagic Complications of t-PA
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30 mins into infusion he starts talking again,
weakness improves
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Then becomes drowsy GCS 15 -13
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Stop infusion
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Call medical team
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CT scan
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Neurosurgical opinion
Post CT scan
Management of Bleeding Complications
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If bleeding is suspected stop infusion of a
thrombolytic drug immediately.
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Send FBC, APTT, PT/INR, and fibrinogen.
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Grouped and matched if transfusions are needed
4 to 6 U of cryoprecipitate or fresh frozen plasma,
platelets
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These therapies should be made available for
urgent administration.
Allergic reaction
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anaphylactoid reaction, laryngeal oedema, orolingual angioedema,
rash, and urticaria
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usually respond to conventional therapy – antihistamine and
hydrocortison if caught early – otherwise full anaphylaxis protocol
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many of these patients received concomitant ACEI therapy
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Most cases resolved with prompt treatment; there have been rare
fatalities as a result of upper airway haemorrhage from intubation
trauma
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Other Adverse Reactions
Nausea and/or vomiting, hypotension and fever have also been
reported – Treat symptoms
Patient 2 : Right hemilingual
angioedema
Time is Brain
Impact of thrombolysis
Number making full recovery per 100 treated
30
Benefit
20
10
Harm
0
0
2
4
6
Time (hours)
Saver, Stroke 2006
First 24 hours of care
Monitored bed on stroke unit
 Thrombolysis pathway
 24-36 hour repeat CT scan
 No antiplatelets for 24 hours
 No IM injections, catheterisations or
invasive procedure unless unavoidable.
 Bed rest for 24 hrs
 IV access
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Research areas
Time window (DIAS)
 Dose (Enchanted)
 Other medications (DIAS III)
 Intra arterial (PISTE)
 Clot retrieval
 Awakening stroke (WAKE UP)
 Anticoagulation thrombolysis
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Summary
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Thrombolysis is effective if used within
hyperacute unit setting
Time is Brain, rapid treatment improves
outcome
There are risks of bleeding can differ between
cases
Appropriate place is for all strokes is
hyperacute stroke unit
There are outstanding research
questions
The End
Questions?