FMC Stroke Care for Physicians

Instructions for Completion of Learning Packet

Review any information in the module that may be new or unfamiliar to you ALL materials that are required are included in this packet. You should not need to complete

additional materials or websites to complete this. Thoroughly review the material in the FMC Stroke Alert Protocol Complete the two case studies

o There is an answer sheet (and answer key) in the packet Please feel free to check over your answers

Once complete, please send your completed answer sheet to Crystal Probasco in the CME office.

o FAX: 740-687-8143 o Phone: 740-687-8479 o email: crystalp@fmchealth.org

Your completion will be noted in the Medical Staff Office. You will be emailed a certificate of completion indicating that you have met the requirement

approximately 7-10 working days after receipt. o This will be emailed to you by Katie Hannahs in Learning and Development o It will be emailed to your FMC email account o There are no CME for this learning

If you have questions, please contact Katie Hannahs in Learning and Development o Phone: 740-687-6942 o Email: katieha@fmchealth.org

Welcome to Stroke Facts

This is a brief review of general information regarding acute ischemic stroke. Learning Objectives:

Discover the impact of acute ischemic stroke on patients. Learn about the efficacy and safety profile of Activase in acute ischemic stroke. Understand the inclusion and exclusion criteria for determining patient eligibility for Activase. Know the steps for assessing an acute ischemic stroke patient within the Golden Hour. Review how to reconstitute and properly administer Activase for acute ischemic stroke. Identify FMC's Acute Ischemic Stroke management standards Describe the treatment of the acute ischemic stroke patient

Activase for Acute Ischemic Stroke Full Prescibing Information is included in this packet as it is frequently referenced

throughout the activity.

Activase is indicated for the management of acute ischemic stroke in adults for improving

neurological recovery and reducing the incidence of disability. Treatment should only be

initiated within 3 hours after the onset of stroke symptoms, and after exclusion of

intracranial hemorrhage by a cranial computerized tomography (CT) scan or other

diagnostic imaging method sensitive for the presence of hemorrhage (see

CONTRAINDICATIONS in the full Prescribing Information).

Important Safety Information

CONTRAINDICATIONS

Acute Ischemic Stroke (AIS):

Treatment should only be initiated within 3 hours after the onset of stroke symptoms,

and after exclusion of intracranial hemorrhage by a cranial computerized tomography

(CT) scan or other diagnostic imaging method sensitive for the presence of

hemorrhage [See CONTRAINDICATIONS in the full prescribing information].

Activase therapy in patients with AIS is contraindicated in certain situations (eg, suspicion of

subarachnoid hemorrhage on pretreatment evaluation), recent (within 3 months) intracranial

or intraspinal surgery, history of intracranial hemorrhage, uncontrolled hypertension at time of

treatment, active internal bleeding, known bleeding diathesis (eg, current use of oral

anticoagulants, administration of heparin within 48 hours of onset of stroke, platelet count

<100,000/mm3) [See CONTRAINDICATIONS in the full prescribing information]

WARNINGS

The risks of Activase therapy for all approved indications may be increased and should be

weighed against the anticipated benefits in certain conditions [See WARNINGS in the full

prescribing information].

Cholesterol embolism has been reported rarely in patients treated with all types of

thrombolytic agents; the true incidence is unknown.

Acute Ischemic Stroke (AIS):

Patients with severe neurological deficit (eg, NIHSS >22) at presentation. There is an

increased risk of intracranial hemorrhage in these patients.

Patients with major early infarct signs on a computerized cranial tomography (CT) scan (eg,

substantial edema, mass effect, or midline shift).

Treatment of patients with minor neurological deficit or with rapidly improving

symptoms is not recommended

PRECAUTIONS (AIS)

Orolingual angioedema has been observed in postmarketing experience in patients treated

with Activase for AIS. Patients should be monitored during and for several hours after infusion

for signs of orolingual angioedema.

ADVERSE REACTIONS

The most common complication during Activase therapy is bleeding. Should serious bleeding

in a critical location (intracranial, gastrointestinal, retroperitoneal, pericardial) occur, Activase

therapy should be discontinued immediately, along with any concomitant therapy with heparin.

Death and permanent disability are not uncommonly reported in patients who have

experienced stroke (including intracranial bleeding) and other serious bleeding episodes.

Acute Ischemic Stroke Incidence

Acute Ischemic Stroke - Pathophysiology

Acute Ischemic Stroke Facts

Approximately 795,000 strokes occur in the United States each year.2Impact of Stroke

Impact of Stroke

Acute ischemic stroke is a leading cause of mortality and disability in the United States.

*Among ischemic stroke survivors at least 65 years of age.

Clinical Experience

Evidence-based recommendations from national organizations support intravenous (IV)

recombinant tissue plasminogen activator (rtPA) use for acute ischemic stroke:

Intravenous rtPA (0.9 mg/kg, maximum dose 90 mg) is recommended for selected patients

who may be treated within 3 hours of onset of ischemic stroke (Class 1; Level of Evidence A,

2013 AHA/ASA Guidelines).1

In patients eligible for intravenous rtPA, benefit of therapy is time dependent, and treatment

should be initiated as quickly as possible. The door-to-needle time (time of bolus

administration) should be within 60 minutes from hospital arrival (Class 1; Level of Evidence

A, 2013 AHA/ASA Guidelines).1 Affirmed by AAN and endorsed by AANS and CNS

In order to improve functional outcomes, IV tPA should be offered to acute ischemic stroke

patients who meet NINDS inclusion/exclusion criteria and can be treated within 3 hours after

symptom onset (Level A Recommendation, 2013 ACEP/AAN Joint Clinical Policy).*7

Once the decision is made to administer IV tPA, the patient should be treated as rapidly as

possible. Supported by ENA and endorsed by NCS7

*The effectiveness of tPA has been less well established in institutions without the systems in

place to safely administer the medication.

Intravenous rtPA (0.9 mg/kg; maximum of 90 mg), with 10% of the dose given as a bolus,

followed by an infusion lasting 60 minutes, is recommended treatment within three hours of

onset of ischemic stroke (1996 AAN Practice Advisory, reaffirmed in 2003).8,49

Recommended by AAN for over 15 years

CASES=Canadian Alteplase for Stroke Effectiveness Study; NINDS=National Institute of Neurological Disorders and Stroke; SITS-MOST=Safe Implementation of Thrombolysis in Stroke-Monitoring Study; STARS=Standard Treatment with Alteplase to Reverse Stroke.

8-11

NINDS Trial

Activase is proven to reduce disability in patients treated within 3 hours of acute ischemic

stroke symptom onset as shown by the National Institute of Neurological Disorders and Stroke

(NINDS) trial.13

The NINDS trial was a randomized, double-blind, placebo-controlled trial of patients with acute

ischemic stroke treated with Activase or placebo within 3 hours of stroke symptom onset. The

trial was carried out in 2 parts13:

Part 1 (n=291) assessed changes in neurologic deficits 24 hours after the onset of stroke

Part 2 (n=333) assessed clinical outcomes at 90 days

Safety

The safety of Activase was evaluated in patients treated within 3 hours of acute ischemic stroke onset. The incidence of symptomatic intracranial hemorrhage (sICH*) and 90-day mortality rates are shown below.

9,13

Of the 6.4% of Activase patients who experienced sICH within 36 hours9,13

o 45% experienced fatal sICH (9 of 20) vs 50% (1 of 2) for patients treated with placebo

o 55% experienced nonfatal sICH (11 of 20) vs 50% (1 of 2) for patients treated with placebo

There was no increase in the incidence of 90-day mortality in Activase-treated patients compared to patients treated with placebo9

Postmarketing studies

STARS, CASES, and SITS-MOST were large, postmarketing, multicenter, open-label registry studies initiated to assess safety and efficacy endpoints of Activase in helping achieve a favorable outcome in acute ischemic stroke patients when administered within 3 hours of symptom onset.

10-12

CASES=Canadian Alteplase for Stroke Effectiveness Study; NINDS=National Institute of Neurological Disorders and Stroke; SITS-MOST=Safe Implementation of Thrombolysis in Stroke-Monitoring Study; STARS=Standard Treatment with Alteplase to Reverse Stroke. mRS=modified Rankin Scale.

*A hemorrhage was considered symptomatic if it was not seen on a previous CT scan and there had subsequently been either a suspicion of hemorrhage or any decline in neurologic status.12

†

Data at 30 days available for 382 patients.

§

The SITS-MOST definition of sICH was local or remote parenchymal hematoma type 2 on the 22- to 36-hour posttreatment imaging scan, combined with a neurologic deterioration of ≥4 points on the NIHSS from baseline, or from the lowest NIHSS value between baseline and 24 hours, or leading to death.

12

Patient Selection for Activase

Activase treatment begins with proper patient selection, which can be done in 4 steps:

Step 1: Identify eligible patients13

Step 2: Ensure patients are not contraindicated13

Step 3: Review additional warnings13

Step 4: Treat eligible patients with Activase13

Golden Hour of Acute Ischemic Stroke

Acute ischemic stroke is a serious medical emergency. It is critical to assess and manage acute

ischemic stroke patients as soon as they arrive in the emergency department (ED) of the hospital. In

a typical large-vessel acute ischemic stroke, 1.9 million neurons may be lost each minute without

medical management.1

Did you know that in 2010, only 29.5% of hospitals participating in the American Heart

Association/American Stroke Association (AHA/ASA) Get with the Guidelines®

registry achieved a

door-to-treatment time of ≤60 minutes?15

Stroke Treatment Guidelines

Activase Dosing and Administration The recommended dose of Activase is 0.9 mg/kg (not to exceed 90-mg total dose) infused over 60

minutes with 10% of the total dose administered as an initial intravenous (IV) bolus over 1 minute.

A copy of the Activase Product Insert follows for your reference if needed.

Educating Patients and Families

Welcome to FMC Standards of Care for Acute Ischemic Stroke FMC utilizes the American Heart Association's guidelines for management of Acute Ischemic Stroke patients.

FMC STROKE ALERT POLICY POLICY

A STROKE Alert will be initiated in house by the physician who responds to a CAT call or in the

ER by the emergency department physician based on prior notification by pre-hospital personnel

or by his/her evaluation

PURPOSE

Provide rapid assessment, stabilization, and early determination of treatment needs of patients

presenting with cerebral stroke symptoms. A stroke Alert will be activated to establish an

organized and consistent approach to the clinical practice and care of patients that present with

symptoms of stroke

RESPONSIBILITIES

IN HOUSE:

Primary RN initiates a CAT call

House physician/neurologist makes determination for Stroke Alert

Primary RN remains with Pt throughout the process and continues to document and gather

data

ER RN manages the e-stroke cart

OSU physician makes determination for continuation of care either in house or transfer

ER:

ER physician makes determination for Stroke Alert

ER RN remains with patient through process, documents and manages the e-stroke cart

OSU physician makes determination for continuation of care

CORE Measures:

Assessment to Stroke Alert Call 10 minutes

CT scan immediately, within 25 minutes of stroke alert (Stroke Alert to time to CT results 45

minutes)

DEFINITION

Telestroke- a neurologist-delivered health service provided via electronic communication for a

patient referred by a physician at a different site for diagnosis related acute cerebral vascular

syndrome.

Spoke – refers to Fairfield Medical Center, the referring institution.

Hub – refers to OSU, the consulting institution

Stroke RESPOND - is the medical technology company used by OSU Telestroke Program

In-Touch – is the required computer equipment which includes a digital camera.

LKW - Last known well

PROCEDURE

In House Stroke Alert Process

A. Primary RN identifies possible stroke Symptoms, initiates a CAT call (Dial 3111)

a) Alerts Hospitalist

b) CAT RN’s

c) Supervisor

d) Respiratory therapy

B. Hospitalist determines the need for Stroke Alert to be called (DIAL 3111)

a) Alerts Neurologist (8:30 to 5 weekdays for in patients only)

b) Pharmacist

c) Supervisor

d) Lab

e) Respiratory Therapy

f) CT

g) ER

h) Chaplin

C. Supervisor alert ED of need for stroke cart to be ready

D. Primary RN and CAT RN to assess: glucose, last known well, O2, VS, assure 1 working IV,

MD orders for CT and STAT labs

E. Pt Transferred to CT immediately per Primary RN/CAT RN/Hospitalist/Supervisor/Lab

(Exception will be for 6N in which case the nursing supervisor will determine the best course of

action for continued coverage of unit)

ER Stroke Alert Process

A. Stroke Alert initiated by ER physician based on prior notification by pre-hospital personnel

or by rapid assessment

a) Alert CT

b) House Supervisor

c) Assigned ED personnel

B. Turn Telestroke System on ASAP (requires time to warm up)

C. Rapid assessment by the Primary Care RN and the ED physician including brief history and

physical assessment.

D. Collect demographic information for potential Telestroke consult.

E. Draw Stroke Panel, blood glucose(POC), initiate two IV lines(18 g or higher) with blood

draw

F. Send patient to CT ASAP

G. For patients with LKW of > 8 hours assessment will be done by phone only (no robot)

Process from here is the same for both in-house and ER process

A. Prior to leaving CT room, if not already completed draw labs to include PT, PTT, INR, and

CBC without differential ASAP and initiate the 2 large bore IV’s (If these labs are available

within the past 24 hours they can be used instead)

B. Primary RN stay with the patient and maintains primary responsibility for the patient care

throughout the entire process, documents in HED, assists ER RN with stroke assessment and

transfer of care as identified by OSU physician/neurologist/house physician

C. Maintain continuous cardiac monitoring

D. Maintain NPO status until dysphasia screening is complete by RN

E. Primary RN to document vital signs, Pulse Ox and neuro checks completed and

documented in HED, q 15 minutes

F. CAT RN, primary RN and ER RN discussed the need for CAT RN to remain or leave based

on patient acuity.

G. Provide oxygen to maintain O2 Sats>94%

H. ED technician will be assigned as needed to stroke alert patient

I. Stat 12 lead EKG to be completed ASAP

J. Complete Chest X-Ray

K. Pt to remain NPO until dysphasia screen completed in HED

L. Any medication required for the patient while in ER may be taken out of the Pyxis under the

patient’s name

M. ED RN logs into Tele-stroke system and begin entering information in required fields:

Assure name of the physician, ED, in-house, neurologist, is entered as the requesting

physician. Continue to enter information as it becomes available

N. Call OSU hotline (614-366-8111). Advise them that this is a "Telestroke consult" Provide the

patient names and facility name, Internal versus ED.

O. The OSU hotline will notify the on-call physician. The physician will need some time to go to

the designated laptop to initiate the camera and consult. (Please call early to provide the

physician enough time.)

P. Once physician logs into the camera the cart will make a whistle sound.

Staff must be available to answer questions. Hospitalist/ED physician/in-house neurologist

must be at the bedside to initiate patient discussion with stroke physician- initial handoff.

Have camera stationed at the end of the patient’s bed with camera facing patient.

Q. Continue to update vital signs and labs values as they become available. MUST hit the

update button for information to be viewed by the OSU physician.

Lab results should be available within 45 minutes of time stroke is CALLED.

R. Facilitate the NIHSS under the direction of the neurologist/OSU physician.

S. If a decision to treat is made by the OSU physician/hospitalist/neurologist, prepare for

possible administration of tPA. Pharmacist to obtain tPA and mix/prepare drug for

administration.

T. The hospitalist/ED physician/in-house physician is required to complete the tPA checklist on

all patients receiving tPA and have on file for reference in the medical record. USE THE OSU

tPA THERAPY CHECKLIST PAPER FORM PROVIDED ON THE TELE CART TO MEET OSU

REQUIREMENTS

U. Administer tPA, (ED nurse to give and Primary floor nurse to document med giver per_____

ED RN using paper MAR located in Stroke folder) if ordered, and evaluate clinical status and

bleeding precautions; prepare for additional instructions from OSU. Have ED UC notify Air

Evac of need for transfer to OSU. If not flying then ground transportation needs arranged.

V. If decision is made for pt to remain in this facility, the consult ends. If ER patient follow the

normal process for admission

W. If in-house patient, the hospitalist/neurologist makes a decision on level of care required for

the patient. Notifies the attending physician of Stroke Alert outcome

X. Supervisor will make bed arrangements and let the receiving unit know patient is coming

directly from ED and report will be given at the bedside between the current primary RN and

the receiving RN.

Y. If decision to transfer to OSU, proceed with existing protocol for patient transfers. ED team

and Primary RN to complete transfer if in-patient.

Z. ED charge or assigned to print copy of stroke consult to give to primary RN if patient stays

at FMC to place on the chart and/or to send to OSU if transferring

AA. Primary RN contacts medical records to copy the in house chart when pt transfers to OSU

BB. Primary RN will give a verbal report to the transfer team (medics) and a verbal report to

the receiving unit at OSU

CC. Assure printed consult form is included with patient’s medical record

DD. Hospitalist/Neurologist continues care of the patient until transfer out of ER to provide in-

patient care ( ER doc does not assume care of the in house patient at any time)

EE. Hospitalist/neurologist to notify family of in patients on change in condition and decision

made.

DOCUMENTATION

A. Primary RN will continue to document in HED the following

a. Location of belongings (especially dentures, glasses etc.)

b. Family updates

c. Put orders in HED as physician orders – tests, meds, treatments, etc.

d. Continued Assessments, VS, Pulse Ox, Neuro Checks q 15 min

e. Document medications on paper MAR

B. ED RN documents required information gathered from Primary RN/Lab/Monitors in the Tele-stroke

computer

C. Additional points of documentation include:

a. Times as noted on Stroke-Alert Checklist

PROTOCOL ORDERS

FMC Stroke Protocol orders can be accessed by accessing the "Stroke iForm"

AHA/ASA guidelines were included below, a summary follows. They can also be accessed in

their entirety at:

http://stroke.ahajournals.org/content/44/3/870.full.pdf+html

2013 Acute Ischemic Stroke Management Guidelines

American Heart Association/American Stroke Association

and

The National Institute of Neurological Disorders (NINDS)

NINDS Time Goals

Immediate general assessment by a stoke team, emergency physician, or other

expert within 10 minutes of arrival, including the order for an urgent CT scan

Neurologic assessment by stroke team and CT scan performed within 25 minutes of arrival

Interpretation of CT scan within 45 minutes of ED arrival

Initiation of fibrinolytic therapy, if appropriate, within 1 hour of hospital arrival and 3

hoursfrom onset of symptoms

Door-to-admission time of 3 hours

For those who work in the in-patient setting, these times are based on the time the patient was

identified to be symptomatic with possible stroke symptoms.

PATIENT IDENTIFICATION

Stroke Algorithm Step 1 - Identify Signs of Stroke

Think "FAST"

F – Facial Droop

A – Arm Drift

S - Speech

T – Time – Get assistance immediately

GET HELP

Stroke Algorithm Step 2 - Get Help!

Depending on your location -

Call 911 or

Stroke Alert

***NINDS GOAL - 10 MINUTES***

Stroke Algorithm Step 3 - Assessment

Actions:

Define and recognize the signs of stroke.

Support the ABC's (airway, breathing, and circulation).

Assess the patient using standardized stroke assessment tools

Give oxygen as needed.

Establish time zero.

o Time Zero: set the time when the patient was last known to be neurologically

normal.

o If the patient was sleeping and wakes up with symptoms, time zero is the last time

the patient was seen to be norma

Consider triage at a stroke center, if possible.

o Transport the patient quickly.

***NINDS GOAL - 25 MINUTES***

Stroke Algorithm Step 4

Actions:

•Assess circulation, airway, breathing and evaluate vital signs.

•Give oxygen if patient is hypoxemic (less than 92% saturation).

•Make sure that an IV has been established.

Take blood samples for blood count, coagulation studies, and blood glucose.

•Check the patient's blood glucose and treat if indicated.

•Give dextrose if the patient is hypoglycemic.

•Give insulin if the patient's serum glucose is more than 300.

•Give thiamine if the patient is an alcoholic or malnourished.

•Assess the patient using a neurological screening assessment i.e. NIH Stroke Scale

•Order a CT brain scan and have it read quickly by a qualified specialist.

•Obtain a 12-lead ECG and assess for arrhythmias.

•Do not delay the CT scan to obtain the ECG.

•The ECG is taken to identify a recent or ongoing acute MI or arrhythmia as a cause of

embolic stroke.

•Life-threatening arrhythmias can happen with or follow a stroke.

***NINDS GOAL - 25 MINUTES***

Stroke Algorithm Step 5

Actions:

•Review the patient's history, including past medical history.

•Perform a physical exam.

•Establish time zero, if not already done.

•Perform a neurological exam to assess patient's status using the NIHSS or the Canadian

Neurological Scale.

•The CT scan should be completed within 25 minutes from the patient's arrival in the ED

and should be read within 45 minutes.

***NINDS GOAL - 45 MINUTES***

Stroke Algorithm Step 6

Based on CT or MRI results:

HEMORRHAGE PRESENT

Note that the patient is not a candidate for fibrinolytics.

Arrange for a consultation with a neurologist or neurosurgeon.

Consider transfer, if available.

HEMORRHAGE NOT PRESENT

Decide if the patient is a candidate for fibrinolytic therapy.

Review criteria for IV fibrinolytic therapy by using the fibrinolytic checklist.

Repeat the neurological exam (NIHSS).

PATIENT RAPIDLY IMPROVING

If the patient is rapidly improving and moving to normal, fibrinolytics may not be necessary.

***NINDS GOAL - 60 MINUTES***

Stroke Alogrithm Step 7

ALL PATIENTS (tPA or Not)

•Begin stroke pathway.

•Support patient's airway, breathing, and circulation.

•Check blood glucose.

•Watch for complications of stroke and fibrinolytic therapy.

•Transfer patient

FIBRINOLYSIS IN ACUTE ISCHEMIC STROKE PEARLS

If the patient is a candidate for fibrinolytic therapy, review the risks and benefits of therapy with

the patient and family (intracranial hemorrhage) and give (tPA).

Anticoagulants and Fibrinolysis in Acute Ischemic Stroke - Do not give anticoagulants or

antiplatelet treatment for 24 hours after tPA until a follow-up CT scan at 24 hrs does not show

intracranial hemorrhage.

Aspirin in non-fibrinolytic candidataes - If the patient is NOT a candidate for fibrinolytic

therapy, give the patient aspirin.

Blood Glucose in Stroke - Patients with acute ischemic stroke who are hypoglycemic tend to

have worse clinical outcomes, but there is no direct evidence that active glucose control

improves outcomes. Consider giving IV or subcutaneous insulin to patients whose serum

glucose levels are greater than 200 mg/dL.

tPA INCLUSION CRITERIA

•Patient 18 yrs of age or older

•Diagnosis of an ischemic stroke with neurologic deficit

•Time from onset of symptoms is within 3 hours

tPA EXCLUSION CRITERIA

•Evidence of intracranial hemorrhage from CT or MRI scan

•Clinical presentation suggestive of a subarachnoid hemorrhage, even with normal CT

•History of intracranial hemorrhage

•Known AV malformation, neoplasm, or aneurysm

•Witnessed seizure at stroke onset

•Active internal bleeding or acute trauma, such as a fracture

•Acute bleeding diathesis, including but not limited to:

–Platelet count < 100,000/mm3

–Heparin received within 48 hours prior to onset of stroke, with elevated aPTT

–Current use of anticoagulant (e.g., warfarin) with an INR > 1.7

•Intraspinal surgery, serious head trauma, or previous stroke within the past 3 months

•Arterial puncture at a non-compressible site within the past 7 days

tPA RELATIVE CONTRAINDICATIONS

•Minor or rapidly improving stroke symptoms

•Major surgery or serious trauma within the past 14 days

•Recent GI or urinary tract hemorrhage within the past 3 weeks

•Post-MI pericarditis

•AMI within the past 3 months

•Blood Glucose < 50 mg/dl or > 400 mg/dl

BLOOD PRESSURE - ACUTE ISCHEMIC STROKE

BP MONITORING - ALL PATIENTS

During or after TREATMENT: Check BP

every 15 min for 2 hrs, then

every 30 min for 6 hrs, and finally

every hr for 16 hrs

Ineligible for tPA -

•Systolic >220 or diastolic >120

•Systolic > 220 or diastolic 121 to 140

•Diastolic > 140

BP Treatment

Systolic >220 or diastolic >120

Observe patient unless there is other end-organ involvement.

Treat the patient's other symptoms of stroke (headache, pain, nausea, etc).

Treat other acute complications of stroke, including hypoxia, increased intracranial pressure, seizures, or hypoglycemia.

Systolic > 220 or diastolic 121 to 140

Labetalol 10 to 20 mg IV for 1–2 min—

may repeat or double every 10 min to a maximum dose of 300 mg OR

Nicardipine 5 mg/hr IV infusion as initial dose; o titrate to desired effect by increasing 2.5 mg/hr every 5 min to max of 15 mg/hr o if blood pressure is not controlled by nicardipine, consider sodium nitroprusside

Diastolic > 140 Nitroprusside 0.5 µg/kg per min IV infusion as initial dose with continuous blood pressure

monitoring

Aim for a 10% to 15% reduction in blood pressure

Eligible for tPA – o PRETREATMENT: Systolic >185 or diastolic >110

References: •https://www.acls.net/acls-suspected-stroke-algorithm.htm •http://www.bing.com/search?q=AHA+stroke+guidelines&src=IE-SearchBox&FORM=IE8SRC •http://my.americanheart.org/professional/StatementsGuidelines/ByTopic/TopicsQ-Z/Stroke-Statements-Guidelines_UCM_320600_Article.jsp

BP Treatment

SBP> 185 or DBP> 110

Labetalol 10 to 20 mg IV for 1–2 min—may repeat x 1 or

Nitropaste 1–2 “

Systolic 180 to 230 or diastolic 105 to 120

Labetalol 10 mg IV for 1–2 min—may repeat or double every 10 to 20 min to a maximum dose of 300 mg

OR give initial labetalol dose, then start labetalol drip at 2 to 8 mg/min

Systolic > 230 or diastolic 121 to 140

Labetalol 10 to 20 mg IV for 1–2 min—

may repeat or double every 10 min to a maximum dose of 300 mg OR

Nicardipine 5 mg/hr IV infusion as initial dose;

titrate to desired effect by increasing 2.5 mg/hr every 5 min to max of 15 mg/hr

If blood pressure is not controlled by nicardipine, consider sodium nitroprusside

Diastolic > 140 Nitroprusside 0.5 µg/kg per min IV infusion as initial dose with continuous blood pressure monitoring

Aim for a 10% to 15% reduction in blood pressure

This chart is being provided as areference tool in assisting with calculating the NIHSS Score.

http://img.medscape.com/fullsize/migrated/550/818/jnn550818.fig1.gif

Patient Vignette 1

Patient: Christine Gender: female Age 40 Ethnicity: African American Christine is arriving at the ED. Time last known well = 0930 EMS Eval:

BP = 190/100mm/Hg Blood Glucose = 99 mg/dL O2 Saturation = 96%

TIME:

LNW = 00:35 Stroke Golden Hour: 00:00

Past Medical History

No relevant medical history No prior stroke or TIA

Medications

No prescription drugs

Allergies

No Known Allergies

Social History

Non-Smoker Low ETOH consumption (1-2 drinks per week)

Physical Examination

Initial BP 190/100 mmHg o response to 10 mg IV Labetalol 170/95 mmHg

Neurologic Assessment:

Profoundly slurred speech Notable poor comprehension of verbal cues Eyes deviated to the left

Complete paralysis of lower right face Right leg weakness with partial lift Not obeying any commands Responsive to pinch

QUESTION # 1: What is Christine's NIHSS Score?

A. 12 B. 14 C. 16 D. 18

Time:

LKW 01:10

Golden Hour 00:35

Laboratory Report:

Troponin <0.03 ug/L

BUN 18 mmol/L

Creatinine 0.9 mg/dL

Glucose 99 mg/dL

INR 1.1

Hemoglobin 13.3 g/dL

Platelets 155x109/L

aPTT 33 sec

PT 14 sec

CT Results:

No parenchymal signs of ischemia

Left MCA sign suggestive of proximal arterial clot

Time:

LKW = 01:20

Golden Hour: 00:45

Question #2: True or False This patient is a candidate for tPA.

Question #3: At what blood pressure level would Christine no longer be considered a

candidate for tPA?

A. 120/80

B. 140/90 C. 160/100

D. > 185/110

Question #4: Christine weighs 78 kg.

What is the total dose of tPA to be administered? hint: (0.9 mg/Kg) not to exceed 90 mg.

A. 68.4 mg B. 70.2 mg

C. 82.6 mg D. Exceeds maximum of 90 mg

Question #5:

What is the bolus dose of tPA that is to be administered to Christine and over what time frame? Hint = 10% of total dose A. 6.8 mg over 5 minutes B. 7.02 mg over 5 minutes C. 7.02 mg over 1 minute D. 9 mg over 1 minute

Question #6: Which of the following infusion orders below is correct?

A. 70.2 mg tPA administered via IV infusion over 60 minutes B. 90 mg tPA administered via IV infusion over 60 minutes C. 7.02 mg tPA administered via IV infusion over 60 minutes D. 63.18 mg tPA administered via IV infusion over 60 minutes

Vignette 2:

Patient: Mary Age 67 yr Ethnicity: Caucasian Diabetes: Yes

NOTE: Due to the increased risk of misdiagnosis, special diligence is required in making the diagnosis of stroke in patients with blood glucose values less than 50 mg/dL or greater than 400 mg/dL

Mary was admitted 18 hours ago with questionable seizure activity for further evaluation. She is on the telemetry unit. At 11:45 am, the nursing unit calls for assistance with Mary. You arrive to her room and you note:

Generalized seizure Bilateral tonic/clonic movements of >60 sec duration Post ictal somnolence post tonic/clonic activity Post ictal BP of 132/85 mmHg

Question 7: The first anticipated intervention includes (in addition to staying with patient):

1. Call a CAT call to get additional assistance 2. Restrain the patient so she remains in bed if she seizes again 3. Check blood glucose 4. Follow hypoglycemia/hyperglycemia protocols as appropriate.

A. 1, 2, 3 B. 1, 2, 4 C. 1, 3, 4 D. 1, 2, 3, 4

Time: LKW - 00:55 Golden Hour: 00:25

Past Medical History:

Restless leg syndrome Depression

Medications: No prescription medications Acetominophen

Allergies: No Known Drug Allergies

Medications Provided:

D50 Fosphenytoin

Social History

n/a

NEUROLOGIC ASSESSMENT

Somnolent Follows commands appropriately when prompted Disoriented to time and self Severe aphasia Partial paralysis left side of face Left arm and leg exhibit no effort against gravity Speech very slurred

QUESTION 8: What is the patient's NIHSS Score?

A. 13 B. 14 C. 15 D. 16

QUESTION 9: Which of the following diagnostic examinations must be completed without delay:

A. EKG B. Labs C. Chest XRay D. CT of the head

QUESTION 10:

Which of the time frames listed below is consistent with the national guidelines for

stroke care?

1. 10 minutes from assessment to calling Stroke Alert 2. CT scan within 25 minutes of calling Stroke Alert

3. Reading of CT scan within 45 minutes of calling Stroke Alert 4. Reading of CT scan within 60 minutes of calling Stroke Alert

5. tPA if eligible within 3 hours of onset of symptoms

A. 1, 2, 3, 4

B. 1, 3, 4, 5 C. 1, 2, 4, 5

D. 1, 2, 3, 5

QUESTION 11: In-House responsibilities in a Stroke Alert include all of the following except:

A. Primary RN initiates a CAT call B. House physician/neurologist makes determination for Stroke Alert C. Resident/house physician calls for neurologist consult to complete more in-depth assessment prior to proceeding with Stroke Alert D. Primary RN remains with Pt throughout the process and continues to document and gather data E. ER RN manages the e-stroke cart F. OSU physician makes determination for continuation of care either in house or transfer

QUESTION 12: Responsibilities during a Stroke Alert in the ED include all of the following except:

A. Inbound Paramedic makes determination for Stroke Alert B. ER physician makes determination for Stroke Alert C. ER RN remains with patient through process, documents D. ER RN manages the e-stroke cart E. OSU physician makes determination for continuation of care

QUESTION 13:

Stroke Alert respondents include who of the following:

1. Neurologist (8:30 to 5 weekdays for in patients only) 2. Patient's nurse 3. CATeam if occurs in house 4. Pharmacist 5. Supervisor 6. Lab 7. Respiratory Therapy 8. CT 9. ER 10. Chaplain

A. All of the above

B. All except the pharmacist C. All except the neurologist D. All except the patient's nurse

QUESTION 14: Expected interventions in an in-house Stroke Alert include all of the following EXCEPT:

A. Primary RN identifies possible stroke Symptoms, initiates a CAT call (Dial 3111) alerting: a) Hospitalist b) CAT RN’s c) Supervisor d) Respiratory therapy

B. Hospitalist determines the need for Stroke Alert to be called (DIAL 3111) alerting: a) Neurologist (8:30 to 5 weekdays for in-patients only) b) Pharmacist c) Supervisor d) Lab e) Respiratory Therapy f) CT g) ER h) Chaplain

C. Supervisor alerts ED of need for stroke cart to be ready. ED turns on Tele-Stroke cart to warm up device

D. Primary RN and CAT RN assess: Glucose, Last Known Well, O2, VS, At least 1 working IV Physician orders for CT and STAT labs

E. Patient held on unit until EKG and Labs drawn and then transported to CT Scan

F. Pt Transfer to CT immediately accompanied by Primary RN (except 6N - contact supervisor) CAT RN Hospitalist Supervisor Lab

QUESTION # 15 The following interventions are to be expected during a Stroke Alert in the ED EXCEPT:

a. Stroke Alert initiated by ER physician based on prior notification by pre-hospital personnel or by rapid assessment alerting:

A) CT b) House Supervisor c) Assigned ED personnel

B. Turn Telestroke System on ASAP (requires time to warm up)

C. Rapid assessment by the Primary Care RN and the ED physician including brief history and physical assessment.

D. Collect demographic information for potential Telestroke consult.

E. Draw Stroke Panel, blood glucose(POC), initiate two IV lines (18 g or higher) with blood draw F. Delay transfer to CT until two large bore IV lines are established and functional G. Send patient to CT ASAP

QUESTION #16: True or False

Interventions following completion of the CT occur in the ED and are the same for patients whose Stroke Alert was initiated in the ED or in-house.

QUESTION #17:

Additional anticipated orders include:

A. Labs to include

PT, PTT, INR, CBC without differential ASAP

o Lab results available within 45 minutes of time stroke is CALLED. o If these labs are available within the past 24 hours they can be used instead

B. initiate the 2 large bore IV’s C. Continuous cardiac monitoring D. NPO status until dysphasia screening is complete by RN and documented in HED E. Primary RN to document vital signs, Pulse Ox and neuro checks completed and documented in HED, q 15 minutes F. Provide oxygen to maintain O2 Sats>94% G. Stat 12 lead EKG to be completed ASAP H. Complete Chest X-Ray I. Tele-Stroke procedure and protocol J. All of the above

QUESTION #18: I have reviewed the guidelines/standards/protocols for management of the Acute Ischemic Stroke Patient.

FMC Stroke Protocol Answer Sheet

1. A B C D

2. T F

3. A B C D

4. A B C D

5. A B C D

6. A B C D

7. A B C D

8. A B C D

9. A B C D

10. A B C D

11. A B C D E F

12. A B C D E

13. A B C D

14. A B C D E F

15. A B C D E F G

16. T F

17. A B C D E F G H I J

18. I have reviewed the guidelines/standards/protocols for management of the Acute Ischemic

Stroke Patient. __________________________________________________ __________________________ Signature Date

________________________________________ Printed Name

Submit completed answer/signature/attestation sheet to Crystal Probasco at: FAX: 740-687-8143 Phone: 740-687-8479 email: crystalp@fmchealth.org

Check Your Work!

FMC Stroke Protocol Answer KEY

1. A B C D

2. T F

3. A B C D

4. A B C D

5. A B C D

6. A B C D

7. A B C D

8. A B C D

9. A B C D

10. A B C D

11. A B C D E F

12. A B C D E

13. A B C D

14. A B C D E F

15. A B C D E F G

16. T F

17. A B C D E F G H I J

18. Signature

Submit completed answer/signature/attestation sheet to Crystal Probasco at:

o FAX: 740-687-8143 o Phone: 740-687-8479 o email: crystalp@fmchealth.org