1. No category

Level Three General
Stroke Center
Acute Stroke Sample Protocol
[Facility Name]
PATIENT PRESENTING WITH ACUTE STROKE TO [FACILITY NAME]
POLICY
Patients presenting to [FACILITY NAME] with symptoms of an acute stroke will be emergently transported to
[IDENTIFIED FACILITY] after assessment and evaluation for thrombolytic therapy. Total time from assessment and
treatment to the initiation of transfer to the nearest appropriate facility to for continued care and monitoring of the patient
will be less than 60 minutes per best practice guidelines.
PROCEDURE
Patient presents with onset of stroke and qualifies for thrombolytic therapy.
Emergent Evaluation: Patients with stroke or suspected stroke are admitted and evaluated emergently
1. Diagnosis & Time of Onset. Evaluate patient for diagnosis of stroke and determine time of onset of
symptoms
2. Brain Imaging. Order STAT non-contrast head CT; specify Dx: "Emergent Acute Stroke"
3. IV Access: Establish IV line, preferably 2 separate lines on opposite arms
4. STAT Laboratories:
a.
CBC & platelet count
b.
PT, PTT, fibrinogen, INR
c.
Serum electrolytes, BUN, creatinine, glucose
d.
Markers of cardiac ischemia
e.
Glucose finger stick
f.
Pregnancy test (if female of child bearing potential)
g.
Urinalysis
5. Emergent Notification of Receiving Facility for Further Management if Necessary
a. Transfer
i. Notify the receiving facility of the patient transfer request
ii. Determine with receiving facility appropriate transfer (air or ground)
b. If appropriate and available, consider telestroke
6. Obtain 12-lead ECG
7. Obtain O2 Saturation
8. Document patient's weight (in kg if possible).
9. Blood pressure monitoring q 15 minutes
10. Place on cardiac monitoring
11. Place Foley catheter if patient unable to urinate or anticipate IV t-PA therapies.
12. Perform and document NIHSS exam and score
CRITERIA FOR IV THROMBOLYTIC TREATMENT
Any significant doubts about eligibility should be enough to exclude the patient. These criteria are meant as guidelines,
and waiving them is at the discretion and responsibility of the physician.
Eligibility Criteria:
1) Age older than 18.
2) Clinical presentation consistent with acute ischemic stroke
3) Significant and persistent neurologic deficits, without major consistent improvement
4) Onset of symptoms well established and started less than 4.5 hours from beginning of t-PA infusion. (Onset of
symptoms is defined as the last time patient documented to be normal before symptoms started; i.e.: if awakened
with stroke, onset is considered the time patient went to sleep the night before, etc. ...)
5) Head CT consistent with acute ischemic stroke (No hemorrhage, SDH, or tumor)
EXCLUSION CRITERIA FOR TREATMENT WITH IV THROMBOLYTICS FROM 0 – 4.5 HOURS OF SYMPTOM
ONSET:
Clinical Presentation Exclusion Criteria
a) Symptoms suggestive of subarachnoid hemorrhage (even if head CT normal)
b) Definite seizures at onset of stroke symptoms
c) Minor or rapidly improving deficits
History Exclusion Criteria
a) Previous history of intracerebral hemorrhage
b) Female patient known or suspected of being pregnant
c) History of GI bleed or urinary bleed in the past 3 weeks
d) History of stroke or head trauma in preceding 3 months
e) History of major surgery or serious trauma (head trauma excluded) in the past 14 days
f) History of serious illness that could interfere with benefit from t-PA
g) Arterial puncture at a non-compressible site in the previous 7 days
h) Patient received heparin in the past 48 hours with elevated PTT
i) Patient taking warfarin and elevated INR > 1.7 (for patients presenting within 3 hours)
j) Significant disability at baseline that could obviate benefits from thrombolytic therapy
k) History of MI in last 3 months
Additional Exclusion Criteria for Treatment with IV Thrombolytics from 3 – 4.5 of Symptom Onset:
a) Patients older than 80 years
b) Patient taking oral anticoagulants (regardless of INR)
c) NIHSS score greater than 25
d) Patients with a history of both stroke and diabetes
Blood Pressure Exclusion Criteria
a) Consistently refractory severe hypertension: SBP > 185 mm Hg; DBP > 110 mm Hg / on 3 readings within 30
minutes in spite of treatment.
b) Aggressive therapy is needed to maintain BP in specified limits (i.e., nipride drip)
Laboratories Exclusion Criteria
a) PT > 15 sec, Platelets < 100,000
b) Glucose < 50 mg/dl or > 400 mg/dl
c) Heme positive stools or Hematuria
d) Positive pregnancy test
e) INR > 1.7 in patients presenting within 3 hours
Head CT (non-contrast) Exclusion Criteria
a) Evidence of non-ischemic intracranial pathology: tumor, abscess or metastases
b) Evidence of intracranial hemorrhage: parenchymal, subarachnoid, subdural, epidural
c) Early signs of large cerebral infarction: edema, hypodensity, mass effect, obliteration of sulci in more than 1/3 of
middle cerebral artery territory (Only relative contraindication)
IV THROMBOLYTIC TREATMENT PLAN
BP Management:
Indication that patient is eligible for treatment with intravenous t-PA or other acute reperfusion intervention:
Blood pressure level
Systolic > 185 mm Hg or diastolic > 110 mm Hg
a. Labetalol 10 to 20 mg IV over 1 to 2 minutes may repeat x 1;
or
b. Nitropaste 1 to 2 inches;
or
c. Nicardipine infusion, 5 mg/h, titrate up by 2.5 mg/h at 5 to 15 minute intervals, maximum dose 15 mg/h; when
desired blood pressure attained, reduce to 3 mg/h
***WARNING*** IF BLOOD PRESSURE DOES NOT DECLINE AND REMAINS > 185/110 MM HG ***WARNING***
DO NOT ADMINISTER T-PA
IV t-PA DOSE AND ADMINISTRATION
Persons to Order (Immediately after CT) in order of preference
[MUST SPECIFIY WHO WILL HAVE RESPONSIBILITY FOR ORDERING THROMBOLYTIC]
Order
[INSTRUCTIONS SPECIFIC TO FACILITY FOR ORDERING rt-PA]:
Drug: "intravenous t-PA (Alteplase) for ischemic stroke"
Administration:
1) Dose: 0.9 mg/kg body weight (maximum 90 mg). Dose will be calculated and verified by two providers
a. Drug will arrive in two vials/bags (one bolus, one infusion)
b. Intravenous administration methods will be provided on labels
c. 10 % of dose given as bolus (over one minute)
d. Remainder of dose infused over 60 minutes
POST-INFUSION CARE
First 24 hours
a. Admission to Intensive Care Unit
b. Cardiac and O2 monitoring
c. Close monitoring of BP (q 15 minutes x 2 hr; then q 30 minutes x 6 hr; then q 1 hr x 24hr)
d. Treatment of BP to keep SBP < 180 mm Hg; DBP < 105 mm Hg
e. Frequent neuro checks (q 15 min x 2 hr, then q 30 minutes x 6 hr; then q 1 hr x 16hr)
f. No NG tube, Foley catheter, or invasive lines/procedures x 24 hr unless necessary
g. STAT brain CT with any signs of clinical deterioration, or suggestion of intracranial bleed
h. Observe carefully for any signs of systemic bleeding
i. No anticoagulant or antiplatelet agent use for 24 hours after treatment (possible exception for aspirin)
j. NPO x 24 hrs
k. Repeat head CT 24 hours after beginning treatment, even if no deterioration
l. Labs 24 hrs: CBC, platelet count, electrolytes, BUN, creatinine, UA, Stools heme testing
After First 24 Hours
a. If patient stable move out of ICU to [APPROPRIATE UNIT]
b. Close observation over the following 2 days for any neurologic worsening or symptoms of intracranial hemorrhage
c. Neuro checks and vital signs q 4 hours x 24 hours, then q shift
d. Antiplatelet agents can be started if indicated
e. Complete dysphagia screen
f. Initiate early nutrition
GUIDELINES FOR BLOOD PRESSURE MANAGEMENT POST INFUSION
Monitor blood pressure closely for first 24 hours after initiating t-PA infusion:
- Every 15 minutes for 2 hours, then
- Every 30 minutes for 6 hours, then
- Every 60 minutes for 16 hours
If BP still elevated, continue monitoring every 60 minutes
If BP controlled, change measurements q 4 hours x 24 hrs then to every shift
Management of Acute Hypertension
Monitor blood pressure every 15 minutes during treatment and then for another 2 hours, then every 30 minutes for 6
hours, and then every hour for 16 hours.
Blood pressure level
Systolic 180 to 230 mm Hg or diastolic 105 to 120 mm Hg
a. Labetalol 10 mg IV over 1 to 2 minutes, may repeat every 10 to 20 minutes, maximum dose of 300 mg;
or
b. Labetalol 10 mg IV followed by an infusion at 2 to 8 mg/min
Systolic >230 mm Hg or diastolic 121 to 140 mm Hg
a. Labetalol 10 mg IV over 1 to 2 minutes, may repeat every 10 to 20 minutes, maximum dose of 300 mg;
or
b. Labetalol 10 mg IV followed by an infusion at 2 to 8 mg/min;
or
c. Nicardipine infusion, 5 mg/h, titrate up to desired effect by Increasing 2.5 mg/h every 5 minutes to maximum of 15
mg/h
If blood pressure not controlled, consider sodium nitroprusside.
After First 24 hours consider beginning oral maintenance therapy.
MANAGEMENT OF INTRACRANIAL HEMORRHAGE (ICH) POST IV t-PA INFUSION
Indicators of higher risk for Symptomatic Intracerebral Hemorrhage (6-20 %)
a. Severity of initial neurologic deficit (NIHSS > 20)
b. Age > 75 years
c. Significant large areas with early ischemic abnormalities on CT (< 3 hours from onset)
d. Time interval from stroke onset to starting treatment (> 3 hours)
e. Combination with aspirin or heparin in first 24 hours
f. Refractory hypertension not adequately managed prior to treatment
Procedures
a. If ICH SUSPECTED, discontinue t-PA infusion immediately and notify MD
b. STAT brain CT scan for any neurological deterioration
c. STAT lab studies: PT, PTT, fibrinogen, CBC, platelet count and type/cross
d. Emergent Notification of Receiving Facility for Further Management if Necessary
1) Transfer
i. Notify the receiving facility of the patient transfer request
ii. Determine with receiving facility appropriate transfer (air or ground)
e. Anticipate and prepare for patient transfer
1) Documentation to Be Sent with Patient to Receiving Facility
a. CD-Rom Copies of Imaging if Available
b. Lab Results
c. History and Physical
d. Medication List
RELATED POLICIES/PROCEDURES
[XXX
Acute Stroke Team]
[XXX Stroke Team Pager Protocol]
Developed by:
Nebraska Stroke Advisory Council, Task Force for ED/Hospital Management
[NSAC PHYSICIAN REVIEWED BY…]
Reviewed by:
[FACILITY COORDINATOR]
[FACILITY MEDICAL DIRECTOR/ED HOSPITAL DIRECTOR]
Approved by:
Level 3-General Stroke Center
Acute Stroke Orders for Treatment Candidate
Emergency Department
Patient Name: ________________________________ MR# ________________ Date _____/_____/_____
Mode of Transport: q Private Vehicle q EMS q Prehospital Screen Used
Times: Symptom Onset or Last Seen Normal:__________________________________
Arrival to Emergency Department:_____________________________________
Initiate the following Orders:
____ Vital Signs now and q15 minutes: Initial BP____/____ Temp____ oF
____ Neurologic Exam now and q30 minutes with NIHSS
____ NIH Stroke Scale Score _____ (see next page)
____ Cardiac Monitor
____ O2 per NC or Mask to keep O2 sat >92%
____ STAT Head CT no contrast
____ Two (2) IVs: ____ 18 gauge saline lock
____ 20 guage. Start 0.9 NS @ 75 cc/hr
____ STAT CBC, Basic Metabolic Panel, UA, Troponin, PT/PTT, INR _______
____ STAT finger stick blood glucose if not already done________
____ STAT EKG
____ Accurate weight in Kg. ___________
____ NPO
____ Tylenol for rectal T > 99.5
____ Foley catheter if severely impaired
____ No Heparin, aspirin, Coumadin, Plavix or any other antiplatelet or anticoagulant
____ Elevate head of bed to 20-30 degrees
BP Management: Do not atempt to lower BP unless BP > 185/100 on two seperate
measurements 15 min. apart
* t-PA Candidates*: ____ Give Nitropaste 1-2” to chest/back. OR
____ Give Labetalol 10 to 20 mg IV over 1-2 min. May repeat x 1 OR
____ Nicardipine infusion, 5 mg/h, titrate up by 2.5 mg/h at 5 to 15 minute intervals,
maximum dose 15 mg/h; when desired blood pressure attained, reduce to 3 mg/h
Note: If BP not easily controlled with above steps exclude patient from consideration.
* Allow BP 220/120 for Non-treatment Candidates
Labs: If Patient taking warfarin wait for INR before continuing. Patient may be considered for thrombolysis if
INR < 1.7.
v
Date: _____/_____/______ Time:______________ Physican Signature:________________________________
Related Policies/Procedures
[ Level 3-General Stroke Center Acute Stroke Protocol]
[NIH Stroke Scale]
[Acute Thrombolytic Therapy for Ischemic Stroke Exclusion Criteria]
[t-PA (Alteplase Dosing Guidelines]
[Acute Stroke Transfer Protocol, Assessment and Transfer Documentation Form]
Patient Identification. ___ ___-___ ___ ___-___ ___ ___
Pt. Date of Birth ___ ___/___ ___/___ ___
Hospital ________________________(___ ___-___ ___)
Date of Exam ___ ___/___ ___/___ ___
Interval: [ ] Baseline
[ ] 2 hours post treatment [ ] 24 hours post onset of symptoms ±20 minutes
[ ] 3 months [ ] Other ________________________________(___ ___)
[ ] 7-10 days
Time: ___ ___:___ ___ [ ]am [ ]pm
Person Administering Scale _____________________________________
Administer stroke scale items in the order listed. Record performance in each category after each subscale exam. Do not go
back and change scores. Follow directions provided for each exam technique. Scores should reflect what the patient does, not
what the clinician thinks the patient can do. The clinician should record answers while administering the exam and work quickly.
Except where indicated, the patient should not be coached (i.e., repeated requests to patient to make a special effort).
Instructions
Scale Definition
1a. Level of Consciousness: The investigator must choose a
response if a full evaluation is prevented by such obstacles as an
endotracheal tube, language barrier, orotracheal trauma/bandages. A
3 is scored only if the patient makes no movement (other than reflexive
posturing) in response to noxious stimulation.
0 = Alert; keenly responsive.
1 = Not alert; but arousable by minor stimulation to obey,
answer, or respond.
2 = Not alert; requires repeated stimulation to attend, or is
obtunded and requires strong or painful stimulation to
make movements (not stereotyped).
3 = Responds only with reflex motor or autonomic effects or
totally unresponsive, flaccid, and areflexic.
1b. LOC Questions: The patient is asked the month and his/her age.
The answer must be correct - there is no partial credit for being close.
Aphasic and stuporous patients who do not comprehend the questions
will score 2. Patients unable to speak because of endotracheal
intubation, orotracheal trauma, severe dysarthria from any cause,
language barrier, or any other problem not secondary to aphasia are
given a 1. It is important that only the initial answer be graded and that
the examiner not "help" the patient with verbal or non-verbal cues.
0=
Answers both questions correctly.
1=
Answers one question correctly.
2=
Answers neither question correctly.
1c. LOC Commands: The patient is asked to open and close the
eyes and then to grip and release the non-paretic hand. Substitute
another one step command if the hands cannot be used. Credit is
given if an unequivocal attempt is made but not completed due to
weakness. If the patient does not respond to command, the task
should be demonstrated to him or her (pantomime), and the result
scored (i.e., follows none, one or two commands). Patients with
trauma, amputation, or other physical impediments should be given
suitable one-step commands. Only the first attempt is scored.
2. Best Gaze: Only horizontal eye movements will be tested.
Voluntary or reflexive (oculocephalic) eye movements will be scored,
but caloric testing is not done. If the patient has a conjugate
deviation of the eyes that can be overcome by voluntary or reflexive
activity, the score will be 1. If a patient has an isolated peripheral
nerve paresis (CN III, IV or VI), score a 1. Gaze is testable in all
aphasic patients. Patients with ocular trauma, bandages, pre-existing
blindness, or other disorder of visual acuity or fields should be tested
with reflexive movements, and a choice made by the investigator.
Establishing eye contact and then moving about the patient from side
to side will occasionally clarify the presence of a partial gaze palsy.
Rev 10/1/2003
Score
______
______
0 = Performs both tasks correctly.
1 = Performs one task correctly.
2 = Performs neither task correctly.
______
0 = Normal.
1 = Partial gaze palsy; gaze is abnormal in one or both eyes,
but forced deviation or total gaze paresis is not present.
2 = Forced deviation, or total gaze paresis not overcome by the
oculocephalic maneuver.
______
Patient Identification. ___ ___-___ ___ ___-___ ___ ___
Pt. Date of Birth ___ ___/___ ___/___ ___
Hospital ________________________(___ ___-___ ___)
Date of Exam ___ ___/___ ___/___ ___
Interval: [ ] Baseline
[ ] 2 hours post treatment [ ] 24 hours post onset of symptoms ±20 minutes
[ ] 3 months [ ] Other ________________________________(___ ___)
[ ] 7-10 days
______
7. Limb Ataxia: This item is aimed at finding evidence of a unilateral
cerebellar lesion. Test with eyes open. In case of visual defect,
ensure testing is done in intact visual field. The finger-nose-finger
and heel-shin tests are performed on both sides, and ataxia is scored
only if present out of proportion to weakness. Ataxia is absent in the
patient who cannot understand or is paralyzed. Only in the case of
amputation or joint fusion, the examiner should record the score as
untestable (UN), and clearly write the explanation for this choice. In
case of blindness, test by having the patient touch nose from
extended arm position.
8. Sensory: Sensation or grimace to pinprick when tested, or
withdrawal from noxious stimulus in the obtunded or aphasic patient.
Only sensory loss attributed to stroke is scored as abnormal and the
examiner should test as many body areas (arms [not hands], legs,
trunk, face) as needed to accurately check for hemisensory loss. A
score of 2, “severe or total sensory loss,” should only be given when
a severe or total loss of sensation can be clearly demonstrated.
Stuporous and aphasic patients will, therefore, probably score 1 or 0.
The patient with brainstem stroke who has bilateral loss of sensation
is scored 2. If the patient does not respond and is quadriplegic, score
2. Patients in a coma (item 1a=3) are automatically given a 2 on this
item.
9. Best Language: A great deal of information about comprehension
will be obtained during the preceding sections of the examination.
For this scale item, the patient is asked to describe what is happening
in the attached picture, to name the items on the attached naming
sheet and to read from the attached list of sentences.
Comprehension is judged from responses here, as well as to all of
the commands in the preceding general neurological exam. If visual
loss interferes with the tests, ask the patient to identify objects placed
in the hand, repeat, and produce speech. The intubated patient
should be asked to write. The patient in a coma (item 1a=3) will
automatically score 3 on this item. The examiner must choose a
score for the patient with stupor or limited cooperation, but a score of
3 should be used only if the patient is mute and follows no one-step
commands.
0 = Absent.
1 = Present in one limb.
______
2 = Present in two limbs.
UN = Amputation or joint fusion, explain: ________________
0 = Normal; no sensory loss.
1 = Mild-to-moderate sensory loss; patient feels pinprick is
less sharp or is dull on the affected side; or there is a
loss of superficial pain with pinprick, but patient is aware
of being touched.
______
2 = Severe to total sensory loss; patient is not aware of
being touched in the face, arm, and leg.
0 = No aphasia; normal.
1 = Mild-to-moderate aphasia; some obvious loss of fluency
or facility of comprehension, without significant
limitation on ideas expressed or form of expression.
Reduction of speech and/or comprehension, however,
makes conversation about provided materials difficult
or impossible. For example, in conversation about
provided materials, examiner can identify picture or
naming card content from patient’s response.
______
2 = Severe aphasia; all communication is through fragmentary
expression; great need for inference, questioning, and guessing
by the listener. Range of information that can be exchanged is
limited; listener carries burden of communication. Examiner
cannot identify materials provided from patient response.
3 = Mute, global aphasia; no usable speech or auditory
comprehension.
10. Dysarthria: If patient is thought to be normal, an adequate
sample of speech must be obtained by asking patient to read or
repeat words from the attached list. If the patient has severe
aphasia, the clarity of articulation of spontaneous speech can be
rated. Only if the patient is intubated or has other physical barriers to
producing speech, the examiner should record the score as
untestable (UN), and clearly write an explanation for this choice. Do
not tell the patient why he or she is being tested.
Rev 10/1/2003
0 = Normal.
1 = Mild-to-moderate dysarthria; patient slurs at least some
words and, at worst, can be understood with some
difficulty.
2 = Severe dysarthria; patient's speech is so slurred as to be
unintelligible in the absence of or out of proportion to
any dysphasia, or is mute/anarthric.
UN = Intubated or other physical barrier,
explain:_____________________________
______
Patient Identification. ___ ___-___ ___ ___-___ ___ ___
Pt. Date of Birth ___ ___/___ ___/___ ___
Hospital ________________________(___ ___-___ ___)
Date of Exam ___ ___/___ ___/___ ___
Interval: [ ] Baseline
[ ] 2 hours post treatment [ ] 24 hours post onset of symptoms ±20 minutes
[ ] 3 months [ ] Other ________________________________(___ ___)
[ ] 7-10 days
______
7. Limb Ataxia: This item is aimed at finding evidence of a unilateral
cerebellar lesion. Test with eyes open. In case of visual defect,
ensure testing is done in intact visual field. The finger-nose-finger
and heel-shin tests are performed on both sides, and ataxia is scored
only if present out of proportion to weakness. Ataxia is absent in the
patient who cannot understand or is paralyzed. Only in the case of
amputation or joint fusion, the examiner should record the score as
untestable (UN), and clearly write the explanation for this choice. In
case of blindness, test by having the patient touch nose from
extended arm position.
8. Sensory: Sensation or grimace to pinprick when tested, or
withdrawal from noxious stimulus in the obtunded or aphasic patient.
Only sensory loss attributed to stroke is scored as abnormal and the
examiner should test as many body areas (arms [not hands], legs,
trunk, face) as needed to accurately check for hemisensory loss. A
score of 2, “severe or total sensory loss,” should only be given when
a severe or total loss of sensation can be clearly demonstrated.
Stuporous and aphasic patients will, therefore, probably score 1 or 0.
The patient with brainstem stroke who has bilateral loss of sensation
is scored 2. If the patient does not respond and is quadriplegic, score
2. Patients in a coma (item 1a=3) are automatically given a 2 on this
item.
9. Best Language: A great deal of information about comprehension
will be obtained during the preceding sections of the examination.
For this scale item, the patient is asked to describe what is happening
in the attached picture, to name the items on the attached naming
sheet and to read from the attached list of sentences.
Comprehension is judged from responses here, as well as to all of
the commands in the preceding general neurological exam. If visual
loss interferes with the tests, ask the patient to identify objects placed
in the hand, repeat, and produce speech. The intubated patient
should be asked to write. The patient in a coma (item 1a=3) will
automatically score 3 on this item. The examiner must choose a
score for the patient with stupor or limited cooperation, but a score of
3 should be used only if the patient is mute and follows no one-step
commands.
0 = Absent.
1 = Present in one limb.
______
2 = Present in two limbs.
UN = Amputation or joint fusion, explain: ________________
0 = Normal; no sensory loss.
1 = Mild-to-moderate sensory loss; patient feels pinprick is
less sharp or is dull on the affected side; or there is a
loss of superficial pain with pinprick, but patient is aware
of being touched.
______
2 = Severe to total sensory loss; patient is not aware of
being touched in the face, arm, and leg.
0 = No aphasia; normal.
1 = Mild-to-moderate aphasia; some obvious loss of fluency
or facility of comprehension, without significant
limitation on ideas expressed or form of expression.
Reduction of speech and/or comprehension, however,
makes conversation about provided materials difficult
or impossible. For example, in conversation about
provided materials, examiner can identify picture or
naming card content from patient’s response.
______
2 = Severe aphasia; all communication is through fragmentary
expression; great need for inference, questioning, and guessing
by the listener. Range of information that can be exchanged is
limited; listener carries burden of communication. Examiner
cannot identify materials provided from patient response.
3 = Mute, global aphasia; no usable speech or auditory
comprehension.
10. Dysarthria: If patient is thought to be normal, an adequate
sample of speech must be obtained by asking patient to read or
repeat words from the attached list. If the patient has severe
aphasia, the clarity of articulation of spontaneous speech can be
rated. Only if the patient is intubated or has other physical barriers to
producing speech, the examiner should record the score as
untestable (UN), and clearly write an explanation for this choice. Do
not tell the patient why he or she is being tested.
Rev 10/1/2003
0 = Normal.
1 = Mild-to-moderate dysarthria; patient slurs at least some
words and, at worst, can be understood with some
difficulty.
2 = Severe dysarthria; patient's speech is so slurred as to be
unintelligible in the absence of or out of proportion to
any dysphasia, or is mute/anarthric.
UN = Intubated or other physical barrier,
explain:_____________________________
______
Patient Identification. ___ ___-___ ___ ___-___ ___ ___
Pt. Date of Birth ___ ___/___ ___/___ ___
Hospital ________________________(___ ___-___ ___)
Date of Exam ___ ___/___ ___/___ ___
Interval: [ ] Baseline
[ ] 2 hours post treatment [ ] 24 hours post onset of symptoms ±20 minutes
[ ] 3 months [ ] Other ________________________________(___ ___)
11. Extinction and Inattention (formerly Neglect): Sufficient
information to identify neglect may be obtained during the prior
testing. If the patient has a severe visual loss preventing visual
double simultaneous stimulation, and the cutaneous stimuli are
normal, the score is normal. If the patient has aphasia but does
appear to attend to both sides, the score is normal. The presence of
visual spatial neglect or anosagnosia may also be taken as evidence
of abnormality. Since the abnormality is scored only if present, the
item is never untestable.
[ ] 7-10 days
0 = No abnormality.
1 = Visual, tactile, auditory, spatial, or personal inattention
or extinction to bilateral simultaneous stimulation in one
of the sensory modalities.
______
2 = Profound hemi-inattention or extinction to more than
one modality; does not recognize own hand or orients
to only one side of space.
______
______
Date: _____/_____/______ Time:______________ Physican Signature:________________________________
Rev 10/1/2003
Acute Thrombolytic Therapy for Ischemic Stroke
Exclusion Criteria
Exclusion Criteria: If any of the following apply, patient is not a candidate.
____ CT Brain with any hemorhage (Note: patients with large hypodensities in appropriate region on CT should
be questioned in greater detail regarding true time of onset or last seen normal.)
____ BP > 185/110 at time of treatment
____ Minor symptoms (NIHSS <4) or Rapidly improving symptoms
____ Clinical history suggestive of subarachnoid hemorrhage even with normal CT
____ INR >1.7 or receiving heparin with elevated PTT (Note: patients receiving heparin but have a normal PTT
prior to treatment may still be considered eligible candidates.)
____ Seizure at onset
____ Platelets <100K
____ History of any of the following:
__ Intracranial hemorrhage/Neoplasm/AVM
__ Major surgery in < 14 days
__ Stroke or head trauma in last 3 months
__ Arterial puncture at non-compressible site < 7 days
__ GI or GU hemorrhage in last 21 days
__ Lumbar puncture in past 24 hours
__ Recent MI (< 3 weeks) with or without presumed pericarditis
____ Glucose <50 or >400 (Note: this may be corrected to see if symptoms resolve. If they do not resolve with
normalization of values then patient may be considered eligible.)
____ Presumed septic embolus
If patient meets all criteria for thrombloysis for acute ischemic stroke, notify the Neurologist to determine
if patient needs a transfer.
Administration of IV t-PA (Alteplase)
*Note: Maximum does is 90mg (see t-PA dosing guidelines).
DO NOT use Cardiac Dose.
DO NOT give ASA, Heparin
Patient Weight: ___________ (kg)
Total dose = 0.9mg/kg X________{weight (kg)} = _________mg
Give 10% of total ________ (mg) over 1 minute Time given___________ ____/____/____
Give 90% of total ________ (mg) over 1 hour
Time given___________ ____/____/____
Continue to monitor vitals and neurologic exam q15 minutes. Suspect Intracranial Hemorrhage if acute
worsening, new severe headache, acute hypertension or sudden nausea with vomiting.
Date: _____/_____/______ Time:______________ Physican Signature:________________________________
t-PA (Alteplase) Dosing Guidelines for
Acute Ischemic Stroke
Weight in
lbs.
220+
210
200
190
180
170
160
150
140
130
120
110
100
Weight
conversion
to kg
100
95.5
90.9
86.4
81.8
77.3
72.7
68.2
63.6
59.1
54.5
50
45.5
Total IV t-PA
dose (mg) at
0.9mg/kg
90
85.9
81.8
77.7
73.6
69.5
65.5
61.4
57.3
53.2
49.1
45
40.9
t-PA bolus (mg)
10% of total
t-PA bolus (ml)
Discard dose t-PA
(not for infusion)
Infusion
dose (mg)
Infusion
rate (ml/hr)
9
8.6
8.2
7.8
7.4
7
6.5
6.1
5.7
5.3
4.9
4.5
4.1
9
8.6
8.2
7.8
7.4
7
6.5
6.1
5.7
5.3
4.9
4.5
4.1
10
14.1
18.2
22.3
26.4
30.5
34.5
38.6
42.7
46.8
50.9
55
59.1
81
77.3
73.6
70
66.3
62.6
58.9
55.2
51.5
47.9
44.2
40.5
36.8
81
77.3
73.6
70
66.3
62.6
58.9
55.2
51.5
47.9
44.2
40.5
36.8
Acute Stroke Care Plan
Time
Actions
Patient Arrival
20-30 min.
Provider Assessment
1. ABCs /Vitals
2. History Onset/Time Last Seen
Normal________ ____/____/____
3. Warfarin / Antiplatelet
q YES
q NO
4. General Exam
5. Perform NIHSS
Initial Care
1. O2 Sat >92%
2. Keep NPO
3. Initiate BP Protocol
4. Treat temp > 99.5
Diagnostics
1. Labs: CBC, PTT, PT/INR, Lytes, Glucose
2. EKG
3. CT performed STAT
Level of Care
Does patient/family desire aggressive
treatment/resuscitation efforts?
Disposition Decision
1. Treatment Candidate
2. Transfer Patient
3. Admit Patient
Quality Measures
q Private
q EMS
q Prehospital Screen
Vitals including weight completed
Onset or last seen normal time noted
Y/N
Y/N
Anti-coagulation history noted
Y/N
NIHSS Completed
Y/N
NPO Noted
Y/N
Labs Completed
EKG Completed
Time to CT & results received < 45min
Y/N
Y/N
Y/N
Discussed treatment options including t-PA Y/N
Admitted/Transferred
t-PA considered in those onset < 3hrs
If yes, t-PA treated
Y/N
Y/N
Date: _____/_____/______ Time:______________ Physican Signature:________________________________
Acute Stroke Protocol, Assessment and
Transfer Documentation Form
Transfer Protocol
u Initiate Hospital Transfer protocol ASAP to avoid unnecessary delays.
u Contact ED of receiving facility and ask for ED physician or Neurologist on-call
u Provide the following details when communicating with receiving facility:
1. Symptom onset time or last seen normal in as much detail as possible
2. NIHSS Score
3. Presence of atrial fibrillation
4. Whether patient is taking warfarin or not
5. BP, glucose, and pertinent lab work
6. EKG results
u Keep NPO
u Follow BP parameters closely
u Fax documents to receiving facility
1. Acute Stroke Orders Form
2. NIHSS form
3. Labs when available
4. EKG
u Complete Acute Stroke Assessment and Transfer Documentation Form and send with Patient or fax.
Acute Stroke Protocol, Assessment and
Transfer Documentation Form
Date:______/______/______ (MM/DD/YEAR) Time:________:_________ AM PM
Referring Facility:___________________________Referring Physician:_______________________________
Patient Name:_______________________________ Date of Birth: ______/______/______ (MM/DD/YEAR)
Name of Person Witnessing Event:_____________________Witnessing Person’s Phone #:________________
SYMPTOM TIMELINE
Last Time Known Well (Onset)_____/_____/_____ (MM/DD/YEAR) Time :_____:______ AM PM
Presenting Symptoms:
Initial NIHSS: q YES Time:
Score:
Vitals on Arrival to Referring Facility:
O2 Sats
q NO
BP
% q RA q NC HR
RR
T
L
BRAIN IMAGING
CT Head Completed? q YES q NO
Interpretation of first brain imaging: q Hemorrhage
Copy of Imaging Attached q YES q NO
q No Hemorrhage
q N/A
PAST MEDICAL HISTORY
Recent H&P Attached?
q YES
q NO
HOME MEDICATIONS
Recent Medication List Attached
q YES q NO
IV THROMBOLYTIC THERAPY
IV t-PA Initiated: q YES q NO
Date & Time IV t-PA Initiated: ____/____/____ _____:______ AM PM
Pt Weight (kg):
Total Dose = 0.9mg/kg x _______weight (kg) = _________mg
Give 10% of total
(mg) over 1 minute
Time Given ______:_______ AM PM
Give 90% of total
(mg) over 1 hour
Time Given ______:_______ AM PM
CONTRAINDICATION TO THROMBOLYTICS
q SBP >185 or DBP >110mg.Hg despite treatment
q Seizure at Onset
q Recent Surgery/Trauma (<15days)
q Active Internal Bleeding (<22 days)
q Recent intracranial or spinal surgery, head trauma, or stroke (< 3 months)
q Platelets < 100,000, PTT > 40 sec after heparin use, or PT > 15 or INR > 1.7, or known bleeding diathesis
q History of intracranial hemorrhage or brain aneurysm or vascular malformation or brain tumor
q CT finding (ICH, SAH, or major infarct signs)
WARNINGS
q Advanced Age
q Care team unable to determine eligibility
q Glucose < 50 or > 400 mg/dl
q Increased risk of bleeding due to co-morbid conditions
q Pregnancy
q Pt./Family Refused
q Life expectaancy < 1 year or severe co-morbid illness q Rapid Improvement or Stroke severity too mild
q Stroke severity too severe (e.g., NIHSS > 22)
Date: ____/____/____ Time:________ Referring Physican Signature:__________________________________
Admission Orders for Stroke/TIA
Page 1 of 2
Date ____/____/____
Admission Status: Time: _______________
q Inpatient
q Outpatient
Admit to: ________________________________
Probable Diagnosis:
Code Status:
q Hemorrhage
q Full Code
Co-Morbid conditions:
Prior History:
q Infarct
q TIA
q No or Limited Code
q HTN
q Hyperlipidemia
q TIA
q Cardiac Monitor
q Stroke
q DM
q PVD
q CHF
q MI
q Cardiomyopathy
q Afib
q Smoker
q Aneurysm
Attending Physician: __________________________________ Consult:______________________________
ALLERGIES:______________________________________________________________________________
DIET:
____ NPO until cleared by bedside swallow study, then advance as tolerated.
* Notify MD if patient still NPO after 24 hours from admission as patient may need tube-feeding.
IV:
____ Saline lock or IV________________ at _______________ml/hr.
* Note: AVOID using paralyzed arm. AVOID hypotonic solutions.
LAB: In AM, fasting lipid panel and glucose
OTHER LAB:_____________________
_____________________
_______________________
X-RAY/DIAGNOSTICS:
____ STAT NON-CONTRAST CT BRAIN for any acute neurological deterioration or acute hypertension, and
NOTIFY ATTENDING PHYSICIAN IMMEDIATELY.
____ MRI Brain
____ Carotid Duplex studies
____ Cardiac Echo
____ MRA Brain
VITAL SIGNS
____ Monitor blood pressure and pulse every 4 hours X 24 hours, then routine
____ Neurological observation every 2 hours for 12 hours, then every shift
____ Termperature every 4 hours x 24 hours, then routine. If temp >99o F, give acetaminophen (order on pg. 2)
** IF STROKE/TIA IS FLUCTUATING OR PROGRESSING, NOTIFY PHYSICIAN AND**
____ Monitor BP at least every 30 minutes until stabilized, then as above
____ Monitor Neurological status at least every 30 minutes until stabilized, then as above
Page 2 of 2
Admission Orders for Stroke/TIA
Date ____/____/____
Time: _______________
ACTIVITY:
____ HOB h 30 degrees -- (After eating, keep HOB h 90o for one hour)
____ Bedrest with bathroom privileges as able
____ Up with assist
____ Activity as tolerated
____ Turn patient every 2 hours if patient weak or decreased level of consciousness
CONSULTS:
____ Speech Therapy
____ Physical Therapy
____ Occupational Therapy
____ Pastoral Care
____ Dietary
TREATMENTS:
____ O2 Protocol, Keep O2 saturation >95%
____ Avoid foley catheter unless there is significant tisk of skin breakdown, and/or decreased arousal.
Consider texas catheter.
____ If patient immobile, pneumatic TEDS
____ Add cooling blanket if needed to keep temperature < 99o F
____ Fingerstick blood glucose. Try to keep blood glucose approximately 100. (See sliding scale below)
____ If NPO, check every 6 hours
____ If taking po, check before meals and at bedtime (if not diabetic, check until 4 readings are <100, then DC)
MEDICATIONS:
____ Famotidine (Pepcid) 10mg PO every 12 hours or may give IV if patient is NPO.
____ Heparin 5000 Units subcutaneous every 12 hours
____ Lovenox 40mg subcutaneous every 24 hours
____ Aspirin 325mg po/PR once daily (if CT negative for hemorrhage)
____ Acetaminophen (Tylenol) 650mg po/PR every 4 hours for termperature < 99o F orally
____ Laxative of choice_______________________________
____ Insulin sliding scale prn to keep blood glucose approximately 100.
____ units regular insulin subcutaneous for BG > _____________
____ units regular insulin subcutaneous for BG > _____________
____ units regular insulin subcutaneous for BG > _____________
____ units regular insulin subcutaneous for BG > _____________
____ units regular insulin subcutaneous for BG > _____________
Date: _____/_____/______ Time:______________ Physican Signature:________________________________
Clinical Guidance for Inpatient Stroke Care
** During the In-Patient stay, there are specific issues that can significantly impact the patient’s
outcome which need to be addressed consistently.
____ Prior to any oral intake, including medication, ALL stroke patients need to be SCREENED
FOR DYSPHAGIA (See bedside swallow screen chart)
** Note: all that is needed at first is a screen, not necessarily a video swallow, so any facility can do this
even without a speech therapist.
____ Closely monitor temperature. Fever worsens the outcome in stroke, therefore a temperature of > 99o F
orally needs to be treated aggressively as well as looking for the source of the fever.
____ Keep Glucose moderately controlled (120’s-180’s)
** The vascular pathology of stroke is varied including small vessel occlusion, large vessel occlusion, artery to artery embolism and cardiac emboli. Since secondary prevention of stroke depends on
the vascular pathology, a thorough evaluation of the cause of stroke is necessary.
A MINIMUM EVALUATION consists of:
____ Carotid Duplex
____ MRI/MRA of the Brain
____ Echocardiography
____ Monitoring of the Cardiac Rhythm
____ Fasting Lipid Panel and Glucose
** In general, patients with a low ejection fraction <25% and those with atrial fibrillation should
be anti-coagulated. Those with carotid stenosis 70% or greater on the side of the stroke (but not occluded) need to be considered for carotid endarterectomy. All other patients need anti-platelet agents.
All patients needs aggressive treatment of vascular risk factors.
Clinical Guidance for Inpatient Stroke Care
REHABILITATION:
** Rehabilitation evaluation is essential for optimal patient outcome. PT, OT and ST consults
should be obtained, depending upon the resources available within the facility. Consider the use of
telehealth for these services. Consider an Acute In-Patient Rehabilitation Facility, even if it means
travel for the patient and family.1
Rehabilitation Scale for determining need of Acute In-Patient Rehabilitation Facility
Does your patient need assistance with any of the following?
Mobility:
Communication/Cognition:
Bed Mobility q Yes q No
Verbal Comunication
Transfers
q Yes q No
Decision-making
Walking
q Yes q No
Problem Solving
ADLs:
Bowel
Bladder
Feeding
Grooming
Dressing
Bathing
q Yes
q Yes
q Yes
q Yes
q Yes
q Yes
q Yes
q Yes
q Yes
q No
q No
q No
q No
q No
q No
q No
q No
q No
** If the answer is YES to One (1) or more items in One (1) or more category, strongly consider calling an
admission coordinator at one of the in-patient rehabilitation facilities. (see CARF Rehab list)
Coordinators will review the following criteria:
____ Medical Stability- determined by accepting rehabilitation physician.
____ Adequate therapy tolerance- at least 3 hours daily, 5 days per week or more. Therapy notes from referring
facility will be reveiwed to determine therapy tolerance.
____ Need for Interdisciplinary services- PT and OT and possibly ST and/or Prosthetic and Orthotic Services
and the need for 24-hour rehabilitation nursing services.
____ Discharge anticipated to Non-Institutional setting- family and/or caregiver may need to be identified prior
to admission, especially if the patient is likely to need assistance after discharge.
____ Admission is usually subject to financial review prior to acceptance for in-patient rehabiliation.
1 Management of Adult Stroke Rehabilitation Care: A Clinical Practice Guideline. Pamela W. Duncan, Richard Zorowitz, Barbara Bates, John Y.
Choi, Joanthan J. Glasberg, Glenn D. Grahm, Richard C. Katz, Kerri Lamberty and Dean Reker. Stroke 2005;36;e-100-e143.
CARF Accredited Stroke Specialty Rehabilitation
Programs in Nebraska
Consumers like you have choices in directing your services. Carefully researching and selecting
your options are essential steps to finding the services you need and achieving the results you
desire. The Commission on the accreditation of Rehabilitation Facilities (CARF) signals a service
provider's commitment to continually improving services, encouraging feedback, and serving the
community. Through accreditation, CARF assists service providers in improving the quality of their
services, demonstrating value, and meeting internationally recognized organizational and program
standards.
CARF Stroke Specialty Inpatient Rehabilitation for Adults
Acute Rehabilitation Unit at Regional West Medical Center (RWMC)
4021 Avenue B
Scottsbluff, NE 69361
http://www.rwhs.org
CARF Stroke Specialty Inpatient Rehabilitation for Adults
Alegent Health Immanuel Rehabilitation Center (IRC)
6901 North 72nd. Street
Omaha, NE 68122
402-572-2295
http://www.alegent.org
CARF Stroke Specialty Inpatient and Outpatient Rehabilitation for Adults and Pediatrics
Madonna Rehabilitation Hospital
5401 South Street
Lincoln, NE 68506
402-489-7102
http://www.madonna.org
CARF Stroke Specialty Inpatient Rehabilitation for Adults
Methodist Hospital Rehabilitation Center- Omaha (NMH)
8303 Dodge Street
Omaha, NE 68114
402-354-4400
http://www.bestcare.org
CARF Stroke Specialty Program for Residential Rehabilitation and Vocational Services
Quality Living, Inc. (QLI)
6404 North 70th Plaza
Omaha, NE 68104
http://www.qliomaha.com
Nursing Bedside Swallow Screen
** Use this form to document a bedside swallow screen prior to oral intake for ALL Ischemic Stroke,
Hemorrhagic Stroke and TIA patients. When complete, place form in physician orders.
Hemorrhagic Stroke TIA patients. When complete, place form in physician orders.
Bedside Swallow Screen
No Patient is alert/ ↑ 90° Position
A swallow screen is not
to be performed on
patients who have:
↓ LOC
unable to
follow
commands
uncontrolled
seizure activity
Able to clinch teeth/close lips/show face
symmetry, tongue midline
These patients should
remain NPO until a level
of safety has been
established
Able to cough, manage oral secretions with dry
voice (no drooling)
Yes, continue
Yes, continue
Yes, continue
No No No Able to find words with no slurring or other
difficulties
Yes, continue
No Able to swallow tsp water without coughing,
wet voice, or choking. May do 1-3 trials
Yes, continue
Able to chew cracker with no cough or
clearing of throat, and
no pocketing in L or R cheek
No