Temple University Hospital - pnett.orgpnett.org/strokepacket.pdfCancel CTP / CTA if non-con CT positive for hypertensive ICH, tumor. Call Attending NeiiroIR as CTP started (on-call

Temple UniversityHospitalTemple University Health System

HYPERACUTE STROKE CAREEM/NEUROLOGY NEUROIR

D Brief history, including time of onset, H/O disability (mRS).Focused exam on ventilation, BP, current NIHSS.

D Patient with acute stroke symptoms < 5 hours duration, NIHSS > 4.

D Page Neurology Resident.Page Research Staff (see list).Call 2-4373 CT Tech and ask that the Radiology Resident be bedside for wet read.

D "Hyperacute Stroke Care" order set.Order non-contrast CT and CTP/CTA.Run green bullet tube to STAT lab for Creatinine (phone # tor lab tech to call back).Place 2 IVs, one 16-gauge for CT contrast.

D To CT for non-con CT, CTP/CTA.Radiology Resident reads non-con CT for obvious hemorrhage or tumor.Cancel CTP / CTA if non-con CT positive for hypertensive ICH, tumor.Call Attending NeiiroIR as CTP started (on-call list in stroke packet).CT Tech to process CTP immediately upon completion.

D Is patient eligible for IV tPA?Sxs < 3 hoursReview Patient Eligibility Checklist, CT/CTPNeuroIR Attending notifies EM Attending of CTP.Read using 2-6556 or 2-6554.Confer with Neurology for plan.

D If yes, use rtPA Administration Procedure, Pre-, During-, and Post-rtPA Guidelines, dosing guides in stroke

packet.

L] Is patient eligible for IA tPA or Mechanical Clot Retrieval?Sxs > 3 hoursReview history, CT/CTP/CTANeuroIR Attending notifies EM Attending with read and plan on 2-6556 or 2-6554.

KIT-STROKE / PAGE 1 OF 11 (05/08)


TEMPLE UNIVERSITY HOSPITALAPPROACH TO ELEVATED BLOOD PRESSUREIN ACUTE ISCHEM1C STROKE

PRETREATMENT

Systolio 185 OR

Diastolic>110

Labetalol 10-20 mg IV over 1-2 minutes.

May repeat X 1 OR Nitropaste 1-2 inches

If blood pressure is not reduced and maintained at desired levels (systolic < 185 and diastolic < 110), do notadminister r-TPA.

DURING AND AFTER TREATMENT

1. Monitor BP

2. Diastolic>140

3. Systolic > 230 OR

Diastolic 121-140

4. Systolic 180-230 OR

Diastolic 105-120

Check BP every 15 minutes for 2 hours, then every 30 minutes for 6 hours, an

then every hour for 16 hours.

Sodium nitroprusside 0.5 ug / kg / min IV infusion as initial dose and titrate to

desired blood pressure.

Labetalol 10 mg IV over 1 - 2 minutes. May repeat or double Labetalol every 10

minutes to a maximum dose of 300 mg or give the initial Labetalol bolus andthen start a Labetalol drip at 2 to 8 mg / min.

ORNicardipine 5 mg / hour IV infusion as initial dose; titrate to desired effect byincreasing 2.5 mg / hour every 10 minutes to maximum of 15 mg / hour. If BP notcontrolled by Labetalol, consider sodium nitroprusside.

Labetalol 10 mg IV over 1 - 2 minutes. May repeat or double every 10 to 20

minutes to a maximum dose of 300 mg or give the initial Labetalol bolus andthen start a Labetalol drip at 2 to 8 mg / minute.



la. LOC

1 b. LOC Questions-Ask pf s age and month.Must be exact.

Ic . Commands--open/close eyes, grip and releasenon-paretic hand, (Other 1-step commands orrnirmc ok)

2. Best Gaze-Horizontal EOM by voluntary orDoll's.

j. Visual Field-Use visual threat if nee. Ifmonocular, score field of good eye.

4. Facial Palsy-If stuporous. check symmetry ofgrimace to pain.

5. Motor Arm-arms outstretched 90 deg (sitting)or 45 deg (supine) for 10 sees. Encourage besteffort, CircJe paretic arm in score box

6. Motor Leg-raise leg to 30 deg supine x 5 seci.

7. Limb Ataxu-check finger-nose-finger ;heel-shin; and score only if out of proportion to:paralysis

8. Sensory-Use safety pin. Check grimace orj withdrawal if stuporous. Score onlystroke-related losses.

9. Best Language -- Describe cookie jar picture ,name objects. May use repeating, writing,stereognosis.

10. Dysarthria-read list of words

1 1 .Extinction/Neglect.- simultaneously touchpatient on both hands, show fingers in both visfields, ask about deficit, left hand.

KIT-STROKE / PAGE 3 OF 1 1 (05/08)

(Hilert and responsive-arausable to minor stimulation

2-arousable only to painful stimulation3-reflex reponses or unarousable

0-Both correctI -One correct (or dysarthnX intubated, foreign lang)2-Neither correct

Q-Both correct (ok if impaired by weakness)I -One correct2-Neither correct

0-NormalI -partial gaya palsy, abnl gaze in I or both eyes2~r oreed eye deviation or total paresis which' cannot be overcome byDoll's.

0-No visual I oss-Partial herraanopia, quadrantanopia. extinction

2-Complete hemianopiaj-Bilateral hemianopia or blindness

0-Naraial-minor paralysis, flat NLF, asymm smile

2-partial paralysis (lower face~UMN)3-complete paralysis [upper & lower face)

0-No drift x 10 sees1 -Drift but doeai't hit bed2-Some antigra\ity effon, but can't sustain3-No antijf a\aty eftbrL but even mimrnal m\1 counts4-No movement at allX-unable to assess due to amputation, fusion, &. etc.

0-No drift x 5 seesI -Drift but doesn't hit bed2~Some antigravity effort, but can't sustainJ-No antigravity effort but es'en minimal mvt counts4—No movement at allX-unable to assess due to amputation, fusion, &. etc.

0-No ataxk (or aphaac. herniplegic)1-ataxia in upper or lower extremity2- ataxia in upper AND lower extremityX-unable to assess due to amputation, fusion, ft, etc.

0-Normal1-rrri Id-mod unilateral loss but pt aware of touch (or aphasic. confused)2-Total loss, pt unaware of touch. Coma, bilateral loss

0-Ncrma]l-rniki-inod aphasia; (diff but partly comprehensible)2-severe aphasia; (almost no info exchanged)j-mute, global aphasia,, coma. No 1 step commands

0-Normal1 -mi Id-mod: slurred but intelligible2-sfuvBK, imimdligibleunnuieX-mtubation or mech.banier

iO-Norrnal, none detected (vis loss alone)1-Naglects or extinguishes to double simult stimulation in any modality(vis, aud, sens, spatial, body parts)2-profound neglect in more than one modality

LorR

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MAMA

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FIFTY-FIFTY

THANKS

HUCKLEBERRY

BASEBALL PLAYER



TEMPLE UNIVERSITY HOSPITALACTIVASE r-TPA (0 - 3 HOURS)PATIENT ELIGIBILITY CHECKLIST

INCLUSION CRITERIAD Age> 18 years oldG Clinical diagnosis of ischemic stroke causing a measurable neurological deficit defined as impairment of language,

motor function, cognition and/or glaze, vision, or neglect.

G Treatment with drug can be initiated between 0-3 hours of the onset of symptoms (time patient was last observed

asymptomatic must be reliably ascertained, especially for those patients awakening with symptoms).

EXCLUSION BY HISTORYQ Onset of stroke cannot be verified.G Uncontrolled Hypertension BP> 185/110 by repeated IV attempts to lower it.

n Rapidly improving (and NIHSS< 4).

G Seizure generalized tonic-clonic at onsetG Hx suggests SAH (bad headache) even if CT is normal.

G Known IntracranialAneurysm.AVM, or tumor.

G Ml or pericarditis suspected.

G Stroke in the past three months.G Intracranial Surgery past three months.G Serious head trauma last three months.

G Major surgery < 14 days

G Gl and GU bleeding < 21 days.

G LP last 7 daysG Pregnancy / Lactation (consider IA rtPA)G Subacute bacterial endocarditis.G Known bleeding diathesis, e.g., renal failure, liver failure, heparin, Lovenox, Coumadin.

EXCLUSION BY CT SCANG ICHinCT.G Obvious diffuse hypodensity > than 1 /3ra of MCA territory.

EXCLUSION BY LABSG Platelet count < 100,000 / mm3

G PT>15.G INR> than 1.5 to 2 times normal.G Elevated PTTG Renal failureG Qluoooo -< 00 or >- 400

*Consider IA Therapy if CVA < 6 hours and contraindications to IVrTPA exist confer with stroke attending.


TEMPLE UNIVERSITY HOSPITALr-TPA ALTEPLASE / ACTIVASE FOR STROKE

PatientWeight inKilograms

3032343638404244464850525456586062646668707274767880828486889092949698

100>100

PatientWeight InPounds

6670757984889297

101106110114119123128132136141145150154158163167172176180185189194198202207211216220

>220

ReconstituteWith tpA Diluent (SWFI)

Vial Size

50 ml in 50 ma vial50 ml in 50 ma vial50 ml in 50 mq vial50 ml in 50 mq vial50 ml in 50 mq vial50 ml in 50 mq vial50 ml in 50 mg vial50 ml in 50 mq vial50 ml in 50 mg vial50 ml in 50 ma vial50 ml in 50 ma vial50 ml in 50 mq vial50 ml in 50 ma vial1 00 ml in 1 00 ma vial1 00 ml in 1 00 ma vial100 ml in 100 mq vial100 ml in 100 mq vial100 ml in 100 mq vial100 ml in 100 mq vial100 ml in 100 ma vial100 ml in 100 mq vial100 ml in 100 mq vial100 ml in 100 mq vial1 00 ml in 1 00 mq vial100 ml in 100 mq vial100 ml in 100 mq vial100 ml in 100 mq vial100 ml in 100 mg vial100 ml in 100 mq vial100 ml in 100 mq vial100 ml in 100 mq vial100 ml in 100 mq vial100 ml in 100 ma vial100 ml in 100 mq vial100 ml in 100 mq vial100 ml in 100 mq vial100 ml in 100 mg vial

Withdraw andAdminister0.09 mg / kg

Over 1 to 2 MinutesBolus MLS

2.72.93.13.23.43.63.84.04.14.34.5474.95.05.25.45.65.85.96.16.36.56.76.87.07.27.47.67.77.98.18.38.58.68.89.0

9

Withdrawand Discard

Excess

Discard

23.021.219.417.615.814.012.210.48.66.85.03.21.4

49.647.846.044.242.440.638.837.035.233.431.629.828.026.224.422.620.819.017.215.413.611.810.010.0

Infuse Over 1 Hour0.81 mg / kgOverl HourInfusion MLSOver 1 Hour

24.325.927.529.230.832.434.035.637.338.940.542.143.745447.048.650.251.853.555.156.758359.961.663.264.866.468069.771.372974.576.177.879.481.0

81

0.9 mg / kgTotal Dose

Bolus+ Infusion

27.028,830.632.434.236.037.839.641.443.245.046.848.650.452.254.055.857.659.461.2

_ 63.0_ 64.8

66.668.470.272.073.875.677.479.281.082.884.686.488.290.0

90

RECONSTITUTION: DO NOT SHAKE ACTIVASE. SWIRL GENTLYTO DISSOLVE.

50 mg Activase Vial: Using a syringe and large bore needle, transfer 50 mL of t-PA diluent (SWFI) into 50 mg Activase vial. DO NOTshake. Withdraw the required bolus dose to administer to patient over 1 to 2 minutes. Withdraw and discard excess Alteplase. SpikeActivase vial with administration set. Administer infusion at correct flow rate over one hour.

100 mg Activase Vial: Using the transfer pin, or syringe with large bore needle, transfer 100 ml of t-PA diluent (SWFI) into 100 mgActivase viaL Remove one of the spike covers and spike the diluent. Remove the other spike cover and push the 100 ml Activase vialdown on to the upwardly pointing spike. Turn the vials upside down to allow the diluent to run into the Activase vial. Discard the emptydiluent vial and spike. Withdraw the required bolus dose to administer to patient over 1 to 2 minutes Withdraw and discard excessAlteplase. Spike Activase vial with administration set. Administer infusion at correct flow.

KIT-STROKE / PAGE 8 OF 11 (O5/00)


TEMPLE UNIVERSITY HOSPITALr-TPA ADMINISTRATION PROCEDURE

D Give tissue plasminogen activator at mg IV over one minute as a 10% bolus followed immediately by

mg IV by continuous infusion over 60 minutes for total dose of mg.

DOSE CALCULATION:

Choose the smallest of the following two total stroke treatment doses:

n Maximum total dose 90 mg

n Estimate patient weight in kilograms: x 0.9 mg / kg = mg

Total stroke dose = mg, prepared as a 1:1 dilution

10% of total dose. Total dose X 0.1 = mg over 1 to 2 minutes

Total dose mg - bolus mg = mg continuous infusion over 1 hour

D Vital signs and neuro-checks Q 15 minutes for 2 hours after start of r-TPA infusion.

D No heparin, warfarin or aspirin for 24 hours from start of r-TPA infusion.

D Maintain systolic BP < 185 mm Hg and diastolic BP < 110 mm Hg as per protocol.

D Do not put in a line, central line, or any invasive lines for 24 hours after thrombolysis.

D For headache, vomiting, change in mental status, worsening stroke during and after infusion: D/C r-TPA, immediate

non-contrast CT for ICH.

D Transfer to Intensive Care Unit for monitoring.



TEMPLE UNIVERSITY HOSPITALACUTE ISCHEMIC STROKEPOST ADMINISTRATION RESPONSIBILITIES

IZl Monitor vital signs and neurological assessment Q 15 minutes X 2 hours after starting drug infusion; then Q 30

minutes X 6 hours; then Q 60 minutes until 24 hours post-infusion.

O Observe for neurological changes and any signs and symptoms of ICH:• Changes in LOG

• Sudden marked changes in vital signs

•N/V

• Diaphoresis

• Headache

• Pupillary changes

n Observe for any signs of adverse drug reaction:

• Gingival oozing

• Ecchymosis

• Petechiae

• Abdominal and/or flank pain

• Arrhythmias

• Hemoptysis

• Hematemesis

•SOB

D Assess IV / arterial puncture sites, urine color, and other signs of bleeding.

D No IM injections, ABGs, foley catheters, NOT insertions, and other types of procedural punctures post-TPA

administration.

D Monitor extremities and skin for color, temperature, and sensation.


Documents

Temple University Hospital - pnett.orgpnett.org/strokepacket.pdfCancel CTP / CTA if non-con CT positive for hypertensive ICH, tumor. Call Attending NeiiroIR as CTP started (on-call