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Stroke Reperfusion Therapy: IV/IA Pre-treatment Phase

Comments in brackets denote activities specific to MGH, or additional commentary regarding national standards or guidelines. For example:

Activate the Stroke Team

[MGH Beeper 34282]

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ED Triage Nurse Responsibilities

  • Identifies patients with symptoms of acute stroke based on clinical presentation or entry notification from prehospital EMS personnel
  • If the patient was last seen normal (or at baseline level of functioning) < 6 hours before ED arrival, immediately notify the Stroke team
    [Page the Acute Stroke Beeper #34282 with message "Acute stroke, (state patient name), in ED now; (state Trauma attending name)"]
  • Obtain Acute Stroke Protocol packet and review responsibilities as outlined on cover:
    • Document vital signs
    • Document time patient last seen well
    • Specifically assess for exclusion criteria for t-PA as outlined on packet cover including:
      • Past medical/surgical history
      • Allergies
      • Medications (if on Coumadin or aspirin, note time of last dose)
  • Send to Trauma/Acute and notify ED Attending

Coordinator in Trauma/Acute

  • Notify Neurology Resident on call for ED and immediately page Acute Stroke Team if not already notified by Triage RN
    [Neurology Resident pager #20000]
    [Quick register patient]

Primary Nurse in Trauma/Acute

  • Acquire 12-lead ECG and immediately prepare for patient to travel to CT with portable monitor and oxygen
  • Document vital signs every 15 minutes
  • Place IV (preferably 18 gauge, preferably right sided antecubital), saline lock
  • Check O2 saturation - deliver oxygen as needed to maintain O2 sat > 92%
  • Send orders for labs as follows:
    • CBC, platelets, ESR
    • Blood bank specimen for type & screen
    • PT/PTT/INR
    • Na/K/Cl/CO2/BUN/Cr/Glucose
    • SGOT, SGPT, alk phos
    • CPK, troponin
    • If the patient's age is < 55 years, add hypercoagulation screen
  • Travel with patient to CT (bring IV tPA to CT if indicated and ordered)
  • Document hourly neurologic reassessment (more frequently if changes occur)
  • Maintain strictly NPO (including meds) until swallowing screen performed and passed
  • Anticipate order for IV tPA to be started in CT
  • Do not insert NG tube or foley unless ordered by MD

ED Physician Responsibilities

  • Ensure that Stroke Team has been paged
  • Notify CT of Acute Stroke Patient for urgent CT/CTA
    [Phone: 726-6760]
  • If accepting request for transfer of acute stroke patient, inform the referring facility that the Stroke Team will contact them and immediately page the Acute Stroke Team
    [Pager #34282 with message, "Acute stroke (state name of patient) at (state name of referring facility and telephone number), (state ED attending name)."]
  • Rapid evaluation of patient to rule out acute MI, aortic dissection, other co-morbid condition or non-stroke etiology (i.e., stroke mimic) and medical contraindications to tPA. Identify severity of neurologic deficit and potential contraindications to IV tPA.
  • Obtain CXR before Brain CT only if clinically indicated for respiratory compromise or to exclude underlying aortic or cardiac injury
  • Unless airway compromise requires immediate need for intubation, facilitate rapid assessment of NIH Stroke Scale by Stroke Team prior to intubation
  • Review treatment plan with Acute Stroke Team and any potential contraindications

Neurologist Responsibilities (includes resident, fellow, or attending):

  • Respond within 5 minutes to Acute Stroke Pager contact
  • Examine patient, document NIHSS, establish time of onset, review indications/contraindications/warnings for IV tPA and document reasons for non-treatment if appropriate
  • Review non-contrast CT with radiologist and order CTA-CTP unless contraindicated. Be prepared to start IV tPA in the CT suite if the NCCT does not demonstrate a contraindication and the diagnosis of acute ischemic stroke is considered highly likely. Do not delay initiation of tPA for further imaging (e.g. MRI) unless diagnosis of stroke is unlikely or uncertain and MR is required to confirm appropriateness of treatment
  • Discuss risks and benefits of tPA and other treatment options with family/patient from standard tPA information sheet and obtain written consent when appropriate at the discretion of the treating physician.
  • Consider indications for catheter-based reperfusion.
  • Management of blood pressure
    Determine if eligible for IV t-PA:
    • If IV t-PA eligible, then manage BP to achieve SBP/DBP less than 185/110 (see algorithm)
    • If not eligible, then looser BP guidelines apply and caution should be exercised when lowering BP (see algorithm).

Radiologist Responsibilities:

  • Report to CT immediately upon start of non-contrast CT, and provide immediate interpretation upon completion of imaging.
  • Supervise the administration of IV contrast for CTA/CTP.
  • Provide immediate access to the 64 slice CT scanner for any acute stroke patient who is a thrombolysis candidate, including removing a patient from the scanner if necessary.

Radiology Technologist Responsibilities:

  • Facilitate the immediate access of acute stroke patients into the scanner
  • Assist in obtaining IV access for contrast if none present
  • Page the emergency neuroradiologist as soon as notified of the acute stroke patient and upon patient arrival in the scanner area
  • Execute the standard acute stroke CT/CTA protocols in collaboration with the neuroradiologist and Acute Stroke Team

See also IA / Catheter Based Reperfusion: Pre-Thrombolysis Management

Authoring Information

Reviewed/Approved by: Schwamm, Lee, M.D. on behalf of ASQT

Last updated: 12/23/2009

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Educational Video

Still from the Stroke Evaluation simulation

This video simulation of an Emergency stroke evaluation illustrates the care of patients with acute stroke by the MGH Acute Stroke team.