Hyper acute stroke management guidance

Hyper acute stroke proforma.

NIHSS proforma.

Where cut-offs are given, judgement should be exercised if a patient falls close to the cut-off.

Please ensure that this list is considered at the time of first assessment, even if this assessment is by phone:

• Symptoms beginning more than 4 ½ hours prior to infusion
• Known history of or suggested intracranial haemorrhage
• Symptoms suggestive of subarachnoid haemorrhage, even if CT-scan is normal
• Evidence of intracranial haemorrhage (ICH) on the CT-scan
• Manifest or recent severe or dangerous bleeding
• Known Haemorrhagic diathesis
• Systolic blood pressure >185 or diastolic BP >110mm hg and unable to get below this threshold within 4.5 hours of symptom onset

• Time of symptom onset is unknown.
• Patients receiving oral anticoagulants, e.g. warfarin sodium (unless INR below 1.7).
• Administration of IV heparin within the previous 48 hours AND APTT exceeding the upper limit of normal.
• Treatment dose LMWH.
• Any history of central nervous system damage (i.e. neoplasm, aneurysm, intracranial or spinal surgery).
• Recent (less than 10 days) traumatic external heart massage, obstetric delivery.
• Recent (less than 10 days) puncture of a non-compressible blood-vessel (e.g. subclavian vein).
• Bacterial endocarditis, pericarditis.
• Acute pancreatitis.
• Documented ulcerative gastrointestinal disease during the last 3 months, oesophageal varices, aterial-aneurysm, arterial/venous malformations.
• Neoplasm with increased bleeding risk.
• Severe liver disease, including hepatic failure, cirrhosis, portal hypertension (oesophageal varices) and active hepatitis.
• Major surgery or significant trauma in past 3 months.
• Minor neurological deficit (e.g. NIHSS 4 or less) or symptoms rapidly improving before start of infusion (NB. dysphasia and homonymous hemianopia are worth treating).
• Severe stroke as assessed clinically (e.g. NIHS above 25) and/or by appropriate imaging techniques.
• Pre-presentation Rankin Score 4 or above indicating significant disability, especially if due to previous stroke.
• Seizure at onset of stroke.
• Patients with any history of prior stroke and concomitant diabetes.
• Prior stroke within the last 3 months.
• Platelet count of below 100,000/mm3.
• Uncorrected blood glucose  below 2.8 or above 22 mmol/L.

NB. This is a stroke outcome scale and should be interpreted with caution for causes of disability other than stroke.

Score    Description

0           No symptoms at all

1           No significant disability despite symptoms; able to carry out all usual duties and activities

2           Slight disability; requiring some help but able to walk without assistance

3           Moderate disability; requiring some help, but able to walk without assistance

4           Moderately severe disability; unable to walk without assistance and unable to attend to own bodily needs without assistance

5           Severe disability; bedridden, incontinent and require constant nursing care and attention

6           Dead

Two consecutive BP readings 10 minutes apart must demonstrate SBP or DBP above the relevant thresholds.

In ischemic stroke eligible for thrombolysis:

• Timescale:Before thrombolysis and for 24 hours afterwards.
• Threshold: SBP over 185 or DBP over 110.
• Target: SBP under 180 or DBP under 105 as soon as possible for the first 24 hours

IV labetalol:

• Contraindicated in asthma, uncontrolled heart failure, severe bradycardia under 50bpm and following acute MI.
• The standard preparation is labetalol hydrochloride 100mg/20ml solution for injection ampoules. Withdraw dose required from 100 mg in 20 ml ampoules. Do not dilute.
• The maximum effect usually occurs within 5 min and the duration of action is usually about 6 hours, but may be as long as 18 hours.

Administration: 

1. Initially give labetalol 10mg IV over 1-2 minutes.
2. After 10 minutes Labetalol 20mg IV over 1-2 minutes can be given.
3. Repeat boluses of Labetalol 20mg IV over 1-2 minutes can be given every 10 minutes up to a maximum of 200mg.
4. Check for other contributing factors such as urinary retention and pain.

Patients must be continuously monitored prior to and during drug administration and for at least 24 hours following administration.

1. Total dose: 0.9mg/kg based on actual or estimated body weight. Maximum dose is 90mg.
2. Must be prescribed on front sheet of protocol.
3. Reconstitute 50mg Alteplase vial(s) with 50mls of water for injection (and 20mg vials with 20ml water) via transfer spike (inserted into water first) to give a solution with concentration 1mg/ml.
4. Initial 10% of total dose given as an IV manual push over 2 minutes administered with an experienced doctor present.
5. Commence pump immediately after initial bolus. Give remaining 90% of dose IV over 60 minutes via an infusion pump.
6. In patients over 100kg use 90 mg maximum (9 bolus and 81 infusion).