Stroke Thrombolysis CUH

Haemorrhage

May occur with or without thrombolysis. rt-PA is rapidly cleared from the plasma. Fibrinogen is depleted in the first few hours (<40% at 4 hours) but is back to 80% of normal level by 24 hours. Bleeding after 36 hours is rarely due to rt-PA.

Suspect Intracranial Haemorrhage if:

• Headache
• Nausea and vomiting
• Fall in GCS
• New focal neurological signs
• Acute hypertension

Action:

• Discontinue rt-PA infusion
• Call for immediate medical review
• Full Medical and Neurological reassessment with documentation of new neurological deficit
• Check fibrinogen (if thrombolysed), PT, APTT, FBC, group and save
• Arrange urgent CT head scan
• Inform relevant consultant on call for stroke

If Bleed Confirmed:

• Discuss with consultant on call for stroke (±Consultant Haematologist on-call and Neurosurgery if appropriate)
• If thrombolysed consider treatment with:
  • Fibrinogen 3-4 grams IV (aim for fibrinogen levels > 1.5 g/L); 4 grams of fibrinogen will elevate plasma fibrinogen by 1g/L
  • Or fresh frozen plasma 15mls/Kg; 1300 mls of FFP is equivalent to approx. 3 grams of fibrinogen
  • Platelets 2 pools (for platelet dysfunction and not thrombocytopaenia, as rt-PA can impair platelet function.)

Extracerebral Bleed Post Thrombolysis

• Discontinue rt-PA infusion
• Perform full set of observations
• O₂ 15 litres via non re-breathing mask
• Raise foot of bed if SBP>100 mmHg
• Immediate medical review (shock)
• Direct compression if possible
• IV canullae (large x2) FBC, U+E, PT, APTT, fibrinogen, group and crossmatch
• Transfuse as necessary
• Involve surgical team for haemostasis if appropriate

Anaphylaxis during thrombolysis

Suspect if:

• Rapid fall in BP
• Urticarial rash
• Angioedema, swelling of tongue or around mouth / lips
• New wheezing or breathlessness

Action:

• Discontinue rt-PA infusion
• Assess and protect Airway
• Adrenaline IM
• O₂
• IV volume replacement
• ± Hydrocortisone / Chlorpheniramine IV

Orolingual Angioedema

Is usually mild and transient and rarely causes airway compromise unlike anaphylaxis.

If there are no other signs of angioedema or anaphylaxis it would be reasonable to continue the rt-PA infusion

More on Angioedema

Pyrexia

• Cooling measures
• Give paracetamol 1g if >37.5 C
• Ask for medical review if persists or >38C
• Septic screen

Rapid fall in BP to <100 systolic

• Ensure accurate reading (caution in AF)
• Check manually if in doubt
• Raise foot of bed
• Administer 24% O₂ even if normal sats
• Medical review
• Consider drug effects and may need IV 0.9% saline
• Consider pressor agents

A drop in blood pressure will reduce flow to the penumbral regions. Aim for MAP > 130 mmHg in hypertensive patients and 110 in normotensive patients in the first 24 hours.

Rise in Blood Pressure

• More on BP in stroke
• Aim to keep SBP <220 or DBP <120 mmHg in all patients with stroke
• Aim for a BP of >180/105 for patients who are receiving or have received thrombolysis
• Repeat and monitor every 15 minutes
• Check if any underlying cause such as distress, pain, urinary retention
• If persists on 2 occasions, ask for medical review
• Labetalol – give IV in 2mg doses, checking BP after each dose initially
• 10mg can be given IV over 1-2 mins
• May repeat or double every 10 mins to max of 300 mg; or give initial dose then infusion at 2-8 mg/min
• Aim for only 10-15% reduction in BP
• DO NOT use rapid acting Ca++ antagonists or short acting ACE inhibitors such as captopril
• More on BP in stroke

Acute Ischaemic Stroke Care

Schedule of observations from admission

1. Pulse, BP, O₂ Sats, T° &GCS every 15 min for first hour every hour for 4 hours every 4 hours for 24 hours
2. POST rt-PA: every 15 minutes for first hour every 30 minutes x 6 hours every hour x 17 hours
3. Capillary glucose: Measure on admission and - 4 hourly if abnormal or diabetic - 12 hourly if normal and nondiabetic
4. ECG: Continuous for 24 hours

General Management Post Stroke

• Bed rest for 24 hours (may not be essential if patient very stable)
• Pulse oximetry - maintain O₂ Sats > 95%
• Maintain normal temperature. Paracetamol if temp >37.5 C
• Blood Glucose: maintain blood glucose < 10 mmol/l using IV insulin if necessary
• No arterial punctures, IM injections, NG tubes or central lines for 24 hours
• No urinary catheters for at least 1 hour after infusion ended
• Avoid suctioning whenever possible, caution giving mouthcare
• Repeat CT head at 24-36 hours
• No Aspirin, Clopidogrel, Dipyridamole or anticoagulant (heparin, low molecular weight heparin or warfarin) for 24 hours post thrombolysis until repeat CT performed
• Hydration / Nutrition
• Falls prevention and pressure area care

Admission policy

• 1a if possible for all stroke patients >65
• Admission to 1a obs or CCU post thrombolysis
• Remain in resus post thrombolysis until appropriate ward bed available

Indications for urgent repeat CT Scan

• New acute headache or worsening severity of headache
• Acute hypertension
• Nausea and vomiting
• Agitation
• Seizure

Neurological deterioration is significant if there is:

• A deterioration of >2 points on GCS
• A drop in the NIHSS >4 points
• Any potential motor signs on the opposite side to the patient‘s initial presenting weakness