Stroke - Adverse Events



Adverse events (in acute ischaemic stroke)

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 thrombolysis.

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, O2
  • Adrenaline IM (0.5mg in an adult)
  • 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

Unexpected ↓GCS or ↑Drowsiness

  • Check & document O2 sats, Pulse, Temp, BP, glucose
  • Ask for medical review
  • Consider:
    • Intracereberal haemorrhage
    • Seizure, sepsis, dehydration
    • Drug reaction, CCF, dysrhythmia
    • MI, DVT/PE, metabolic derangement
    • Urinary retention

Hypoxia (O2 Sats <95%)

  • Check airway
  • Reposition & suction only if clearly necessary
  • Give O2 mask or nasal cannulae (titrate to sats 95%)
  • Persistent or needing >24% O2 - ask for medical review
  • ? aspiration, pulmonary oedema, PE etc

Pyrexia

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

Abnormal Capillary Glucose

  • <3.5 give glucose PO (100mls Lucozade)
  • IV dextrose 10% if unable to give orally
  • 3.5 - 4 check again in 10 minutes
  • >10 medical review
  • Consider insulin infusion

Abnormal Heart Rate/Rhythm

  • <50 or >120
  • New irregular pulse
  • Perform 12 lead ECG and ask for medical review

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/TNK: 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

CUH Admission policy

  • Acute stroke units all stroke patients
  • 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


Content by Dr Íomhar O' Sullivan. Last review Dr ÍOS 16/06/24.