Post Thrombolysis Care and Complications Gill Cluckie Clinical lead, stroke Guy’s and St. Thomas’ NHS Foundation Trust

Essential Care 1:1 Nursing for the first 24 hours? Bed Rest for 24 hours? Appropriate equipment at the patients bedside, EG, cardiac monitor, suction, drip stand and pump, oxygen, emergency equipment

Observations Consistent and full neurological observations: - Every 15 mins for 2 hours - half hourly for 6 hours - hourly for 16 hours MRC grading for limb power NIHSS trained staff to identify significant clinical changes

Things to Remember No heparin, warfarin, anti-platelets Swallow assessment Do not pass NG Tube until 24 hours No arterial punctures or central lines Avoid catheterisation. If essential, 30 mins after completion of thrombolysis NO SHAVING!!

Complications Blood Pressure Management Intracranial Haemorrhage Anaphylaxis Extra-Cranial Haemorrhage

Blood Pressure Strict BP control to prevent increased risk of intra-cranial haemorrhage – less than 180/100mmHg If either reading is above limit, recheck in 5 minutes If 3 readings at least 5 minutes apart show BP higher than limit – administer IV labetalol 10-20mg as bolus Do you usually give IV labetalol in your unit?

Intracranial Haemorrhage What are the signs and symptoms? Symptoms: nausea, vomiting, headache, altered limb function Signs: increasing difficulty obtaining same GCS, agitation, drowsiness, drop in GCS, altered limb function, vomiting How would you observe these in a drowsy patient?

Intracranial Haemorrhage Decision on stopping the infusion if still in progress Decision on urgent repeat CT brain to confirm haemorrhage Follow protocols on referral of these patients to neuro-surgeons Decisions on escalation plans or palliative care option

Case Study 1 54 year old man collapsed with left face, arm and leg weakness Drowsy on assessment, clinically had R MCA infarct NIHSS = 12 Thrombolysed within 2 hours of onset

Case study 1 At 14 hours – improved face and leg weakness and less drowsy- NIH had reduced to 7 Went for repeat CT, nurse noticed on way to CT that his left leg had deteriorated Post-CT he was much more drowsy

Case study 1 Needed neurosurgery Died 3 weeks later

Extra-Cranial Haemorrhage What are the signs and symptoms? Symptoms: abdominal pain or discomfort, nausea, obvious bleeding, malena Signs: haematemesis, malena, haemodynamic compromise, pallor, increasing drowsiness, heavy blood loss, tachycardia

Extra-Cranial Haemorrhage Common oozing from cannulation sites, gum bleeding Post-angioplasty – careful management of sheath site, likely to require Fem-stop device to prevent haematoma development GI bleed – management of blood pressure, blood volume, follow protocols for surgical reviews and administering blood products

Extra-Cranial Haemorrhage Ecchymosis Watch the restless patient and cannula sites

Anaphylaxis What are the signs and symptoms to observe for? Symptoms: increased breathlessness, tightness in chest, itch, tingling lips or tongue, tightness in throat, dysphagia Signs: oral oedema, facial oedema, audible wheeze, stridor, desaturation, increased respiratory rate and effort, respiratory arrest

Anaphylaxis Stop infusion if still in progress Administer adrenaline, chlorpheniramine and hydrocortisone as for anaphylaxis Protect airway and maintain adequate oxygenation May require intubation urgently via crash call

Case Study 2 64 yr old female Thrombolysed Arrival at Ward Neuro obs unchanged Cardio obs unchanged Gum bleeding observed WITHIN 5 MINUTES!! CRASH CALL

Case study 2 Tongue, face, eyes swollen No BP fall or tachycardia Difficult Intubation Died in ITU due to secondary cerebral oedema Rate around 0.5-1% Some anecdotes that angio-oedema is more common in patients on ACE inhibitors on admission

Plan Ahead Hand over to on-call teams/hospital at night Staff coverage – appropriate trained people. Have the ability to react quickly and appropriately when you notice a change no matter how little or subtle Think of weekends and nights, drug charts, escalation Never be worried to put out a Crash Call