1. Stroke Protocol Time Lost Is Brain Lost!

2. Objective: Improve patient care & outcomes Offer a standard of care Increase efficiency Meet accreditation recommendations To establish a stroke protocol

3. Assessment Define and recognize the signs of stroke. FAST EXAM Positive ? <10minutes from arrival time No Yes CAT SCAN Within < 25 minute from arrival time. Radiologist Reading within 45minutes from arrival Time. Neurology Is there a hemorrhage is present ? Notification of possible stroke Follow up care As needed No Yes Follow up care As needed tPA Candidate? Yes No ICU ? Stroke I will admit you to the ICU. ED attending will decide whether to activate stroke team based on this information. Time Lose = Brain Lose We will assess you while you’re in the ICU and may order other test Like: Labs or a MRI……….. tPA Given Stroke Protocol Flow Chart Images Sent <60 minutes from arrival

4. Assessment Define and recognize the signs of stroke. FAST EXAM Positive? <10 minutes form arrive ED attending will decide whether to activate stroke Protocol based on results of FAST Exam Follow up care As needed No Yes Stage 1 Cat Scan Within <25 minutes from arrival time Active Stroke Protocol via Operator Key Purple Arrow = Staff Communication Blue Arrow = Patient Care/Flow * Do not delay sending the patient to CT scan in order to complete the ECG, or chest x-ray unless specifically requested by physician. Ideally, labs should be drawn prior to going to CT. Operator will Page: CT Department Radiologist Neurology Lab Respiratory

5. Assessment Record time of patient’s Arrival to ED Record time of Fast exam within <10 minutes of arrival time.

6. Cat Scan Within <25 minutes from arrival time Images sent Radiologist Reading within <45minutes from arrival Time. Stage 2 Neurology Is there a hemorrhage present? Fast Exam Positive Yes No Follow up care As needed tPA Candidate?

7. Indications New symptomatic ischemic stroke with clearly defined onset Non-contrast CT showing NO intracranial hemorrhage or well-established acute infarct Patient should be evaluated by an in-house neurology Fellow or Resident

8. Guidelines for Use of Intravenous tPA in Acute Ischemic Stroke Approved FDA use for LESS than 3.0 hours from initial symptoms Off-label use for 3 to 4.5 hours The only FDA approved treatment for ischemic strokes is tissue plasminogen activator (tPA, also known as IV rtPA, given through an IV in the arm ).

9. Contraindications (risks must be weighted against anticipated benefits) Age < 18 CT scan findings (intracranial hemorrhage, or major acute infarct signs) Suspicion of subarachnoid hemorrhage (even if head CT is negative for hemorrhage) Recent (within 3 months) major surgery or trauma (discuss with Attending) History of intracranial hemorrhage or brain aneurysm or vascular malformation or brain tumor (May consider IV tPA in patients with CNS lesions that have a very low likelihood of hemorrhage, such as small unruptured aneurysms or benign tumors with low vascularity) Known bleeding diathesis  Current use of oral anticoagulants with INR > 1.7 or PT > 15 seconds  Use of heparin within 48 hours preceding onset of stroke AND prolonged aPTT at time of presentation  Platelets <100,000  Internal hemorrhage (GI hemorrhage, urinary tract hemorrhage) < 3 weeks  Dabigatran use in the past 48 hours (if last dose >48 hours, confirm normal renal function [creatinine clearance >50 mL/min] and normal coagulation [aPTT, INR, platelet count] before tPA administration).  Low molecular weight heparin use (i.e.- Lovenox) in the past 24 hours.  Persistent systolic BP >185 mm Hg or diastolic BP >110 mm Hg despite treatment.

10. tPA Candidate? tPA Given ICU I will admit you to the ICU. YES No Follow up care As needed We will assess you while you’re in the ICU and may order other test Like: Labs or a MRI……. Stage 3 <60 minutes from Arrival

11. - Estimated Weight (lbs) Conversion to Kilograms (Kg) Total iv t-PA Dose (mg) at 0.9 mg/kg t-PA Bolus (mg) *10% of total* t-PA Bolus (ml) Discard Dose t- PA (Not for infusion) Infusion Dose (mg) Infusion Rate (ml/hr) 220+100.090.09.0 10.081.0 21095.585.98.6 14.177.3 20090.981.88.2 18.273.6 19086.477.77.8 22.370.0 18081.873.67.4 26.466.3 17077.369.57.0 30.562.6 16072.765.56.5 34.558.9 15068.261.46.1 38.655.2 14063.657.35.7 42.751.5 13059.153.25.3 46.847.9 12054.549.14.9 50.944.2 11050.045.04.5 55.040.5 10045.540.94.1 59.136.8 tPA Dose Chart

12. Administration  The stroke fellow may utilize a phone consultation with the stroke attending prior to administering IV tPA  Administer tPA in monitored setting (unit bed or emergency room)  Mix two 50 mg tPA vials with 50 mL normal saline each --> one mL solution contains one mg tPA for a total of 100mg in 100mL of solution.  Estimate total body weight (if not measured on admission)  Calculate TOTAL tPA DOSE: 0.9 mg per kg (not to exceed 90 mg total dose) - Give 10% as IV bolus - Give other 90% as IV infusion over 60 minutes  Vital signs and neuro checks at least every 15 min for first 2 hours (including NIHSS scores- document in SCM note).  Treat systolic BP if it rises to >180 mm Hg or diastolic BP >105 mm Hg for more than 15 minutes  Avoid BP decrease <160/ 85 mm Hg

13. Assessment Define and recognize the signs of stroke. FAST EXAM Positive? <10 minutes form arrival Follow up care As needed Cat Scan Within <25 minutes from Arrival Images Sent Radiologist Reading within <45minutes from arrival time. Neurology Is there a hemorrhage present? Follow up care As needed tPA Candidate? tPA Given < 60 minutes from Arrival ICU YES NO YES NO YES

14. The Clock is Ticking Time Lost Is Brain Lost! tPA is on the way!

15. References Pöder, U., Dahm, M. F., Karlsson, N., & Wadensten, B. (2015). Standardised care plans for in hospital stroke care improve documentation of health care assessments. Journal Of Clinical Nursing, 24(19/20), 2788-2796. doi:10.1111/jocn.12874 Read, S. J., & Levy, J. (2006). Effects of care pathways on stroke care practices at regional hospitals. Internal Medicine Journal, 36(10), 638-642. doi:10.1111/j.1445-5994.2006.01147.x Rymer, M. M., Anderson, C. S., Harada, M., Jarosz, J., Ma, N., Rowley, H. A., &... Bornstein, N. M. (2014). Stroke service: How can we improve and measure outcomes? Consensus summary from a global stroke forum. Acta Neurologica Scandinavica, 130(2), 73-80. doi:10.1111/ane.12256