1. Administering Thrombolysis Early Management
Angela Roots
Stroke Practice Facilitator

2. What have we learnt so far?

3. What we have learnt so far...
Why thrombolyse
Inclusion/exclusion
Family
Medical history/pre-morbid state
LAS
decision making
Assessment (NIHSS)
Scans
Time

5. On arrival LAS phone ahead Bleep system activated
Stroke team waiting in ED
History from LAS & family
Admit patient, portable monitoring, CT Scan

6. What next? Consent IV access Observations Pre-empting risk Dose
Administration
Communication

7. Consent Up to 4.5 hours Post 4.5 hours
Pt aphasic / confused / mental health problems
Family disagrees
What would you do??

8. IV access 2 cannulas Minimise and monitor puncture sites
Ask for assistance after 3 failed attempts

9. Observations hypertensive
If DBP>110mmHg or SBP >180 mmHg:
IV labetalol mg over 1 minute, repeated after 10 minutes till response
Max. total dose 300 mg/24 hours (HR>60bpm)
IV GTN (0.5-10mg/hour) and use same target parameters
What is your local policy?

10. Observations hypertensive
Higher risk of bleed
Avoid rapid drop in blood pressure
Monitor heart rate
Headache

11. Observations Blood Sugar levels INR ?cause of neurological deficit
Main laboratory
CoaguCheck

12. Plan ahead, what are the risks?
Bleeding
Puncture sites
Wounds GI
Cathlabs
Deterioration
Anaphylaxis
Overnight cover
Staffing skill mix
Ceiling of care

13. Dose
0.9mg/kg
Weight required
Estimated vs actual
90mg maximum dose

14. Estimate the weight
52kg
89.6kg

15. Dose and administration
10% total dose given as a bolus over 2 minutes then remainder via infusion pump over 1 hour

16. Dose and administration
Keep dose calculation chart handy
Ensure clear prescription of total dose or bolus then infusion to avoid confusion once bolus administered
Avoid double concentration 1mg/1ml

17. Dose and administration
Often need more than 1 vial of drug so 2 syringes to be completed
Monitor for extravasation carefully
Keep check on infusion pump rate during the hour
Ensure the infusion tubing is flushed slowly at completion to ensure the 2ml in the infusion tubing is administered

18. Dose and administration
Before you give the drug;
Stop, stand back, reassess
Signs of improvement?

19. Location
ED Resus area
Bolus in CT scanning department (fully monitored)
HASU ? What do you think?

20. Communication Patient, family, carers Ward
Staffing capacity
Skill mix
Cardiac monitored bed
Bed manager/ site nurse practitioner

21. Yes! Lets go, time is brain!!!
So do you think
we should thrombolyse?
Yes! Lets go, time is brain!!!