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Inclusion

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Inclusion

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    1. Inclusion/exclusion criteria and decision making on thrombolysis treatment in stroke. Dr Anthony Pereira Department of Neurology St George’s Hospital

    2. How good is thrombolysis? Therefore, for every 20 patients treated, 1 extra will be cured (Rankin 0) 1 extra will do very well (Rankin 1)

    3. Decision 1: is the diagnosis stroke? Validation of GP diagnosis was confirmed in 44 cases (85%) Validation of A&E diagnosis was confirmed in 169 patients (91%)

    4. Decision 2: time is of the essence

    5. Decision 3: is the scan normal?

    6. Next Day

    7. Or haemorrhage

    8. Decision 4: are we going to harm them? Age under 18 or 80 years Yes No Symptoms more than 3 hours ago? Yes No Time of symptom onset is unknown? Yes No Neurological deficit minor/rapidly resolving? Yes No Very severe stroke (e.g. NIHS>25)? Yes No Was there any seizure activity at stroke onset? Yes No Is subarachnoid haemorrhage suspected? Yes No Is there any evidence of active internal bleeding? Yes No Stroke or head trauma in the past 3 months? Yes No Prior stroke and concomitant diabetes? Yes No Intracranial haemorrhage ever? Yes No History of CNS damage (neoplasm, aneurysm)? Yes No Any intracranial or spinal surgery ever? Yes No Any major surgery or trauma (3 months)? Yes No Arteriovenous malformation or aneurysm? Yes No Known haemorrhagic diathesis? Yes No GI or urinary tract bleeding (3 months)? Yes No GI ulcer disease (3 months)? Yes No Oesophageal varices? Yes No Severe liver disease? (failure, cirrhosis, hepatitis) Yes No Endocarditis or pericarditis? (current) Yes No Pancreatitis? Yes No Pregnant or recent delivery (10days)? Yes No Non-compressible vessel puncture (10 days)? Yes No Lumbar puncture in the last 7 days? Yes No Recent CPR (10 days)? Yes No History of haemorrhagic diabetic retinopathy? Yes No Receiving oral anticoagulants, e.g. warfarin? Yes No Heparin within 48 hours and APPT high? Yes No Blood pressure limits >185/110 (either)? Yes No or IV medication needed to reduce BP to these limits? Yes No Platelet count below 100,000/mm3 Yes No Blood glucose <50 or >400 mg/dl? Yes No rtPA must not be given if the answer to any of these questions is YES

    9. Contraindications: bleeding Is subarachnoid haemorrhage suspected? Yes No Is there any evidence of active internal bleeding? Yes No Intracranial haemorrhage ever? Yes No Arteriovenous malformation or aneurysm? Yes No Known haemorrhagic diathesis? Yes No GI or urinary tract bleeding (3 months)? Yes No GI ulcer disease (3 months)? Yes No Oesophageal varices? Yes No Non-compressible vessel puncture (10 days)? Yes No History of haemorrhagic diabetic retinopathy? Yes No Receiving oral anticoagulants, e.g. warfarin? Yes No Heparin within 48 hours and APPT high? Yes No Platelet count below 100,000/mm3 Yes No

    10. Contraindications: surgery/trauma Stroke or head trauma in the past 3 months? Yes No Was there any seizure activity at stroke onset? Yes No History of CNS damage (neoplasm, aneurysm)? Yes No Any intracranial or spinal surgery ever? Yes No Any major surgery or trauma (3 months)? Yes No Severe liver disease? (failure, cirrhosis, hepatitis) Yes No Non-compressible vessel puncture (10 days)? Yes No Lumbar puncture in the last 7 days? Yes No Recent CPR (10 days)? Yes No

    11. Contraindications: serious disease Was there any seizure activity at stroke onset? Yes No Severe liver disease? (failure, cirrhosis, hepatitis) Yes No Endocarditis or pericarditis? (current) Yes No Pancreatitis? Yes No Pregnant or recent delivery (10days)? Yes No Blood glucose <50 or >400 mg/dl? Yes No

    12. Silly Contraindications Age under 18 or 80 years Yes No Very severe stroke (e.g. NIHSS>25)? Yes No Prior stroke and concomitant diabetes? Yes No Haemorrhagic diabetic retinopathy? Yes No Receiving oral anticoagulants, e.g. warfarin? Yes No IV BP medication needed? Yes No Blood glucose <50 or >400 mg/dl? Yes No

    13. Contraindications Age under 18 or 80 years Yes No Symptoms more than 4˝ hours ago? Yes No Time of symptom onset is unknown? Yes No Deficit minor/rapidly resolving? Yes No Active bleeding? Yes No Trauma in the past 3 months? Yes No CNS damage? Yes No Anticoagulated? Yes No Blood pressure limits >185/110 (either)? Yes No

    14. Protocol violators in ECASS 3

    15. Protocol violators in ECASS 3

    16. Protocol violators in ECASS 3

    17. ADVICE Diagnose the stroke. Time must be under 4 ˝ hours Check the scan is normal. Check there are no contraindications. If you come to a contraindication, STOP. Think it through. Is it strong enough to stop the process dead? Is there a compelling argument to set it aside and continue? Take a moment to stand back and think. Administer tPA.

    18. THE END

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