Thrombolysis East of England Forum

1. Thrombolysis East of England Forum Diana Day Consultant Nurse for Stroke

2. What is thrombolysis • Clot buster • Lyse (breaks up) clots • Drug is called Alteplase (rt-Pa) • Aim to restore blood supply to the brain in the early hours of stroke

3. Global Good Outcome at Day 90 (mRS 0-1, BI 95-100, NIHS 0-1) (N=2776) SITS database 12/12/2007 http://www.acutestroke.org/index.php

4. 13 16 11 14 20 7 18 RCT placebo mRS 0 mRS 1 mRS 2 RCT active rt-PA 20 22 8 14 12 7 18 mRS 3 mRS 4 mRS 5 mRS 6 19 19,9 15,9 14,7 13,9 5,3 11,4 SITS-MOST 0% 20% 40% 60% 80% 100% Recovered Dead SITS-MOST vs RCTs – mRS 3/12 +10% +4,8% Red colours:independent Blue colours:dependent Black colour: dead Lancet 2007; 369: 275-282.

5. Time is brain • Around1.9 million neurons lost a minute

6. Time to treat Max 4.5 hours Recognise React Respond Refer Treat Target 2hrs (30-45mins)

7. Act F.A .S.T Recognise /React Respond Journey time 30 – 45mins (60mins review)

8. Refer and Assess Assess • Event history • NIHSS,PMH, meds • Glucose / bloods Pre alert stroke team

9. Treat with thrombolysis?

10. Telemedicine • Providing regional access to stroke expertise out of hours

11. Who can we treat?Inclusion criteria • Clinical S&S of definite acute stroke • Clear time of onset • Presentation within 4.5 hrs of acute onset • Haemorrhage excluded by CT scan • Age 18 and over • NIHSS less than 25 • Consent discussion

12. Exclusion Criteria • Increase bleeding risk • Greater than 4.5hrs • Rapidly improving or minor stroke symptoms • Stroke or serious head injury 3 months • Major surgery, obstetrical delivery, external heart massage last 14 days, • Seizure at onset of stroke • Severe haemorrhage last 21/7 • History of central nervous damage • Hypo / hyper glycaemia • Warfarin (unless INR below 1.5) • BP > 180/110mmHg (and other exclusions)

13. Potential for thrombolysis

14. Conditions • Hyper Acute stroke unit • Under the care of stroke physician /neurologist • Care at level 2 (HDU) • Physiological monitoring • Nurses trained in thrombolysis & acute skills • Protocols & guidelines for care • Access to immediate imaging (24hrs) • Protocols of care

15. Staffing • Nursing 1:1 – whilst thrombolysing • 1:2 – 1:4 first 24-48 hrs of care • Competency based training • NIHSS trained

16. Seizure Migraine Sub /extra dural Tumour MS Hyperglycaemia Non organic Cerebral abscess /infection Unlikely to be stroke Felt funny & shaking Visual disturbance Pins & needles Fluctuating symptoms Mimics

17. Exclude stroke mimics • Vascular event sudden onset • Maximal at onset • Fits within vascular territory

18. Case 1 • 72 yr old gentleman well this morning • Went to his car at 8.30am • Dropped his keys, and fell to the ground • His wife noticed right sided weakness • Unable to talk properly • Rang 999

19. Assessment – 10.02 • He has PMH high blood pressure • He is being investigated for AF • No previous hospital admissions • BP 179/95, P 114, sats 94%, glu 7.8mmols • NIHSS 21 (aphasic, RSW fal, HH)

20. Early CT scan : time 10:23

21. CT Perfusion Cerebral Blood Flow Time to peak

22. Infusion Alteplase • 0.9mg/kg/body weight, up to max of 90mg. • Diluted with sterile water to 1mg/ml • 10% of infusion as bolus • 90% as infusion using syringe pump over 1 hour.

23. Post Thrombolysis

24. Potential complications • Haemorrhage • Intracerebral • Systemic • Reperfusion hypotension • Improvement then deterioration • Nausea / vomiting

25. Haemorrhagic Complications of t-PA 30 mins into infusion he starts talking again, weakness improves Then becomes drowsy GCS 15 -13 Stop infusion Call medical team CT scan Neurosurgical opinion

26. Post CT scan

27. Management of Bleeding Complications • If bleeding is suspected stop infusion of a thrombolytic drug immediately. • Send FBC, APTT, PT/INR, and fibrinogen. • Grouped and matched if transfusions are needed 4 to 6 U of cryoprecipitate or fresh frozen plasma, platelets • These therapies should be made available for urgent administration.

28. Allergic reaction • anaphylactoid reaction, laryngeal oedema, orolingual angioedema, rash, and urticaria • usually respond to conventional therapy – antihistamine and hydrocortison if caught early – otherwise full anaphylaxis protocol • many of these patients received concomitant ACEI therapy • Most cases resolved with prompt treatment; there have been rare fatalities as a result of upper airway haemorrhage from intubation trauma • Other Adverse Reactions Nausea and/or vomiting, hypotension and fever have also been reported – Treat symptoms

29. Patient 2 : Right hemilingual angioedema

30. Time is Brain Impact of thrombolysis Number making full recovery per 100 treated 30 20 10 0 Benefit Harm 0 2 4 6 Time (hours) Saver, Stroke 2006

31. First 24 hours of care • Monitored bed on stroke unit • Thrombolysis pathway • 24-36 hour repeat CT scan • No antiplatelets for 24 hours • No IM injections, catheterisations or invasive procedure unless unavoidable. • Bed rest for 24 hrs • IV access

32. Research areas • Time window (DIAS) • Dose (Enchanted) • Other medications (DIAS III) • Intra arterial (PISTE) • Clot retrieval • Awakening stroke (WAKE UP) • Anticoagulation thrombolysis

33. Summary • Thrombolysis is effective if used within hyperacute unit setting • Time is Brain, rapid treatment improves outcome • There are risks of bleeding can differ between cases • Appropriate place is for all strokes is hyperacute stroke unit • There are outstanding research questions

34. The End Questions?