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Stroke Reperfusion Therapy: Pre-Thrombolysis Phase

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Activate the Stroke Team

Activate the Stroke Team: ED2CT Group page

ED Triage Nurse Responsibilities

  • Identifies patients with symptoms of acute stroke based on clinical presentation or entry notification from prehospital EMS personnel
  • If the patient was last seen normal (or at baseline level of functioning) < 12 hours before ED arrival, send patient directly to Acute
  • Notify Acute Team via "all-call" on cell phone

Primary Nurse in Acute

  • Undress patient
  • Document vital signs every 15 minutes
  • Place IV (preferably 18 gauge, preferably right sided antecubital), saline lock
  • Check O2 saturation - deliver oxygen as needed to maintain O2 sat > 94%
  • Send orders for labs as follows:
    • CBC
    • Blood bank type & screen
    • PT/PTT/INR
    • Chem 8
    • Troponin
  • Perform POCT Glucometry
  • Immediately prepare for patient to travel to CT with portable monitor
  • Travel with patient to CT (bring IV t-PA, Stroke Kit and large volume pump to CT )
  • Document hourly neurologic reassessment (more frequently if changes occur)
  • Maintain strictly NPO (including meds) until swallowing screen performed and passed
  • Anticipate order for IV t-PA to be started in CT
  • Do not insert NG tube or Foley Catheter unless ordered by MD

ED Physician Responsibilities

  • As soon as information is available for Acute Stroke patient, send ED2CT Group page. Include as much information as available at the time including time LSW, patient name, location.
    • Note: ED2CT recipients include:
      • ED neurology resident
      • Acute Stroke Fellow
      • Neuroradiology Fellow
      • ED CT technologist
      • ED MR technologist
      • ED Radiology Service Representative (RSR)
      • ED Pharmacy
      • OR resource nurse
      • ASQT
      • Stroke research team
  • Rapid evaluation of patient for ABC’s to assess medical stability.
  • Brief neurologic examination
  • Write Orders for CT, CTA, MRI & Labs
  • Review treatment plan with Acute Stroke Team and any potential contraindications

Neurologist Responsibilities (includes Resident, Fellow, or Attending):

  • Respond as soon as possible to patient bedside
  • Examine patient, document NIHSS, establish time of onset, review indications/contraindications/warnings for IV t-PA and document reasons for non-treatment if appropriate
  • Review non-contrast CT with radiologist and be prepared to start IV t-PA in the CT suite if the NCCT does not demonstrate a contraindication and the diagnosis of acute ischemic stroke is considered highly likely. Do not delay initiation of t-PA for further imaging (e.g. CTA or MRI) unless diagnosis of stroke is unlikely or uncertain and further imaging is required to confirm appropriateness of treatmentDiscuss risks and benefits of t-PA and other treatment options with family/patient from standard t-PA information sheet and obtain written consent when appropriate at the discretion of the treating physician. If patient is an endovascular candidate then introduce the concept to the family.
  • Screen for indications for catheter-based reperfusion. If indications are present, page the Neuroendovascular fellow immediately. In a transfer patient with suspected eligibility for intra-arterial intervention, the Neuroendovascular fellow should be alerted by page prior to the patient’s arrival.
  • Management of blood pressure in acute stroke:
    • If IV t-PA eligible, then manage BP to achieve SBP/DBP less than 185/110 (see algorithm)
    • If not eligible, then looser BP guidelines apply and caution should be exercised when lowering BP (see algorithm)

Radiologist Responsibilities:

  • Respond within 5 minutes to patient bedside.
  • Call CT to determine if a scanner is available or how soon a scanner will be available, and communicate this information to the ED and Neurology teams.
  • Discuss imaging plan with ED and Neurology teams.
  • Accompany the patient to the Radiology area, and confirm with the RSR that the CT exam has been scheduled while the patient is being moved onto the scanner.
  • Provide immediate interpretation of CT images.
  • Supervise the administration of IV contrast for CTA, if performed.

Radiology CT Technologist Responsibilities:

  • Upon receiving an ED2CT page, hold a CT scanner open until instructed otherwise by the neuroradiologist. If both scanners are occupied, finish one scan and then clear the scanner immediately.
  • Facilitate the immediate access of acute stroke patients into the scanner
  • Assist in obtaining IV access for contrast if none present
  • Execute the standard acute stroke CT/CTA protocols in collaboration under the supervision of the neuroradiologist. Intravenous contrast may be injected even if serum creatinine measurement is unavailable, or higher than usual MGH guidelines, if and only if medical necessity is declared by the neurologist, and confirmed by the neuroradiologist.

See also Intra-arterial / Catheter-based Therapy

Authoring Information

Reviewed/Approved by: Rost, Natalia, M.D., M.P.H. on behalf of ASQT

Last updated: 1/16/2015

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In the News

The MGH Neurology Department placed 4th in US News Neurology / NeuroSurgery rankings for 2013-14.

Educational Video

Still from the Stroke Evaluation simulation

This video simulation of an Emergency stroke evaluation illustrates the care of patients with acute stroke by the MGH Acute Stroke team.