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    On Admission:: STROKE MANAGEMENT (Beaumont Hospital)

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    Nadia Salwani
    1) Patients admitted with stroke receive immediate CT and CT angiogram to determine eligibility for thrombolysis or thrombectomy. 2) Thrombolysis with rtPA is most effective within 4.5 hours of symptom onset but has contraindications like recent surgery, bleeding risks, or anticoagulant use. 3) Close monitoring is needed after thrombolysis to watch for intracranial bleeding, keeping blood pressure controlled is important for prevention of rebleeding or another stroke.

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    On Admission:: STROKE MANAGEMENT (Beaumont Hospital)

    Uploaded by

    Nadia Salwani
    111 views3 pages
    1) Patients admitted with stroke receive immediate CT and CT angiogram to determine eligibility for thrombolysis or thrombectomy. 2) Thrombolysis with rtPA is most effective within 4.5 hours of symptom onset but has contraindications like recent surgery, bleeding risks, or anticoagulant use. 3) Close monitoring is needed after thrombolysis to watch for intracranial bleeding, keeping blood pressure controlled is important for prevention of rebleeding or another stroke.

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    Stroke Management

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    1) Patients admitted with stroke receive immediate CT and CT angiogram to determine eligibility for thrombolysis or thrombectomy. 2) Thrombolysis with rtPA is most effective within 4.5 hours of symptom onset but has contraindications like recent surgery, bleeding risks, or anticoagulant use. 3) Close monitoring is needed after thrombolysis to watch for intracranial bleeding, keeping blood pressure controlled is important for prevention of rebleeding or another stroke.

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    Download as docx, pdf, or txt
    111 views3 pages

    On Admission:: STROKE MANAGEMENT (Beaumont Hospital)

    Uploaded by

    Nadia Salwani
    1) Patients admitted with stroke receive immediate CT and CT angiogram to determine eligibility for thrombolysis or thrombectomy. 2) Thrombolysis with rtPA is most effective within 4.5 hours of symptom onset but has contraindications like recent surgery, bleeding risks, or anticoagulant use. 3) Close monitoring is needed after thrombolysis to watch for intracranial bleeding, keeping blood pressure controlled is important for prevention of rebleeding or another stroke.

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    of 3

    STROKE MANAGEMENT (Beaumont Hospital)

    On Admission:
    1) Focused history and examination
    2) Immediate urgent non-contrast CT + CT angiogram immediately after non-
    contrast CT* (usually done straight away in Beaumont!)
    3) Calculate the NIHSS score (this is done really while you are escorting the
    patient for CT, as everything is done simultaneously as time is BRAIN!)

    *The rational behind CT angiogram is to visualize the circulation for


    thrombectomy if thrombolysis is CI and also to visualize for any carotid artery
    dissection.

    THROMBOLYSIS window of 4.5 hours dose of 0.9mg/kg up to 90mg,


    10% of total dose given as bolus over 1-2minutes while the rest given in the next
    hour.

    Although there are many CIs for thrombolysis, but the absolute ones that stroke
    physicians really look at urgently will be:

    1) Any use of NOAC/warfarin INR >1.7


    2) Sustained hypertension >180/105

    IV labetolol 10mg over 1-2 minutes , is given as first line and can be
    repeated at 10 minute intervals with max of 200mg + any other adjuncts
    such as vasodilators (sodium nitroprusside).

    Caution in those with asthma or > 1st degree heart block.

    Stroke physicians will try their best to get the BP down to enable
    thrombolysis, as this is usually modifiable.

    3) Any recent surgeries (esp last 2 weeks)

    The rest can be safely mentioned but these 3 are the main ones that they would
    want to hear.

    *IF THROMBOLYSIS is CI aspirin 300mg for 2 weeks and then 75mg


    lifetime

    CARE POST-THROMBOLYSIS
    1) Admit to stroke unit.
    2) Regular neuro-observation (can be as frequent as 0.5-1 hourly)- GCS and
    vitals + manual BP reading
    Observe for any signs of raised ICP or intracranial bleed:
    -Unequal pupils
    -Sudden drop in GCS
    -Onset of drowsiness
    -Onset of nausea, vomiting (photophobia) Rising BP and falling pulse

    3) Keep the BP down (<140 systolic, not too low as you dont want to risk
    hypoperfusion and causing another stroke) especially for the first 24
    hours
    4) After 24 hours of thrombolysis, repeat CT scan to exclude bleeding
    5) Give aspirin 24 hours after thrombolysis and can start LMWH for DVT
    prophylaxis if bleeding is excluded
    6) Avoid any ABGs, NG tube, IM injections or urinary catheterization within
    24 hours if unnecessary to avoid bleeding.
    7) Check for any urinary retention especially in older adults.
    8) Swallowing assessment
    (If they ask how would you test it, its a crude test where you ask the
    patient just to swallow water and feel at the trachea for any swallowing
    movements/they might cough/some physicians ausculate at the area of
    the suprasternal notch for any gurgling)

    9) MDT SALT, Physio, occupational therapy, dietician etc


    10) Only start warfarin if needed 2 weeks after thrombolysis
    11)Antihypertensives is started 2 weeks after too, and PERINDOPRIL is the
    drug of choice in post stroke patients Keep BP under 140 if possible
    12) Check glucose and lipid levels statins and anti-diabetics if known T1DM

    THROMBECTOMY
    1) Thrombectomy is shown to be superior as compared to thrombolysis in
    an ESCAPE study done in Beaumont
    2) Another study that has proven that is MR CLEAN study (can be mentioned
    to impress examiners , as suggested by Prof Williams as everyone in the
    stroke team mention these 2 studies everytime, especially as the base
    centre for trials of the ESCAPE study was done in Beaumont)
    3) Time frame for thrombectomy is 6 hours as mentioned by Prof but can go
    up to 12 hours in certain cases.

    INVESTIGATIONS
    Investigations for the causes of stroke is done only after thrombolysis, as
    establishing the cause is secondary priority.

    Besides the bloods FBC, U&E, Coag, lipids, glucose everyone in Beaumont
    gets:
    1) ECG for atrial fibrillation
    2) 24 hour/4-5 day holter monitor
    3) TTE for any thrombus in left atrial appendage, valvular vegetations for
    septic emboli
    4) Carotid Doppler for carotid stenosis (carotid endarterectomy can be
    done 2 weeks after)

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