NeurovascularMedicine.com
The contents are under continuing development and improvements and may contain errors of omission or fact. This is not to be used for the assessment, diagnosis or management of patients. It should not be regarded as medical advice by healthcare workers or laypeople. It is for educational purposes only. Please adhere to your local protocols. If you are unwell please seek urgent healthcare advice. If you do not accept this then please do not use the website.

A

Hyperacute Care


Introduction

The overriding concept in hyperacute care is that "time is brain" and that systems must be in place to rapidly receive acute stroke patients and quickly assess them. There are two real streams, those who may be suitable for urgent and active therapies and others who need general physiolgical support and the prevention of complications. Urgent therapies would include Stroke Thrombolysis and Mechanical Thrombectomy and reversal of anticoagulation to halt haemorrhage in those with ICH such as those on anticoagulants and those deteriorating due to massive ischaemic or haemorrhagic stroke due to oedema or hydrocephalus or haematoma who may benefit from decompression, External ventricular drainage (EVD) or craniectomy. These patients will become immediately apparent.

Hospital care

The key is to have stroke trained staff receiving these patients with no needless delays holding up the process. Once seen, immediate CT scanning should be done and this will aid management. Locally we aim to deliver thrombolysis within 20 minutes from arrival so we meet and greet the patient, get a handover from paramedics, establish time of onset and any possible contraindications to lysis such as anticoagulation. In the meantime, the patient is quickly booked on systems and CT head booked and it's straight off to CT taking a history and examining on the way and while waiting. The history is focused as is the examination. Family are kept close by to help information gathering and they may be involved in the consenting process. The doctor and stroke nurse push the patient to CT and help radiology staff and at no point should the patient be waiting with no productive activity in place. One the CT is done it can be inspected, the BP re-checked, the weight verified, and a quick checklist of contraindications and consent checked then we can prescribe and administer Alteplase. There is no need to do an ECG or to await blood results on the majority of patients. Each hospital has its own distinct preferences, some thrombolyse in the emergency department, others on the Hyperacute stroke unit. The main issue is to continually review your pathway to make sure it is efficient and safe and remove needless delays. Small improvements can all add up to significant reductions in door to needle times. The initial stroke cased is based around several basic principles of identifying early acute interventions which may help and protecting the patient from complications.

ActionsComments
ABCUrgent management of airway, ventilation, and circulation is vital in patients who have decreased levels of consciousness. Supplemental oxygen is not recommended in nonhypoxic patients. If GCS < 9 assess for ITU bed. Intubation for those who cannot protect airway and ventilate those not breathing. End of life care may be more appropriate in catastophic stroke. Assess NIHSS
Blood glucoseTreat and manage any hypoglycaemia by fingerstick blood draw is acceptable
Assess those with Ischaemic stroke for Stroke ThrombolysisConsider for Stroke Thrombolysis and administer recombinant tissue plasminogen activator within 3 hours (age >80) or 4.5 hrs if Age (<=80) of symptom onset, after appropriate screening for ischaemic stroke. Non contrast CT scan. Determine eligibility for thrombolytic therapy. Ensure door to needle time < 30 mins. Avoid in Patients with known or suspected bleeding diathesis or anticoagulant use: review coagulation studies and platelet count to ascertain eligibility before proceeding
Assess those with Ischaemic stroke for ThrombectomyIf anticipating Mechanical Thrombectomy then get an urgent CTA to look for large vessel obstruction as early as possible but within 6 hours; may be considered in select patients for window of up to 16 to 24 hours with the aim being reperfusion to a modified thrombolysis in cerebral infarction 2b/3 angiographic result to maximize the probability of a good functional clinical outcome
Haemorrhagic stroke or Ischaemic stroke and raised ICPDiscuss need for neurosurgical intervention as appropriate. May need Shunting for those with hydrocephalus or Sub-occipital craniectomy for cerebellar bleeds or Neurosurgical referral for Clot evacuation or Decompressive Hemicraniectomy for malignant MCA syndrome or Coiling or clipping for those with SAH
Haemorrhagic stroke and coagulopathy4 factor Prothrombin complex concentrates and Vitamin K for Warfarin or DOAC induced bleeds. Praxbind for Dabigatran. Platelets for thrombocytopenia

Key facts to acquire before referral to thrombolysis/thrombectomy

ActionsComments
Age of patientDefines thrombolysis window. Aged < 80 we treat up to 4.5 hrs and over 80 only 3 hrs
Time since last wellTime of onset is very useful but if this is unclear we must use Time since last well and time found and work out when we think time of onset was to some degree of accuracy if possible to help define the window
AnticoagulationBeing anticoagulated contraindicates thrombolysis but not thrombectomy
NIHSSTells us severity of stroke. We don't usually offer reperfusion therapies on those with small (NIHSS<4) or very large (>25) strokes
Premorbid stateThrombolysis/thrombectomy reduce dependency. If already dependent then benefits less.
CT reportWe will look at it but do not refer for reperfusion (thrombolysis/thrombectomy) if haemorrhage or tumour or advanced stroke changes suggesting stroke is older than thought. If unsure discuss.
ComorbiditiesIf the patient has advanced malignancy or other diseases possibly contraindicating alteplase. Any recent bleeding issues or trauma must be noted and any non investigated severe anaemia.
Blood pressureNeed BP < 185/110 mmHg to give alteplase.

Managing and Preventing Early complications

Managing and Preventing Early complications
Bedside Swallow assessmentChecking safe swallow before oral intake reduces aspiration
FeedingNG tube placement for feeding when appropriate
VTE preventionUsing methods to prevent VTE - Intermittent pneumatic calf compression, LMWH, Early mobilisation
Hydrate IV fluids to prevent dehydration in those unable to drink
Skin careRegular turns and monitoring to prevent skin damage and ulcers
BowelsBowel management to prevent constipation
ShoulderPrevention of shoulder damage and postural problems
TherapyEarly rehabilitation to enable recovery
SeizuresManagement of seizures
InfectionsManagement of infections - UTI, RTI
BladderManagement of continence, avoidance of catheterisation where possible

Schematic of a pathway

Last updated: 25/11/2018

Note: The plan is to keep the website free through donations and advertisers that do not present any conflicts of interest. I am keen to advertise courses and conferences. If you have found the site useful or have any constructive comments please write to me at drokane (at) gmail.com. I keep a list of patrons to whom I am indebted who have contributed. If you would like to advertise a course or conference then please contact me directly for costs and to discuss a sponsored link from this site.

free web counter