The CT and CTA have been requested.
Things to do whilst waiting for the CT scan
View text alternative for feedback on each of the priorities.
It is important not to waste time on things which can be done after the thrombolysis has been given.
Priorities
NIHSS – The National Institutes of Health Stroke Scale (NIHSS) is a tool for the assessment of stroke severity. You can carry out the NIHSS score if you are trained to do so. The use of the NIHSS ensures a range of neurological signs and symptoms are measured over time. The patient’s neurological status should continue to be observed after completion of the NIHSS. For more detailed information:
Vital signs – Vital signs are taken to provide baseline and comparative information for the monitoring of physiological status while assessment is being conducted and during and post thrombolysis treatment. Very high blood pressure is thought to be associated with a higher risk of intracranial bleeding with thrombolysis treatment and is therefore a relative contraindication.
Weigh the patient – The thrombolysis dosage is calculated on the patient’s weight, that is 0.9 mg/kg up to a maximum of 90 mg tPA. 0.9 mg/kg is infused over 60 minutes with 10% of the total dose administered as an initial intravenous bolus over 2 minutes. Do not waste time getting weighing scales, you may have to speak to the partner and estimate the patient’s weight.
Check Blood Sugar – The patient’s glucose level can be quickly assessed with a BM test. If the BM test is low or high you will need a laboratory tested blood glucose; as a significantly abnormal result may be a reason not to give thrombolysis treatment. Hypoglycaemia can mimic stroke, while a raised glucose level (hyperglycaemia) may be associated with poorer functional outcomes.
Take blood – Blood tests include a full blood count (FBC), clotting screen, erythrocyte sedimentation rate (ESR), blood sugar, urea, creatinine & electrolytes (U&Es), cholesterol and liver function tests (LFTs). You do not need to wait for blood results before giving thrombolysis treatment unless you suspect a significant abnormality. However, severe anaemia (Hb < 100g/l, clotting abnormalities (INR>1.4), hyperglycaemia (blood sugar > 22 mmol/l) or very abnormal biochemistry may be reasons not to give thrombolysis treatment.
Insert IV cannula – Insert an intravenous cannula for access. Thrombolysis treatment is administered as an intravenous bolus (10%) followed by an intravenous infusion (90%) over an hour.
Check for contraindications – It is important to check for contraindications before giving thrombolysis treatment. Local stroke thrombolysis protocols often have a contraindication checklist.
Notify the relevant people of the requirement of a suitable inpatient bed – It is important to ensure a suitable inpatient bed where the patient can be closely observed and monitored after thrombolysis treatment has been given.
Confirm time of onset of symptoms – This should be confirmed as the last time that the patient was symptom free rather than when they first noticed any symptoms. Many patients awake from sleep with symptoms of stroke; they are excluded from thrombolysis treatment as exact time on onset cannot be determined.
Discuss treatment with Angela and her partner
Non priorities
ECG – While an ECG may be ordered, the priority is an accurate stroke diagnosis that establishes whether it is an ischaemic or haemorrhagic event. CT scanning therefore overrides an ECG.
Catheterise the patient – Catheterisation should be avoided in patients post-stroke unless there is specific reason to do so such as urinary retention. In patients who may have / have had thombolysis treatment insertion might cause heavy bleeding.
Send her partner to the canteen – Sending her partner to the canteen may delay treatment. Ask the patient’s partner to remain available to assist the stroke team in determining the time of symptom onset. The stroke team will also wish to discuss the benefits and risks of thrombolysis treatment with the partner.
Give IM sedative – During the assessment period sedation should be avoided to prevent confusion regarding presenting symptoms. It may be that the patient’s partner will need to be reassured if the patient is agitated. IM injections should also be avoided in patients who may have / have had thombolysis treatment as it can cause serious bleeding into the muscle.
Swallow screen – Some patients may be dysphagic and you may have concerns regarding their ability to swallow. However a swallow screen should be delayed until the patient has been CT scanned, a diagnosis confirmed and intervention agreed.
Ask the Junior Doctor to undertake a full medical – A junior doctor undertaking a full medical history and examination is not appropriate at this stage. A more limited medical history and examination by the stroke team is needed for the assessment for thrombolysis treatment.
Phone and wait for the porter to transfer to CT scanning – The radiology department should be notified of an impending emergency CT scan. As soon as the initial assessment has been carried out the patient should be taken for CT scanning. Do not wait on portering staff as wasted minutes reduce the benefits of treatment. The doctor and nurse may take the patient themselves.
Get results of blood tests
