Module test
Category: Advancing Modules
Module test
Conclusion
Having completed this module you should now have a critical understanding of:
- The purpose, evidence-base, benefits and risks of thrombolysis and/or thrombectomy treatment following ischaemic stroke
- The importance of ‘Time is Brain’ in relation to these treatments, and why stroke should be treated as a medical emergency
- The criteria for use, and the potential contra-indications, of thrombolysis and thrombectomy treatments following stroke
- Providing information and support to the patient and their family about these treatments
- The properties, actions, dosages, administration and side-effects of thrombolysis
- The details of thrombectomy which are relevant to those caring for patients with hyperacute stroke.
- Nursing observation, monitoring, care and interpretation of the patient’s condition before, during and after thrombolysis and thrombectomy treatment, responding appropriately to changes or deterioration
- Causes, manifestations and management of adverse reactions following thrombolysis treatment.
- How the patients progress through the hyperacute treatment pathways can be as rapid and smooth as possible
Key Messages
- Time is Brain – it is critical to act quickly
- Careful assessment of a patients history, examination and investigations is essential to selecting patients who are likely to benefit from thrombolysis and thrombectomy
- The chances of a good outcome are far greater, with earlier treatment
- Used appropriately thrombolysis and/or thrombectomy are effective and safe treatment for patients with ischaemic stroke
Vera’s Outcome and Key Messages
Outcome
Vera was repatriated on the day after her thrombectomy. She recovered well, and went home a week after her stroke, able to live independently and care for her husband.
Key messages
- The drip & ship pathway will be the most common route to thrombectomy, but it is complex.
- Excellent coordination and communication between spoke and hub hospitals and the SAS is required to optimise patient safety and outcomes.
- Protocols, documentation and training need to be harmonised across the pathways.
Review of Vera’s pathway – drip and ship
- Drip & Ship is likely to be the commonest pathway in a national thrombectomy service
- It relies on excellent coordination between teams working in SAS, spoke and hub hospitals
- It makes common protocols, assessments, documentation and treatments essential because patients are transferring between hospitals
- Capture of data to monitor the performance of the service to help to optimise delays
- SAS – pre hospital, inter hospital and repatriation delays
- Spokes – DTN, time in, time out, repatriation delays
- Hubs – DTN, Door to puncture (DTP) (for local and drip & ship pts), repatriation delays
Vera’s pathway
Vera’s progress and repatriation
Vera had a thrombectomy, unblocking her right middle cerebral artery (MCA). She is transferred to the hyperacute stroke unit after waking up from the general anaesthetic in recovery. The nurses monitor her condition carefully (see Iain’s story).
Vera is much better (mild facial weakness and mild drift of arm and leg, normal visual fields and slight inattention of left) the following day. Her NIHSS has improved from 15 before transfer to 4.
The stroke physicians assess her progress twice daily to determine when she might be fit for repatriation.
Indicate which of the following 7 statements about repatriation are True or False
Back to Vera
Vera arrives at the thrombectomy centre and is taken straight to the Radiology dept (not ED since she has already been through the first part of the pathway at the spoke hospital). She is met by the team comprising the INR, anaesthetist and hub stroke nurse. The paramedics give a verbal handover.
- A full NIHSS is performed and recorded. Sometimes changes in the patients condition or delays in transfers will mean that the patient needs further brain imaging.
Indicate which of the following statements are True or False.
Iain’s brain imaging
The team in ED need to understand the rationale for the brain imaging they are requesting. Drag the words to describe the rationale for his imaging.
Iain returns from CT and the medical team review the imaging with the neuro radiologist.
CT scan showing early infarct on left side and CTA showing blocked left MCA.
Brain scans by Grant Mair is licensed under CC BY-NC-SA 4.0
Iain’s non-contrast CT scan excludes a bleed but shows a dense (white) middle cerebral artery (MCA) on the left due to clot within the artery. There are also some early ischaemic changes (loss of grey/white matter discrimination) visible. A blocked proximal MCA is confirmed on the CTA (arrow).
Completing the NIHSS score
The NIHSS is an internationally accepted tool for the systematic assessment of stroke severity. It comprises a 15-item neurological examination stroke scale used to evaluate the effect of an acute cerebral event on the levels of consciousness, language, neglect, visual-field loss, extra-ocular movement, motor strength, ataxia, dysarthria and sensory loss. It can be used by appropriately trained healthcare professionals and takes approximately 10 minutes to administer. However, the whole NIHSS does not need to be completed to make the initial diagnosis or to decide that hyperacute treatment would be indicated. It can be completed whilst waiting for the scans. The use of such an assessment tool ensures that a standard range of neurological signs and symptoms can be measured consistently over time providing a basis for clinical decision-making. Patients may not be suitable for thrombolysis (NIHSS<4) or thrombectomy (NIHSS<6) if the stroke is mild and not causing the patients difficulties.
Click the link below to complete the free NIHSS online training:
BlueCloud: Individual Memberships for Healthcare Professionals
All staff (stroke nurses and medical staff) involved in the management of hyperacute stroke patients should have completed training in the use of the NIHSS and be proficient in its use. Watch the video below and score the patient on the NIHSS. You might find it useful to open up the NIHSS assessment form below.
Try filling in a version of the form for yourself: Interactive NIHSS score sheet [.pdf, 955KB]
Video provided by kind permission: Mark Garside – Northumbria Healthcare; Chris Price – Newcastle University.
Duration: 4 minutes 58 seconds
Ambulance arrives
The ambulance arrives at the spoke hospital at 10.40.
The 60min alteplase infusion only started at 10.20. The spoke stroke physician has to make the difficult decision based on an assessment of risks and benefits whether to:
- Stop the alteplase infusion before transfer
- Delay the transfer until infusion has been completed
- Identify a suitably trained nurse who could manage the infusion during transfer
In this case the stroke physician decides to stop the infusion because no nurse is available to accompany the patient and the delay to thrombectomy may be reduced by at least 30 minutes. Had the patient been treated with Tenecteplase which is given as a single bolus no infusion would have been required (link back to “What is thrombolysis?”._
Vera is transferred into the ambulance by the paramedics. No nurse or anaesthetist is required for this transfer.
The family or next of kin do not travel in the transfer ambulance. Vera’s daughter drives John, Vera’s husband, to the thrombectomy centre.
Estimated transfer time: 1 hour.
