Acute Stroke Drip and Ship Protocol

Duluth Area Primary Stroke Center (St. Lukes & St. Marys-Essentia) Pt. Name: ___________________________

DOB: ______/______/______
(Place Patient Label)

A B/P Pulse
S V/S q 15 min with neuro checks
S
Acute Stroke Intervention Algorithm
E Continuous Cardiac Monitoring
S Actual Weight: __________kg
S Time
Pt with
Last signs
Known / symptoms
Well < 8hr Does the facility have CT scan capabilities?
NIHSS on arrival __________
M of stroke
Cincinnati and symptom
Stroke Scale >0
Keep NPO (including meds) Glucose onset < 8 hrs.
> 50mg/dl
E
N
T Yes
Yes
Arrange for rapid
transfer
Is facility able to give tPA? No
Date: ______________
T :
I ED TRIAGE TIME Complete diagnostic
M 10Section.
25 min
E If no exclusion, consider
0 10 min Complete diagnostic
Yes
Yes Complete Assessment Rapid interpretation of
tPA after consult with Section
Date: ______________ and Time Sections CT by Radiologist or
Neurologist for 45 min
Neurologist
Interpretation of CT
TIME LAST KNOWN WELL
: imaging/history review.

D CT Head w/o contrast 60 min If no exclusion, consider If CT negative for

I If tPA ordered, refer to IV tPA. May consult with hemorrhage, refer
CT Results:
A tPA Administration Neurologist on call. to Inclusion /
No acute findings
G Order set and Treatment Exclusion Criteria.
Hemorrhage Section. Transfer to If CT positive for
N
New Ischemic Stroke Duluth Area Primary
Complete
Complete packet.
packet. hemorrhage,
O
Other: Prepare
Prepare forfor rapid to
transfer transfer
S Stroke Center
transport to Duluth
Duluth Area Area
Primary
T
Primary Stroke
Stroke Center.
Center
I Stroke Panel CBC, Platelets, PT-INR
C / PTT, Chem 8/BMP, Cardiac enzymes,
S glucose, Creat, Preg test (optional) t Alteplase (tPA) Checklist t IV Alteplase (tPA)
12-Lead EKG P P 0.9 mg/kg (max dose 90 mg)
A Onset of Sx to tPA bolus <4.5 hrs A 10% total dose as bolus over
If tPA candidate, institute tPA orders one minute
NPO (including meds) until No hemorrhage on CT scan :
C P tPA bolus time
T Dysphagia Screen
R
H Thrombolytic Inclusion / R Remainder over 60 minutes
BP Protocol E Exclusion checklist completed O V/S + neuro checks per flow
E
Ischemic target: 180/105 C T sheet
A No exclusions for administering
T Hemorrhagic target: 140/80 K O q 15 x 2 hour, q 30 min x 6 hr,
No sublingual Nifedipine tPA
M L C then hourly until 24 hours after
E I Discussion with patient / family O treatment
N Baseline O2 sats:_______% S regarding risks/benefits/alternatives L Maintain B/P <180/105
T O2 to keep SATS >92% T Repeat CT head if neuro status
changes
Two Large-bore IV sites No anticoag/antiplatelet for 24
Normal Saline TKO hr

Choose and Call Duluth Area Primary Stroke Center

Stroke Transfer / Drip and Ship Protocol

St. Lukes Call: 218-249-2444 St. Marys-Essentia Call: 1-877-786-4944

Fax packet/records: 218-249-5590 Fax packets/records: 218-786-7396
Call nursing report to SLH ICU: 218-249-5654 Call nursing report & updated ETA: 1-877-786-4944
Version 9.15 Page 1 of 7
 NIHSS

Category Scale Definition Date/Time Date/Time Date/Time

1a. Level of Consciousness 0= Alert 2= Stuperous
(Alert, drowsy, etc.) 1= Drowsy 3= Coma
1b. LOC Question 0= Answers both correctly 2= Answers neither correctly
(Month, age) 1= Answers one correctly
1c. LOC Commands 0= Performs both correctly 2= Performs neither task
(Open, close eyes, make fist, let go) 1= Performs one correctly
2. Best Gaze 0= Normal 2= Forced deviation
(Eyes open patient follows examiners fingers/face) 1= Partial gaze palsy
3. Visual 0= No visual loss 2= Complete hemianopia
(Introduce visual stimulus [or threat] to patient visual 1= Partial hemianopia (blind) 3= Bilateral hemianopia
field quadrants)
4. Facial Palsy 0= Normal 2= Partial paralysis
(Show teeth, raise eyebrows, and squeeze eyes shut) 1= Minor paralysis 3= Complete paralysis
5. Motor Arm 0= No drift 3= No effort against gravity
5a. Left Arm 1= Drift 4= No movement
(Elevate extremity to 90 and score drift/movement) 2= Some effort against gravity UN=Amputation or joint fusion
5b. Right Arm 0= No drift 3= No effort against gravity
(Elevate extremity to 90 and score drift/movement) 1= Drift 4= No movement
2= Some effort against gravity UN=Amputation or joint fusion
6. Motor Leg 0= No drift 3= No effort against gravity
6a. Left Leg 1= Drift 4= No movement
(Elevate extremity to 30 and score drift/movement) 2= Some effort against gravity UN=Amputation or joint fusion
6b. Left Arm 0= No drift 3= No effort against gravity
(Elevate extremity to 30 and score drift/movement 1= Drift 4= No movement
2= Some effort against gravity UN=Amputation or joint fusion
7. Limb Ataxia 0= Absent 2= Present in both limbs
(Finger, nose, heal down shin) 1= Present in one limb UN=Amputation or joint fusion
8. Sensory 0= Normal 2= Severe to total sensory loss
(Pinprick to face, arm [trunk] and leg compare side 1= Mild to moderate sensory loss
to side)
9. Best Language 0= No aphasia, normal 2= Severe aphasia
(Name items, describe a picture and read sentences) 1= Mild to moderate aphasia 3= Mute, global aphasia
10. Dysarthria 0= Normal 2= Severe dysarthria
(Evaluate speech clarity by patients repeating listed 1= Mild to moderate UN= Intubated
words)
11. Extinction and inattention 0= No neglect 2= Profound neglect
(Use information from prior testing to identify neglect 1= Partial neglect
or double simultaneous stimuli)
Score
Initial

Initials:______Signature:_________________________________________

Initials:______Signature:_________________________________________

Initials:______Signature:_________________________________________
Acute Stroke Drip and Ship Protocol Pt. Name: ___________________________
Duluth Area Primary Stroke Center (St. Lukes & St. Marys-Essentia)
DOB: ______/______/______
(Place Patient Label)

Version 9.15 Page 2 of 7

 Alteplase (tPA) Inclusion/ Exclusion Tool

3-Hour Criteria

INCLUSION Yes No
Acute Ischemic Stroke w/defined TLKW less than 3 hours
Age greater than 18 years
Discussed risk / benefit of Alteplase (tPA)
EXCLUSION No Yes
Evidence of hemorrhage on CT scan
Uncertainty about the time of stroke onset (e.g. patients awakening from sleep)
Coma or severe obtundation with fixed eye deviation and complete hemiplegia
Hypertension: systolic greater than 185 mmHg or diastolic greater than 110 mmHg on repeated
measures. (if reversed, can be treated)

Symptoms suggest subarachnoid hemorrhage even with normal CT Scan
Glucose less than 50 or greater than 400 mg/dl
Presumed septic embolus
Platelet less than 100,000
INR greater than 1.7
Heparin within 48hrs AND elevated PTT or has a known hereditary or acquired hemorrhagic
diathesis

Known advanced liver disease, advanced right heart failure or anticoagulation AND INR greater
than 1.5 (no need to wait for INR results in the absence of the former three conditions)

Current use of direct thrombin inhibitors or direct factor Xa inhibitors with elevated sensitive lab
tests (such as aPTT, INR, platelet count and ECT (Ecarin clotting time); TT (thrombin time); or
appropriate Xa assays)

RELATIVE CONTRAINDICATIONS: (Physician to determine risk vs. benefit) No Yes

Intracranial surgery, head trauma, Alteplase or previous stroke within past 3 months
Major surgery within 14 days (consider intra-arterial thrombolysis)
Symptoms mild (NIHSS less than 4) or rapidly improving
Severe stroke (NIHSS greater than 22)
CT evidence of extensive middle cerebral artery (MCA ) territory infarction (sulcal effacement or
blurring of the grey-white junction in greater than 1/3 of MCA territory)

Trauma with internal injuries or ulcerative wound within 30 days
Biopsy or surgery of a parenchymal organ within 30 days that would increase the risk of
unmanageable bleeding

Myocardial infarction within 30 days
GI or GU bleeding in the last 30 days that would increase the risk of unmanageable bleeding
Known intracranial neoplasm, arteriovenous malformation, subarachnoid hemorrhage or
intracranial hemorrhage

Arterial puncture at non-compressible site within 7 days
Pregnancy (consider intra-arterial thrombolysis)
Age greater than 80 years
Seizure: if the presenting neurological deficit is deemed due to a seizure
Concomitant serious, advanced or terminal illness or any other condition that would pose an
unacceptable risk

Version 9.15 Page 3 of 7

 3-4.5 Hour Criteria (includes 3hr+)

RELATIVE EXCLUSION No Yes

Age greater than or equal to 80 years
Use of warfarin (regardless of INR) or any other anticoagulant at anticoagulant dosing
NIHSS greater than 25
Prior stroke and diabetes

Conclusion: Must choose one

Patient meets criteria for Alteplase (tPA)

Patient does not meet criteria for Alteplase (tPA)

MD Signature:_____________________________________

Date/Time:______/______/______ ::

Pt. Name: ___________________________

Acute Stroke Drip and Ship Protocol
Duluth Area Primary Stroke Center (St. Lukes & St. Marys-Essentia) DOB: ______/______/______
Version 9.15 Page 4 of 7 (Place Patient Label)
 Pupil reaction Movement Smile Tongue Deviation
B- Brisk I - Irregular N - Normal S - Symmetrical M- Midline
S - Sluggish L - IOL W - Weak R Right droop R- Right
TPA Vitals and Neuro Checks F- Fixed C - cataract C Cant overcome gravity L Left droop L - Left
Bolus administration time: ____________________ H - Hippus U Unable to assess S Slight movement only U Unable to assess U Unable to assess
Infusion start time: __________________________ P Complete paralysis
Date: Q 15min x 2hrs Q30 min x 6hrs
Pre TPA 1 2 3 4 5 6 7 8 1 2 3 4
Time:
HR
BP
RR
Pupil size R mm
Pupil size L mm
Pupil reaction R
Pupil reaction L
R arm movement
L arm movement
R leg movement
L leg movement
Smile
Tongue Deviation
RN Initials
Q 30 min x 6hrs Q 1hr x 16hrs (continue on back)
5 6 7 8 9 10 11 12 1 2 3 4 5
Time:
HR
BP
RR
Pupil size R mm
Pupil size L mm
Pupil reaction R
Pupil reaction L
R arm movement
L arm movement
R leg movement
L leg movement
Smile
Tongue Deviation
RN Initials
Acute Stroke Drip and Ship Protocol
Pt. Name: ___________________________
Duluth Area Primary Stroke Center (St. Lukes & St. Marys-Essentia)

Version 9.15 Page 5 of 7 DOB: ______/______/______

(Or Place Patient Label)
 Pupil reaction Movement Smile Tongue Deviation
B- Brisk I - Irregular N - Normal S - Symmetrical M- Midline
S - Sluggish L - IOL W - Weak R Right droop R- Right
F- Fixed C - cataract C Cant overcome gravity L Left droop L - Left
H - Hippus U Unable to assess S Slight movement only U Unable to assess U Unable to assess
P Complete paralysis

Q1hr x 16hrs (Further vitals and neuro checks per physician order)
6 7 8 9 10 11 12 13 14 15 16
Time:
HR
BP
RR
Pupil size R mm
Pupil size L mm
Pupil reaction R
Pupil reaction L
R arm movement
L arm movement
R leg movement
L leg movement
Smile
Tongue Deviation
RN Initials

__________________________________________/_________________ __________________________________________/_________________
RN Signature Initials RN Signature Initials

__________________________________________/_________________ __________________________________________/_________________
RN Signature Initials RN Signature Initials

__________________________________________/_________________ __________________________________________/_________________
RN Signature Initials RN Signature Initials

__________________________________________/_________________ __________________________________________/_________________
RN Signature Initials RN Signature Initials

Pt. Name: ___________________________

Acute Stroke Drip and Ship Protocol DOB: ______/______/______
Duluth Area Primary Stroke Center (St. Lukes & St. Marys-Essentia)
Version 9.15 Page 6 of 7 (Place Patient Label)
 Acute Stroke Blood Pressure Management
Duluth Area Primary Stroke Center (St. Lukes & St. Marys-Essentia)

BEFORE IV Alteplase (tPA) or other acute reperfusion therapy BP > 185/110 mmHg

Systolic > 185 mmHg or Diastolic > 110 mmHg

o Labetalol 10 20 mg IV over 1-2 minutes, may repeat x1
OR
o Nicardipine infusion 5mg/hr, titrate by 2.5 mg/hr every 5-15 min, maximum dose
15 mg/hr. When desired BP attained, adjust to maintain proper BP limits.
OR
o Other agents (hydralazine, enalaprilat, etc.) may be considered

If BP is not maintained at or below 185/110 mmHg, do not administer tPA

DURING and AFTER IV Alteplase (tPA) or other acute reperfusion therapy

Maintain BP at or below 180/105 for at least the first 24 hours post tPA
Monitor BP and Neuros q 15 min x 2 hrs, q 30 min x 6 hrs and q 1 hr x 16 hrs
Systolic > 180 - 230 or Diastolic > 105-120
o Labetalol 10 mg IV followed by continuous IV infusion 2-8 mg/min
OR
o Nicardipine infusion 5mg/hr, titrate by 2.5 mg/hr every 5-15 min. Max. dose 15
mg/hr

o If BP not controlled or diastolic BP > 140 mmHg, consider IV sodium

nitroprusside

Non-Alteplase (tPA) Patient

Most patients with ischemic stroke do not require treatment for hypertension; however, it is generally
agreed that patients with markedly elevated BP may have their BP lowered. A reasonable goal would
be to lower BP by ~15% during the first 24 hours after onset of stroke. The level of BP that would
mandate such a treatment is not known, but consensus exists that medications should be withheld
unless systolic BP is > 220 mmHg or the diastolic is > 120 mmHg.

Avoid Hypotension Acute Stroke Drip and Ship Protocol

Duluth Area Primary Stroke Center (St. Lukes & St. Marys-Essentia)

Version 9.15 Page 7 of 7