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THROMBOLYSIS

THROMBOLYSIS. Alteplase: indications and contra-indications Dr Ken Fotherby, New Cross Hospital. Thrombolysis: Yes? No?. Ischaemic stroke (not bleed or mimic) Within 3h onset No ^^risk bleeding (BP>185/110 warfarin/heparin

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THROMBOLYSIS

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  1. THROMBOLYSIS Alteplase: indications and contra-indications Dr Ken Fotherby, New Cross Hospital

  2. Thrombolysis: Yes? No? • Ischaemic stroke (not bleed or mimic) • Within 3h onset • No ^^risk bleeding (BP>185/110 • warfarin/heparin • recent stroke • recent surgery) • Minor/rapidly improving stroke

  3. New Cross experience • DGH serving ~250,000 pop • Thrombolysis service 9am-5pm:May 07 • Assessed 21 patients12 thrombolysed ie. ~1/wk assessed ~1/fortnight treated

  4. Alteplase for ischaemic stroke • N.N.T. to prevent death/severe dependency?

  5. Alteplase for ischaemic stroke • N.N.T. to prevent death/severe dependency? 6 (NINDS) 9 (NICE ) and 3 to reduce dependency (NINDS)

  6. Alteplase for ischaemic stroke • N.N.H. (ie cause symptomatic intra-cranial haemorrhage)?

  7. Alteplase for ischaemic stroke • N.N.H. (ie cause symptomatic intra-cranial haemorrhage)? 17 6% NINDS 4-7% SITS-MOST,CASES,STARS (16% in Cleveland) ( ~1% for MI)

  8. Thrombolysis: Yes? No? • Ischaemic stroke (not bleed or mimic) • Within 3h onset • No ^^risk bleeding (BP>185/110 • warfarin/heparin • recent stroke • recent surgery) • Minor/rapidly improving stroke

  9. Thrombolysis: ?is ischaemic stroke • Clinical diagnosis but CT scan to exclude bleed • Exclude stroke mimics: epileptic fit hypoglycaemia

  10. Thrombolysis: ?within 3 hours • Clear time onset (or when last well) • Usually need eye-witness paramedics report “Time is Brain”

  11. Thrombolysis: ?too risky ^ risk intra-cranial bleeding: • BP>185/110 (reassure,?labetalol or GTN patch) • Abnormal clotting (warfarin,heparin,haemodialysis) (INR 1.4 or less OK) • ?Massive infarct (NIHSS>25) • ?Old age (>80yr) • Prior stroke within 3months (but TIA OK) • Any i/c bleed in past • major surgery, G-I bleed, haematuria past 3 weeks

  12. Thrombolysis: ?too risky Prognosis “too good”: • Small stroke (NIHSS 4 or less) but ? lone dysphasia

  13. Ischaemic stroke (not bleed or mimic) Within 3h onset No ^^risk bleeding (BP>185/110 warfarin/heparin recent stroke recent surgery) Minor/rapidly improving stroke Thrombolysis: Yes? No?

  14. Putting it all together! spouse nurse paramedic BP + BM arrange clinical venflon CTscan assessment bloods porter DOCTOR-PATIENT relatives arrange assent/consent bed NIHSScore weight/dose BP (again) read CT scan start drug

  15. Thrombolysis: how often? • Best = 20% of acute stroke patients (and 2006 NSentinelStroke Audit:39% admitted <2h) • strokes/year = 530 /250,000 pop = c400 admitted (excl MAU discharges) = c250 “ “ “ “ “ and aged <80yrs - 40% of 400 = 160 assessments/y or 3/wk 20% 400 = 80 thrombolyses/y or 1-2/wk

  16. Thrombolysis: an effective & safe service? • Written protocols within an (established) pathway. ( licence & NICE:”only by a physician trained and experienced in the management of acute stroke and in a centre with appropriate facilities”)

  17. Pathways and Protocols for thrombolysis paramedics I A&E I CT scanning I Stroke Unit (9am-5pm)

  18. Pathways and Protocolsfor thrombolysis G.P.s/community I paramedics paramedics I I A&E A&E I I CT scanning CT scanning I I Stroke Unit Stroke Unit (9am-5pm) (8am-8pm+)

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