• Code LVO is activated for:

  • • NIHSS > 6

    • LAMS > 4

    • Positive CTA/CTP

• Stroke nurse will bring the thrombolytics box from ED

• Three thrombolytics boxes will be kept in ED

  • • Pharmacy will restock within 30 min of use

    • Additional thrombolytics vials will be kept in the CT Pyxis

• ED charge nurse will count the thrombolytics boxes each shift and notify pharmacy about number and condition of boxes

• After ED physician determines patient is hemodynamically stable in holding bay, patient will be transported for STAT non-contrast CT Head

• When CT scan begins, ED physician will call neurologist on call to discuss case, including preliminary CT result with attention to bleed and infarction

• Neurologist, via phone, will determine if thrombolytics is indicated or not

• If ED physician and neurologist agree thrombolytics is indicated, ED physician will tell the stroke nurse to mix thrombolytics

  • • Patient may need IV lines inserted if necessary after non-contrast CT Head completed

• Stroke nurse will administer thrombolytics bolus in CT room after radiologist reports to ED physician that there is no ICH and no infarction

• Thrombolytics dose:

  • tPA dose:  0.9 mg/kg total dose IV over 60 min

    • 10% total dose (0.09 mg/kg) IV x1, then

    • Remaining 90% (0.81 mg/kg) IV over 60 min

    • Max: 90 mg

  • tenecteplase:  0.25 mg/kg, max dose 25 mg

• CTP will be completed after thrombolytics bolus has been given

  • • If tPA given , remainder of tPA drip will be started after CTP

• Stroke nurse will notify pharmacist that thrombolytics box has been used and needs restocking within 30 min

• Patient presents as a symptomatic wake-up ischemic stroke ≤ 4.5 hrs since awakening

• If last well known time before sleep ≤ 9 hrs after going to sleep, consider rTPA if:

  • • CTA demonstrates no LVO

    • Patient NOT going to attempted thrombectomy

    • CTP mismatch ratio > 1.2

    • Ischemic/infarcted core ≤ 30 mL

• If last well known time before sleep > 9 hrs after going to sleep, consider rTPA if:

  • • CTA demonstrate no LVO

    • Patient NOT going to attempted thrombectomy

    • CTP mismatch ratio > 1.8

    • Ischemic/infarcted core ≤ 30 mL

    • MRI demonstrates < 5 chronic microbleeds

    • MRI flair is NEGATIVE

• tPA dosing for ischemic stroke

• NIHSS

• LAMS

• ED Stroke RN: 04381 

• Stroke Coordinator (Lucille Jorgensen): 06162 or 06252 

• House Supervisor: 06295

• Neuro-IR / Neurosurgery Resident: 909-264-9323 

• Dr. Miulli: 909-897-2572

• Dr. Johanna Rosenthal: 714-213-0492 

• Dr. Lisa Sovory: 909-800-3246 

• Teleneurology pager: 909-490-5578; Dial 10-digit call back number followed by # key 

• Age less than 18 years 

• Onset of symptoms greater than 4.5 hours 

• Intracranial hemorrhage, neoplasm, arteriovenous malformation (AVM) or aneurysm as determined by physician 

• AMI, Stroke, major head trauma, major surgical procedure involving the brain or spine within 3 months 

• CT Scan shows evidence of intracranial hemorrhage or 2/3 hemispheric stroke 

• Use of Direct Thrombin Inhibitors within 48 hours 

• INR > 1.7; PT > 15.5 sec; Plt < 100,000/mcl; Heparin w/in last 48 hrs and has PTT > 1.5 times control 

• Active internal bleeding or known bleeding diathesis 

• Systolic BP greater than 185 mmHg or Diastolic BP greater than 110 mmHg 

• Patient refusal

• Last known well / symptom onset time

• Arrival to ED Time

• Code status

• Family contact (cell #)

• Time neurology contacted

• Name of neurologist

• NIHSS

Document a reason for delay in TPA administration if Door-to-TPA > 30 min

• Initial patient refusal 

• HTN requiring IV medications 

• Management of acute condition (CPR, intubation, etc.) 

• Unable to determine eligibility / diagnostic uncertainty due to: (list)

• Other: (list)

tPA Bolus administration if SBP < 185, then maintain SBP < 180 

• Labetalol 10mg IV, may repeat x 1

• Nicardipine drip

While in CT: 

• Neurology Consult - (On call day, teleneurology night) 

  • Dr. Johanna Rosenthal 714-213-0492 

  • Dr. Lisa Sovory 909-800-3246 

  • Teleneurology pager 909-490-5578 Dial 10-digit call back number followed by # key 

• Can the Stroke RN mix thrombolytics now? If appropriate, thrombolytics can be given between the CT non-contrast and the CTA/CTP. 

While in Patient Room:

• Check for CTP results on the RAPID App; verify mismatch with Radiologist

NIHSS: Is this deficit disabling to the individual? Consider ADLs, occupation, & hand dominance.

Mismatch map