Ischemic stroke intravenous thrombolytic therapy, using rt-PA

To date, although there are many treatments for ischemic stroke in the clinic, there are only four treatments that have been proven to be definitively effective by evidence-based medicine: stroke unit, ultra-early thrombolytic therapy, antiplatelet therapy, and early onset of formal rehabilitation
.

Randomized controlled trials have shown that intravenous rt-PA thrombolysis within 3 hours of the onset of neurologic symptoms in screened patients with acute ischemic stroke is a very effective treatment (class A evidence) at a recommended dose of 0.

1 The importance of intravenous thrombolytic therapy

Time is the brain: Acute ischemic stroke (AIS hereinafter referred to as stroke) is a common disease and multiple diseases in the clinical clinic of neurology, and is one of the three major diseases that endanger human life and health and lead to human death in the world today, which has the characteristics of
high incidence, high recurrence rate, high mortality rate and high disability rate.

Thrombolytic therapy as the first recommendation: reperfusion therapy is currently recognized worldwide as the only effective means
of reducing the disability and fatality rate of patients.

2rtPA intravenous thrombolysis

From the first international trial in 1995 until the latest international trial completed in 2012, all data confirm that patients benefit from intravenous thrombolysis with rt-PA
.

Three "9" ways to use it:

0.

The maximum dose is 90 mg: 90 mg is still used for those who exceed 90 mg
by body weight.

90% of the remaining total: micropump injection
within 1 hour.

Indications:

1.

2.

3.

4.

5.

Monitoring and care of intravenous thrombolysis:

1.

Observe consciousness, pupils, blood pressure, etc.

3.

4.
Nasogastric tube and urinary catheter should be placed delayed;

5.
Timely review the results of blood routine and blood coagulation analysis according to the instructions
.

Contraindications:

1.
Previous intracranial hemorrhage, including suspected subarachnoid hemorrhage; History of head trauma in the last 3 months; Gastrointestinal or urinary bleeding in the last 3 weeks; Excessive surgical procedures performed in the last 2 weeks; There has been an arterial puncture in the last 1 week at a site that is not easily compressive for hemostasis
.

2.
History of cerebral infarction or myocardial infarction in the past 3 months, but excluding old small space infarction without leaving any signs of neurological function
.
3.
Patients with
severe heart, liver, renal insufficiency or severe diabetes.

4.
Physical examination reveals evidence
of active bleeding or trauma (such as fracture).

5.
Has been oral anticoagulant, and the international standardized ratio > 15; 48 hours have received heparin treatment (APTT beyond the normal range).

6.
The platelet count is lower than 100×109/L, and the blood glucose < 2.
7 mmol/L
.

7.
Blood pressure: > 180/100mmHg
.

8.
Pregnancy
.

9.
Non-cooperation
.

How to calculate the onset of stroke

RT-PA intravenous thrombolytic procedure

The patient meets the above criteria for inclusion and exclusion and signs an informed consent form

(1) Before thrombolysis:

1.
Emergency examination of blood count, platelet count, INR, biochemistry all items meet the thrombolytic conditions;

2.
Explain to the family the necessity of thrombolysis and the possible risks;

3.
The patient or family agrees to the thrombolytic treatment and signs;

4.
Notify the relevant physician
.

(2) Thrombolysis process:

1.
In principle, thrombolytic patients are admitted to the ward for thrombolytic treatment under supervision, and if time does not allow, they are admitted to the hospital after entering thrombolytic drugs in the emergency department;

2.
20% mannitol 250ml before thrombolysis.
iv.
St；

3.
rt-PA dose of 0.
9 mg / kg, the maximum dose does not exceed 90 mg; 10% intravenous bolus of the total dose of rt-PA, the remaining 90% of thrombolytic drugs + normal saline 100 ml intravenous input, the input time > 1 h;

4.
Thrombolytic patients are admitted to the intensive care unit, and the electrocardial, respiratory, blood oxygen and blood pressure monitoring before treatment, intermediate and post-treatment are monitored for at least 24 hours;

5.
Blood pressure is measured once every 15 min during thrombolytic therapy and within 2 hours after treatment, and then every 30 min blood pressure is measured for 6 hours; Then measure blood pressure 1 time per hour for 16 h;

6.
Fill in the thrombolysis registration form
.

(3) After thrombolysis:

1.
After thrombolysis, neuroprotective agents can be given as appropriate; Contraindicated drugs that may cause bleeding, including traditional Chinese medicines;

2.
If there are symptoms worsening after thrombolysis, review CT at any time; If there are no special circumstances, CT is re-examined 24h after dissolution;

3.
Close observation of bleeding after thrombolysis, including intracranial, skin, conjunctiva, respiratory and urinary bleeding;

4.
If there is no bleeding after thrombolysis, aspirin 100mg ~ 300mg/day is given after 24h of thrombolysis; or unfounded patients with stratified risk of vascular disease are given aspirin + clopidogrel in combination;

5.
If there is no bleeding after thrombolysis, carry out standardized secondary prevention;

6.
If bleeding occurs, stop all drugs that may cause bleeding and treat the bleeding accordingly;

7.
Fill in the thrombolysis registration form
.

National Institutes of Health Stroke Scale (NIHSS)

Improved the Rankin scale

1 Despite symptoms, no significant disability is seen; Be able to complete all the duties and activities that you regularly engage in

2 Mild disability; You can't do all the activities you were able to do before, but you can handle personal matters without help

3 Moderate disability; Some assistance is needed, but no assistance is required for walking

4 Severe disability; Not being able to walk without the assistance of others, and not being able to take care of one's own physical needs

5 Severe disability; Bed rest, incontinence, continuous care and attention

Barthel Index (BI) Rating Form

Barthel Index (BI) Rating Form

Name: Gender: Age: Ward: Bed Number: Hospital Number:

Clinical significance: After the score is evaluated, the patient's ADL independence (grade 5)
can be judged according to the following criteria.
Points below 0-20 are extremely serious functional defects and are completely dependent on
ADL.
25-45 = Critical functional defect, heavy ADL dependency
.
50-70 = moderate functional defect, moderate dependency
on ADL.
75-95 = mild functional defect, ADL mild dependence
.
100=ADL self-care
.

Those with a score of 60 or above are those who have mild disabilities but are basically self-conscious; People with 60 to 40 points are moderately disabled and need help in life; People with 40 to 20 points are severely disabled and need great help in life;