Template for plan of management (Ischemic Stroke after thrombectomy + tPA)
Plan:
Neurological:
- Neurological checks per tPA protocol (q15min for 4h then q1h for 24h then q4h)
- Seizure, fall, aspiration precautions
- Head of bed at 30 degrees at all times
- SBP goal 120-180
- No free water, mix everything in NS as this can worsen cerebral edema
- PT/OT/ST consults initiated
Stroke Workup:
- Initial CTH:
- Post thrombectomy CTH:
- CTA:
- MRI brain:
- Stroke labs: TSH, A1C, LDL
- Telemetry, TTE:
After IV tPA administration (Started at ------):
>Neurochecks: Every 15 mins x two hours, then every 30 mins x6 hours, then every hour x 16 hours.
>No foley removal or placement for 24 hours
>No venous/arterial puncture at non-compressible site
>No anticoagulation or anti-platelet agents for 24 hours
>Cardene drip as needed to keep BP < 180/105
After Thrombectomy:
>Will get CTH after thrombectomy, and 24h later.
> Regular check for groin hematoma and distal pulse.
- Meds:
- APAP 500 mg PO q6h PRN for pain or headache
- Will start aspirin 24h after tPA
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Respiratory:
- Aspiration precautions, head of bed above 30 degrees
- PRN O2
- Chest PT with vest q4hr
- Baseline CXR
- Suctioning q1-2 hours
- Meds:
- None
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Cardiology:
- Continuous cardiac telemetry
- SBP goal 120-180 (after thrombectomy)
- Meds:
-Nicardine drip (target SBP < 180)
-Labetalol 10mg IV q4h prn
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Renal:
- Renal function normal
- Monitor daily BMP, Mg, Phos
- Foley with temperature probe for strict I&O monitoring in critical care setting
- Avoid hypotonic fluids as this can worsen cerebral edema
- Meds:
- NS @ 75ml/h
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Gastrointestinal:
- NPO for now
- Last BM: unknown
- Meds:
- Docusate 100 mg PO TID
- Famitidine 20mg tab bid
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Endocrinology:
- FSBS q6hr while NPO
- Check HgbA1c, TSH
- Meds:
- Insulin SS
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Hematology:
- Monitor CBC daily
- SCDs for prophylaxis; no heparins given thrombolytics
- Meds:
- None
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Infectious Disease:
- Current access: PIVs (placed)
- Keep normothermic, aggressive fever control as this worsens neurological outcomes
- Meds:
-none
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Prophylaxis:
DVT: SCDs, no anticoagulation in the setting of recent thrombolytics
GI: famotidine, docusate
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Consults:
Physical therapy
Occupational therapy
Speech therapy
Nutrition
Case Management
Social Work
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Discharge Planning:
Patient requires ICU level of care for close monitoring after thrombectomy
Patient was discussed with the neurocritical care attending who agrees with current plan of management.