NO

Clinical Diagnosis of ischemic stroke causing a measurable deficit defined as impairment of language, motor function, cognition, 0vision

Time of onset of stroke well established to be less than 3 hours (180 minutes)

CT negative for intracranial hemorrhage

Age greater or equal to 18 years

Documented discussion of risks and benefits of treatment with patient and/or designated decision-maker

Discussed with Neurology and consensus exists for thrombolysis

YES

NO

Exclusion Criteria -- SHOULD BE ALL "NO"

Only minor or rapidly improving stroke symptoms

A profound stroke with obtundation, fixed eye deviation and complete hemiplegia

Clinical presentation consistent with subarachnoid hemorrhage even if CT normal

BP greater than 185 / 110 mmHg

Use of anticoagulants in previous 48 hours and a prolonged PTT or an INR greater than 1.5

Platelet count less than 100,000

Active internal bleeding

Gastrointestinal or urinary bleeding within 21 days

Major surgery within 14 days

Blood, serum or plasma Blood Glucose less than 3 or greater than 22 mmol/L

Seizures within 6 hours of onset of stroke

Myocardial infarction within 3 weeks

Pregnant or lactating women

Within 3 months of any intracranial surgery, serious head trauma or previous stroke

History of intracranial hemorrhage

Known arteriovenous malformation or aneurysm

Arterial puncture at a non-compressible site

Lumbar puncture within 7 days

Acute pericarditis

Inclusion / Exclusion criteria completed and signed

2.

Second IV access: saline lock with saline flush in same arm.

3

Cardiac monitor during infusion of tPA

4.

Total dose of tPA: __________ mg over 1 minute as 10% bolus, followed immediately by ___________ mg IV continuous infusion over 60 minutes, for a total of _____________ mgs

DOSE CALCULATIONS: Choose the smallest of the following:

a] Patient’s weight in kg _________x 0.9 mg/kg _________mg.

OR

b] Maximum dose of 90 mgs (Maximum bolus of 9 mgs

Total dose __________ mg

5.

Neurovitals and blood pressure q 15 min x 1 hour after start of infusion,

then q 30 min x 2 hours

then q 1 h x 1 6 hours

then q 2 h x 24 hours

if stable q 6 h x 48 hours

then q12h

Temperature q 2 hr x 24 hours then as per clinical unit routines

6.

NPO except for meds for 24 hours then see Admission Orders.

7.

No heparin, warfarin , aspirin, ticlopidine or clopidogrel or other antiplatelet or anticoagulant durgs or NSAIDs for 24 hours

8.

Bleeding precautions: check puncture sites for bleeding or hematomas.

Apply digital pressure dressings to active compressible bleeding sites.

Evaluate urine, stool, emesis or other secretions for blood.

9.

Notify most responsible physician immediately if evidence of bleeding, neurological

deterioration and/or vital signs outside:

· Systolic blood pressure greater than 185 or less than 110 mm Hg

· Diastolic blood pressure greater than 95 or less than 60 mmHg for 2 or more readings taken more than 5-10 minutes apart

· Pulse less than 50 / min

· Respiration Rates greater than 24

· Temperature greater than38° C

10.

Monitor intake / output x 48 hours and reassess

11.

Avoid intramuscular injections, blood draws, catheterizations or other invasive line / procedures for 24 hours after thrombolysis treatment.

12.

Bladder care:If incontinent: in-out catheterization for residual volume, send for R&M.

Notify most responsible physician if volume more than 200 mL.

If patient does not void within next 8 hours: In-out catheterization for volume.

Send for R&M, culture and sensitivity. Catheterize q6h prn.

Notify most responsible physician if volume less than 200 mL over 8 hours

13.

Activity: bathroom privileges

BRP first 24 hours then as tolerated

Initiate DVT prophylaxis 24 hours after thrombolysis

Initiate antiplatelet or anticoagulant stroke prophylaxis 24 hours after thrombolysis

Consult the following: (cross out those not required)

Physiotherapy; Social Work

Occupational Therapy Speech/Language Pathologist

Registered Dietician Neurology

Bladder care:

If incontinent: in-out catheterization for residual volume, send for R&M. Notify most responsible physician if volume more than 200 mL.

If patient does not void within next 8 hours: In-out catheterization for volume. Send for R&M, culture and sensitivity. Catheterize q6h prn.

Notify most responsible physician if volume less than 200 mL over 8 hours

Bowel Care: Docusate sodium 100 mg bid.

If no BM in 2 days, give Magnesium Hydroxide (Milk of Magnesium) 30 mL po qhs.

If no BM on day 3, give Bisacodyl suppository (Dulcolax) 10 mg per rectum, followed by sodium phosphate (Fleet) enema if needed.

Repeat protocol if needed.