PLACE LABEL HERE

STROKE: TRANSIENT ISCHEMIC ATTACK (TIA)and

ISCHEMIC STROKE ORDERS

The following orders will be implemented. Orders with a “” are choices and are NOT implemented unless checked.

Initial all handwritten order modifications and the bottom of each page when indicated (multipage).

Thrombolytic = Tissue Plasminogen Activator (tPA, Activase, alteplase) has been administered.

TIA ABCD-2 Score
For stroke risk within 2 days / Point Value
(circle)
Age over 60 years / 1 point
Systolic B/P  140 mm Hg / 1 point
Diastolic B/P  90 mm Hg / 1 point
Unilateral weakness / 2 points
Speech impairment without weakness / 1 point
TIA duration  60 minutes / 2 points
TIA duration 10-59 minutes / 1 point
Diabetes / 1 point
TOTAL # POINTS
Low risk (1%) score 0-3 Moderate risk (4.1%) score 4-5 High risk (8.1%) score 6-7

1. Do you expect that the patient’s condition will require a hospital stay that will cross two midnights (includes the time spent in outpatient- ED, surgery, OBS) and the patient has medical necessity for an inpatient admission?

Yes, admit as inpatient, proceed to # 2No, place in observation

2. If admitted as inpatient, Inpatient Physician Certification:

Diagnosis: ______

Level of Care:

Suspected or confirmed cerebellar stroke or stroke with concern for mass effect/rapid worsening.

 Neuro Intermediate  Neuro ICU

 Acute Care Stroke Unit (Neuroscience or GMC-D 4th floor) q 4 hr neurological checks/vital signs

 Intermediate Care (Neuroscience/GMC-D 3rd floor) q 2 hr neurological checks/vital signs

 Critical Care (Neuro ICU/GMC-D ICU) q 1 hr neurological checks/vital signs

 PostTissue Plasminogen Activator (tPA, Activase, Alteplase) (Neuro ICU/GMC-D ICU) per Tissue Plasminogen Activator (tPA, Activase, Alteplase)Stroke orders and flowsheet, finish q 15 min for 2 hrs, then q 30 min for 6 hrs, then hourly for 16 hrs.

  1. Telemetry: If patient Medical/Surgical, must complete form # 36084, Indication: TIA/Stroke
  2. Isolation: Contact Droplet Airborne For: ______
  1. Consults:Neurology consult:______

Neurosurgical consult for cerebellar and cerebral edema/mass effect-see attached Guidelines for

Neurosurgical Consult for Cerebellar and Cerebral Edema

 Social Services consult for post acute rehabilitation

6.Use Stroke Plan of Care (form # 15694)

7. O2 per Protocol

8. Smoking Cessation

9.Rehab: Physical Therapy, Occupational Therapy, Speech Language Pathology

Post Tissue Plasminogen Activator(tPA, Activase, Alteplase): Begin PT/OT/SLP as safely tolerated

10.Lab: HgA1C

Fasting Lipid Profile

Copy to pharmacy Order writer’s initials ______

*3-15695* FORM 3-15695 REV. 06/2018 Page 1 of 3

PLACE LABEL HERE

STROKE: TRANSIENT ISCHEMIC ATTACK (TIA)and

ISCHEMIC STROKE ORDERS

The following orders will be implemented. Orders with a “” are choices and are NOT implemented unless checked.

Initial all handwritten order modifications and the bottom of each page when indicated (multipage).

11.Diagnostics:Post Tissue Plasminogen Activator(tPA, Activase/Alteplase) non-contrast CT at 24 hours, Indication: ______

 CT Brain w/o contrast Time: ______, Indication: ______

 MRI with diffusion of brain without contrast, Indication: ______

VASCULAR IMAGING: MRA head and neck

OR CTA head and neck including aortic arch indication stroke

 Transthoracic echocardiogram (TTE), Reason: TIA/Stroke, Read by: ______

Other: ______

12. Assessment: Vital signs/neuro checks including focused neuro check per level of care.

NIHSS each shift for the first 3 days. (Call Stroke Unit for assessment).

13.Diet: NPO until bedside swallow screen per RN

If swallow screen normal, begin diet as tolerated: ______

If swallow screen abnormal, maintain NPO, elevate head of bed 30°, and await Speech Language Pathology evaluation

14.Nutrition Supplement Orders (form # 31417), initiate if patient meets criteria

15.Foley Catheter Removal and Voiding Assessment/Interventions Standing Orders (form # 31620)

16.Activity: Progress as tolerated

17.Stroke Patient/Family education: Signs and symptoms, activate 911, risk factors, medications and follow-up care.

MEDICATIONS:

18.IVF:  NS at ______ml/hr

19.Antiplatelet:

 If Tissue Plasminogen Activator(tPA, Activase/Alteplase) administered, hold first dose of all antiplatelet or anticoagulant drugs including, but not limited to: Heparin, Lovenox (enoxaparin), Coumadin (warfarin), Pradaxa (dabigatran), Xarelto (rivaroxaban), Eliquis (Apixaban), Aspirin, Aggrenox (aspirin/dipyridamole), Plavix (clopidogrel), Effient (prasugrel) or Brilinta (ticagrelor) for 24 hrs

ANDNursing to Call Intensivist for antiplatelet order after 24 hour post activase non-contrast CT is completed.

OR (Select antiplatelet therapy if Tissue Plasminogen Activator (tPA, Activase, Alteplase)was not administered)

 Contraindication to antiplatelet:______

 Aspirin 325 mg po or per rectum daily

 Plavix (clopidogrel) 75 mg po daily

 Other: ______

20.Blood pressure management(Physician to indicate which medication to use first. If not effective, call physician):

Trandate (labetalol) 10-20 mg IV ____hr PRN HTN (see below), Hold for heart rate < 50/min. Recheck BP within 30 min and notify physician if not in parameters.

or Hydralazine 10 mg IV q _____ hrs PRN HTN (see below), Recheck BP within 30 min and notify physician if not in parameters.

or  ICU only, Cardene (nicardipine): Initial infusion 5 mg/hr, increase by 2.5 mg q5 min to max of

15mg/hr, see Titration Protocol (form # 33883)

Blood Pressure (BP) Administration Parameters (must be completed):

Permissive HTN: Maintain BP ≤ 220 mm Hg systolic and/or ≤ 120 mm Hg diastolic.

orMaintain systolic BP < _____ mmHg and/or diastolic BP < _____ mmHg.

orDC other parameters if thrombolytic given, keep systolic B/P ≤ 180 mm Hg anddiastolic BP ≤ 105 mm Hg.

Copy to pharmacy Order writer’s initials ______

FORM 3-15695 REV. 06/2018 Page 1 of 3

PLACE LABEL HERE

STROKE: TRANSIENT ISCHEMIC ATTACK (TIA)and

ISCHEMIC STROKE ORDERS

The following orders will be implemented. Orders with a “” are choices and are NOT implemented unless checked.

Initial all handwritten order modifications and the bottom of each page when indicated (multipage).

MEDICATIONS (continued):

21.Cholesterol lowering therapy  Contraindication to statin therapy: ______

High Intensity:

 Lipitor (atorvastatin) 80 mg po at bedtime

or Other:______

Moderate Intensity if > 75 years old:

 Lipitor (atorvastatin) 20 mg po at bedtime

or Other: ______

22. VTE prophylaxis, Initiate Venous Thromboembolism (VTE) Prophylaxis Orders (form # 33058)

Heparin 5,000 units SQ q 8 hrs (q 12 hrs if wt < 50 kg or age > 75). Hold for 24 hrs if Tissue Plasminogen Activator( tPA, Activase, Alteplase) administered

or Lovenox (enoxaparin) 40 mg SQ daily at 1700 (30 mg if CrCl < 30). Hold for 24 hrs if Tissue Plasminogen (tPA, Activase, Alteplase) administered

and/or Mechanical devices: SCDs

23. Nicotine patch 14 mg once daily prn apply topically after smoking cessation education

24.Mild pain/temp99.5F/HA: Tylenol (acetaminophen) 650 mg po or per rectumq 4 hrs prn

25.Stool Softener: Colace (docusate) 100 mg po bid prn; if patient has not had a bowel movement

26.Constipation: Milk of Magnesia (MOM) 30 ml po daily prn

27. Electrolyte Replacement Protocol (form # 21340)

ADDITIONAL ORDERS

______

______

______

______

______

DateTimePhysician SignaturePID Number

Copy to pharmacy

FORM 3-15695 REV. 06/2018 Page 1 of 3

REFERENCE - Not Part Of Medical Record

Guidelines for Neurosurgical Consult for Cerebellar and Cerebral Edema

Malignant Middle Cerebral Artery Infarction

for Possible Decompressive Hemicraniectomy

  • Large volume > 50% of MCA territory infarction on CT or DWI volume > 145 ml on MRI after 16 hours of onset of symptoms
  • NIHSS > 16 for non-dominant hemisphere stroke or NIHSS > 20 for dominant hemisphere stroke
  • Patients < 60 yrs with malignant MCA infarction
  • Decompressive hemicraniectomy should preferably be performed within 48 hours of stroke onset
  • Decompressive hemicraniectomy should be offered on a case by case basis for healthy patients > 60 yrs and beyond 48 hrs after stroke onset
  • A thorough discussion with the patient and family about limited evidence of benefit, and likelihood of poor neurologic outcome needs to be addressed.
  • Adequate craniectomy with a target 14 cm anterior, posterior and temporal bone removed down to the middle fossa and duroplasty

Class IIa: Level of Evidence A from the American Stroke Association 2018 Ischemic Stroke Guidelines.

Cerebellar Stroke with Edema

  • Ventriculostomy is recommended for obstructive hydrocephalus from a cerebellar infarct
  • Decompressive suboccipital craniectomy with dural expansion should be performed in patients with cerebellar infarction causing neurological deterioration from brainstem compression despite maximal medical therapy.

Class 1 recommendation from the American Stroke Association 2018 Ischemic Stroke Guidelines

William J. Powers, Alejandro A. Rabinstein et al. 2018 Guidelines for the Early Management of Patients with Acute Ischemic Stroke. Stroke. 2018;49: e1-e344.

REFERENCE - Not Part Of Medical Record