Notice! Confluence will be undergoing system maintenance on Mondays from 5pm to 7pm. During this time the system may be unavailable.
Acute Stroke Call Response / Responding to a Stroke Team call
When the Stroke Team pager goes off
-- If it is an outside hospital, let the stroke attending/fellow answer.
--If it is a pre-hospital activation, send an acknowledgement page back to the pager that you are going to meet the patient in the ED.
--If it is an ED or inpatient activation
- Return the Stroke Team page.
- This call should take less than 2 minutes
- Get the pertinent info:
- time of onset
- current deficits
- any known contraindications to tPA.
- If the patient is an inpatient (non-ICU or PACU), ask the primary service to call the rapid response team.
- This is NOT the time to get family and social histories!
- Which describes your patient?
- Possible IV tpa candidate <4.5 hours
- Possible M1 or M2 syndrome 3-6 hours
- Possible basilar thrombosis within 24 hours
- Not an acute intervention candidate and why.
- Page Stroke Team (#90004) with a brief alpha page.
- Include the patient's:
- Reg #
- Last time known at baseline if a candidate
- If you were called personally rather than through a Stroke Team page, page the Stroke Team yourself (pager 90004 or search under the names for "stroke").
- If you need to speak with the Stroke Team BIG attending/fellow and they're not calling you back, see below.
- Include the patient's:
- GO IMMEDIATELY TO ASSESS THE PATIENT:
- The steps you need to go through are documented in the stroke packet which you should either pick up in the ER or print out from this link: tPA packet. In general:
- #*# Assure IVs in each arm, 0.9 NS, foley if indicated, send labs, finger stick glucose.
- Attempt to determine/confirm the time the patient was last known to be at baseline. Hunt down person with most information. (You may have to call a neighbor, relative, etc).
- If the patient is within 4.5 hours, determine IV rt-PA eligibility using the inclusion/exclusion criteria in the tPA packet.
- Perform an abbreviated neurological examination (NIHSS or Stroke Scale short form) (not the time to assess reflexes!) and review the CT head with your own eyes. Consider possible mimics (eg:seizure, migraine, psychogenic, etc).
- Consider IV rt-PA for those with a disabling stroke (disabling for that particular individual).
- Don't get a CTA with the CT by default as this will slow down IV tPA treatment.
- In the 4.5-6 hour window, consider IA intervention for possible MCA (M1 or M2) occlusion.
- In the 24 hour window, consider IA interventions for possible basilar artery thrombosis.
- Get a CTA of the head and neck while the tPA is infusing to evaluate for a target lesion in patients who may be candidates for IA treatment. Call the neuro-IR team (radiology adult: NIR...) as soon as you think the patient may be a candidate for IA treatment. No need to wait for the CTA results.
- At the earliest time that it becomes clear that the patient is not a candidate for an acute therapy, deactivate the stroke team through an alpha page giving the reason why not a candidate (include your contact #).
- Remember to staff with the appropriate inpatient or consult attending just as you would for any consult.
IN CASE OF STROKE PAGE FAILURE:
Hopefully it happens rarely, but it does happen – it's the middle of the night, you answer a stroke page, you page out your findings, you're not sure what to do . . . and no one from the stroke team calls back. What do you do?
First things first – don't panic! Most of us keep our phones on, and many keep our pagers on even when we're not technically on call. Sometimes we notice that the person on call hasn't responded, and you will get a flood of pages asking you if you're okay or if you need help. If that doesn't happen, try the following:
1. Page the Stroke Team pager again. When you page, make sure you say clearly that you have not been called and that you are waiting for a call back.
2. Look up the person on call for stroke and page them directly. The stroke team call schedule is available at:
Please note that this schedule is accurat at the begining of the month but is not always updated when people trade, etc. Also Internet Explorer 8 will not work, you'll need to cut and paste the link.
3. If that doesn't work, call the Stroke Team person on their phone directly. A list of stroke attending/fellow phone numbers is here. You can also ask the hospital operator to contact the attending at home.
4. Start calling people on the list of stroke team members (again, available here ) until somebody answers.
Complete the stroke navigator and import the content into your note.
Document an NIHSS on patient who receive IV tPA or an IA treatment in the first 2 progress notes after admission (or treatment).
When discharging patients, complete the discharge portion of the stroke navigator.