This video is produced by the South Australian Stroke Clinical Network as a training tool
for nurses and doctors.
It explains the Code Stroke scenario which we use in this state to ensure rapid assessment
of patients to enable administration of thrombolysis wherever possible.
OK, so the bolus is at 11.40, we'll keep a close eye on you.
The community need to recognize a stroke and know what to do.
Spread the word of FAST.
F for face asymmetry of smile, A for arm weakness, S for speech disturbance and T for telephone
zero, zero, zero in Australia and note the time.
Once the ambulance service have been called the code stroke process begins.
And the time of onset was.
OK see you in ED.
Thanks for the call.
Roger.
We'll see you on arrival.
Following the pre-notification the stroke nurse then activates the hospital code stroke
team.
The stroke team meets the patient on arrival in the emergency department.
ISBAR is a tool used to provide effective and accurate communication.
I for introduction; in this case a 49 year old Mr Bob Major.
S for situation; he was at work with a sudden onset of left face, arm, leg weakness and
slurred speech.
Time of onset was 11 o'clock.
B for background; He lives independently at home with a past medical history of atrial
fibrillation.
A is for assessment; the ROSIER score, Recognition Of Stroke In the Emergency Room, he scored
four with a face arm leg weakness and slurred speech.
R is for recommendations; an acute assessment by the stroke team for suitability for thrombolysis.
In a code stroke scenario all members of the emergency department and stroke team have
pre-defined roles so it's a very rapid assessment of the patient.
We do things like heart tracing, taking bloods, putting in a jelco, telling the patient what's
going to happen, doing a neurological assessment and then transferring them to radiology within
about 15minutes.
The National Institute for Health Stroke Severity Scale is known as the NIHSS.
It enables doctors and nurses all over the world to make a standardised assessment of
the severity of stroke.
Bob, we need to do a neurological examination on you.
Tell me how old you are?
49
What month is it now?
It's March
Do this for me, close your eyes, now open them.
With your hand make a fist and open it out.
See my pen here?
Don't take your eyes off my pen.
Follow my pen all the way.
Point to the finger that wiggles.
Ok so he's got some left visual neglect.
Give me a great big smile, show me all your teeth.
Screw up your eyes tight and raise up your eyebrows.
So it's weak on that left side.
Now I need to know whether you can feel this.
This is sharp?
Yes
Can you feel this?
Yes
It's not as sharp.
What about here?
Yep
And here?
Um just
Ok sharper on the right or the left
Much sharper on the
What about here?
OK, no.
So you can feel it but it's not as sharp.
Yeah
So we have some left sensory loss.
Lift up your right arm, keep it up, keep it up strong for 10.
One, two, three, four, five, six, seven, eight, nine, ten.
Lovely.
Lift this one up for me.
Come on, lift if up.
What can you do?
Anything at all?
It's pretty weak, isn't it?
OK, ah so I'm going to give him a three for his arm.
Lift up your right leg.
Keep it up for five.
One, two, three, four, five.
Rest down.
Lift up your left one.
Come on lift it up.
What have we got here anything?
OK still very weak.
With this finger touch my finger touch your nose.
Back to my finger, back to your nose, back to my finger, back to your nose.
Can you try with your left hand?
No
No, there's no ataxia there.
Now please rattle these words off for me please.
Pip, stone, fifteen, catastrophe, impossibility.
Yep.
Um, so we'll need to rush down to the CT scanner.
I've rung them to say we are on our way.
Hi Andrew, this is Bob Major for his code stroke imaging.
Hello Bob.
Have you ever had a CT before?
I don't think so.
I'm going to be taking you in and seeing what we can do for you, yep.
As part of the code stroke imaging protocol all or some of the imaging is performed.
Everyone gets a plain CT scan to determine the type of stroke and to rule out a bleed.
CT angiogram is performed to look at the intra and extra cranial vessels.
A perfusion scan may also be performed which highlights already infarcted brain or whether
there's brain at threat of infarction.
This is the penumbra and that's the brain you're trying to save.
In preparation for thrombolysis the patient must be informed of the risks.
One, the drug will do nothing.
Two it may make you better or totally better.
Three, and this is important, it could make you worse.
It could make you bleed from anywhere in your body, especially your brain, which could be
serious and even life threatening.
Other problems include; allergic reactions and local bruising.
Reassure the patient they will be monitored very carefully for signs of deterioration
over the next twenty four hours.
There are absolute contraindications to thrombolysis, which include; if there's no clear time of
onset, an uncontrolled blood pressure of 185/110, serious bleeding or clotting disorders, an
INR of greater than one point five or seizure at onset without vessel occlusion.
Relative contraindications include; recent heart attacks, strokes, head injuries, a very
severe stroke with a NIHSS of greater than 22, operations or biopsies.
The stroke doctor will discuss the patient with the Consultant.
He will give him a clear time of onset, the clinical findings, the medical history, the
blood test results and the results of the CT scan.
The consultant will review the images and the patient and decide whether thrombolysis
is indicated and the drug will only be offered if the Stroke Consultant thinks it's the best
treatment for the patient.
Bob I want you to sign this consent form for thrombolysis.
Bob how much do you weigh?
89 kilos
89 kilos.
The total dose is 80.1.
Ten percent bolus is eight.
60mil infusion is 72.1 and we're using two 50 milligram vials.
Ok, so our infusion will be 72.1.
Let's go.
Actilyse is given 0.9 milligrams per kilogram.
The maximum dose is 90 milligrams.
It will come in a 50 milligram vial and a ten milligram vial.
The patient will have cardiac monitoring in-situ and be constantly checked to observe for bleeding,
headache, changes in clinical signs, signs of allergic reaction, angioedema and anaphylaxis,
is rare, but possible.
All right Bob, we are going to keep a close eye on you.
By completing standardised neurological and frequent vital signs observations early detection
of deterioration will be made.
The modified NIHSS includes questions on level of consciousness, visual fields, gaze, arm
and leg movement, sensation, language and whether there's neglect.
With a possible score out of 32.
If the score increases by four or more, the patient is deteriorating and will need urgent
medical review and possible re-scan of the brain to rule out a bleed.
You'll be pleased to know that our patient, Bob Major, made a good recovery with his thrombolysis
and was discharged to rehabilitation on day three.