Post Thrombolysis
Care
and Complications
Gill Cluckie
Clinical lead, stroke
Guy’s and St. Thomas’ NHS
Foundation Trust
Essential Care
 1:1 Nursing for the first 24 hours?
 Bed Rest for 24 hours?
 Appropriate equipment at the patients
bedside, EG, cardiac monitor, suction,
drip stand and pump, oxygen, emergency
equipment
Observations
 Consistent and full neurological
observations:
- Every 15 mins for 2 hours
- half hourly for 6 hours
- hourly for 16 hours
 MRC grading for limb power
 NIHSS trained staff to identify significant
clinical changes
Things to Remember
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No heparin, warfarin, anti-platelets
Swallow assessment
Do not pass NG Tube until 24 hours
No arterial punctures or central lines
Avoid catheterisation. If essential, 30
mins after completion of thrombolysis
 NO SHAVING!!
Complications
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Blood Pressure Management
Intracranial Haemorrhage
Anaphylaxis
Extra-Cranial Haemorrhage
Blood Pressure
 Strict BP control to prevent increased risk
of intra-cranial haemorrhage – less than
180/100mmHg
 If either reading is above limit, recheck in 5
minutes
 If 3 readings at least 5 minutes apart show
BP higher than limit – administer IV
labetalol 10-20mg as bolus
 Do you usually give IV labetalol in your
unit?
Intracranial Haemorrhage
 What are the signs and symptoms?
 Symptoms: nausea, vomiting, headache,
altered limb function
 Signs: increasing difficulty obtaining same
GCS, agitation, drowsiness, drop in GCS,
altered limb function, vomiting
 How would you observe these in a drowsy
patient?
Intracranial Haemorrhage
 Decision on stopping the infusion if still in
progress
 Decision on urgent repeat CT brain to
confirm haemorrhage
 Follow protocols on referral of these
patients to neuro-surgeons
 Decisions on escalation plans or
palliative care option
Case Study 1
54 year old man collapsed with left face,
arm and leg weakness
Drowsy on assessment, clinically had R
MCA infarct
NIHSS = 12
Thrombolysed within 2 hours of onset
Case study 1
At 14 hours – improved face and leg
weakness and less drowsy- NIH had
reduced to 7
Went for repeat CT, nurse noticed on way to
CT that his left leg had deteriorated
Post-CT he was much more drowsy
Case study 1
Needed neurosurgery
Died 3 weeks later
Extra-Cranial
Haemorrhage
 What are the signs and symptoms?
 Symptoms: abdominal pain or discomfort,
nausea, obvious bleeding, malena
 Signs: haematemesis, malena,
haemodynamic compromise, pallor,
increasing drowsiness, heavy blood loss,
tachycardia
Extra-Cranial
Haemorrhage
 Common oozing from cannulation sites,
gum bleeding
 Post-angioplasty – careful management of
sheath site, likely to require Fem-stop
device to prevent haematoma development
 GI bleed – management of blood pressure,
blood volume, follow protocols for surgical
reviews and administering blood products
Extra-Cranial
Haemorrhage
 Ecchymosis
 Watch the restless patient and cannula sites
Anaphylaxis
 What are the signs and symptoms to
observe for?
 Symptoms: increased breathlessness,
tightness in chest, itch, tingling lips or
tongue, tightness in throat, dysphagia
 Signs: oral oedema, facial oedema, audible
wheeze, stridor, desaturation, increased
respiratory rate and effort, respiratory
arrest
Anaphylaxis
 Stop infusion if still in progress
 Administer adrenaline, chlorpheniramine
and hydrocortisone as for anaphylaxis
 Protect airway and maintain adequate
oxygenation
 May require intubation urgently via crash
call
Case Study 2
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64 yr old female
Thrombolysed
Arrival at Ward
Neuro obs unchanged
Cardio obs unchanged
Gum bleeding
observed
 WITHIN 5 MINUTES!!
CRASH CALL
Case study 2
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Tongue, face, eyes swollen
No BP fall or tachycardia
Difficult Intubation
Died in ITU due to secondary cerebral
oedema
Rate around 0.5-1%
Some anecdotes that angio-oedema is more
common in patients on ACE inhibitors on
admission
Plan Ahead
 Hand over to on-call teams/hospital at night
 Staff coverage – appropriate trained
people.
 Have the ability to react quickly and
appropriately when you notice a change no
matter how little or subtle
 Think of weekends and nights, drug charts,
escalation
 Never be worried to put out a Crash Call