Date______ Patient Arrival Time______ Time Last Known Normal______ Level (Circle One) a B C

Standard Order Set for Stroke Patients Patient Sticker Here

Date______Patient Arrival Time______Time Last Known Normal______Level (circle one) A B C

Name______MR#______Facility______

Stroke Level A – Symptom onset < 3 hours

IF UNALBE TO COMPLETE ANY ITEM BELOW, TRANSFER IMMEDIATELY TO A PRIMARYSTROKECENTER

□ Activate Stroke Alert
□STAT non-contrast CT Brain
Time to CT:______(door to CT < 25 min)
Time CT resulted:______(door to results < 45 min)
□ STAT bedside glucose assessment:______
□ STAT ECG & continuous cardiac monitoring.
□ Vital Signs every 15 minutes with NIHSS 1, 5, 6.
□ Oxygen ______L/M via nasal cannula
□ Ensure 2 IV lines. / □ STAT lab: CBC, CMP, PT/PTT (door to results < 45 min)
□ NIHSS initial assessment:______
□ Review Inclusion Criteria
□ Review Exclusion Criteria
□ Document Informed Consent; discussion of Risks+Benefits
□ Review time remaining in treatment window—can patient
benefit from intra-arterial tPA or MERCI
□ Prepare for immediate transfer to higher level stroke center
Time EMS called:______EMS arrival time______
Stroke Level B – Symptom onset 3 – 8 hours
IMMEDIATE TRANSFER TO PRIMARY or COMPREHENSIVESTROKECENTER / Stroke Level C – Symptom onset > 8 hours
Transfer to Primary or ComprehensiveStrokeCenter as appropriate
□ Activate Stroke Alert
□ NIHSS score:______
□ STAT Bedside Glucose Assessment:______
□ Ensure 2 IV lines (without delaying transfer)
□ Prepare for immediate transfer to Comprehensive Stroke
Center
Time EMS called:______EMS arrived:______/ □ Activate Stroke Consult
□ STAT non-contrast CT Brain
Time to CT:______(door to CT < 60 minutes)
Time to CT result:______(door to result < 120 minutes)
□ STAT Bedside Glucose Assessment:______
□ STAT ECG & continuous cardiac monitoring.
□ Vital Signs every 15 minutes with NIHSS 1, 5, 6.
□ Oxygen ______L/M via nasal cannula
□ Ensure 2 IV lines.
□ STAT lab: CBC, CMP, PT/PTT (door to results < 45 min)
□ NIHSS score:______
□ Admit / Transfer (circle one) If transferred:
Time EMS called:______EMS arrived:______

Exclusion Criteria for tPA
□ Onset of symptoms > 3 (or 4.5 hours)*
□ History of intracranial hemorrhage
□ SBP > 185 mm Hg treated on more than one measurement
□ DBP > 110 mm Hg treated on more than one measurement
□ Elevated PTT
□ Anticoagulant therapy (ASA is OK)
□ Heparin within preceding 48 hours
□ Lumbar puncture in the previous seven days
□ History suggestive of significant hepatic or ESRD
□ PT > 15 seconds (only if on Coumadin)
□ Platelet count < 100,000
□ Evidence of intracranial hemorrhage
□ Suspicion of subarachnoid hemorrhage
□ Serious head injury, or previous stroke within 3 months
□ Seizure at the onset of stroke
□ Active internal bleeding/major surgery past 14 days
□ intracranial neoplasm, AV malformation or aneurysm
□ Coma
□ Rapidly improving or minor symptoms (acceptable to patient)
□ Blood glucose < 50 mg/dl or > 400 mg/dl
□ GI or GU hemorrhage in previous 21 days
□ Arterial puncture at a non-compressible site within 7 days
□ Clinical presentation suggesting post-MI
□ Pericarditis
□ Pregnant, lactating or suspicion of pregnancy
*(if giving tPA in the expanded window and patient meets the more stringent exclusion criteria)

Inclusion Criteria for tPA
□ Age 18 or over
□ Clinical diagnosis of Ischemic stroke causing a measurable
neurological deficit.
□ Time of onset of symptoms well established to be < 180
minutes before treatment would begin. (or < 270 min)*
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