Rankin scale          Stroke protocol 

 

A Thrombolysis Stroke is a blood clot blocking the blood supply to part of the brain. This clot can lead to some permanent damage. Six months after a stroke about half of all patients will still have disability, with some fatalities. Medicines like Alteplase are used in frontline treatment of thrombolysis stroke. These treatments improve blood supply to the brain and improve chances of a better recovery. Research suggests treatment has to be given as soon as possible and no later than 4./5hrs of onset of the stroke.

Benefits:

Reverse the effect

Reducesthe amount of disability

One person in ten or 10% treated with Alteplase will make a better recovery.

Alteplase appears to increase the number of people who are able to manage without help.

To confirm a stroke from a transient ischaemic attack (TIA) doctors follow a strict protocol listed below to determine which route to take:

Side effects

Serious side effects from a risk of bleeding from the first day after treatment.

Some bleeding risks are minor (EG: bleeding from injection site).

Most severe bleeding in the brain making the stroke worse.

Small number (3 in 100) will be fatal.

This bleeding can also occur naturally without receiving Alteplase.

 

 

Sudden onset of focal neurological deficit If subacute onset, look for typical syndrome Seizure (e.g. limb twitching) at onset makes ischaemic

stroke less likely but does occur.  It is more common in intracerebral haemorrhage. Loss of consiousness is unusual in stroke.  Look for signs of brainstem dysfunction. For diagnostic scores e.g. ROSIER

Ongoing symptoms and less than 3 hours from symptom onset? IF SO, STOP HERE, DO NOT GIVE ASPIRIN, and start THROMBOLYSIS PROTOCOL

NHS Fife Stroke Thrombolysis pathway & Protocol

There is an (in hours) and (out of hours) pathway in place.

Timescale starts when patient arrive with CT request in place within 5 mins of patient arrival. Ideally patient is in CT scanner 15mins after arrival, with 15 mins CT to treatment.

Patient assessed using the ROSIER guide and stroke team and CT advised.

ROSIER score is a measurement of consciousness, seizure activity, speech, weakness in the face, arm and leg. This is measured using a +1/0 scale. The score determines the likeliness of a stroke or Tran ischemic Attack (TIA).

Once a patient has agreed to Treatment, the clock is stopped at the onset of treatment. Optimal timescale is arrival to treatment within 30 minutes.

Treatment is done by IV bolus and infusion doses of Alteplase based on patient weight.  Alteplase is a fibrinolytic drug that acts as thrombolytic by activating plasminogen to form plasmin, which degrades fibrin and so breaks up thrombi.(NICE guidelines).This is done over an hour and the patient monitored over the next 24hrs.

Overview

Strokes

9000 per year

1000 eligable for IV+PA injections

300 severe due to large artery occlusion

Intracranial stent

STEMI

cagnard LINNC 2015

Jeffery L Saver neurosurgeon – Rankin Scale (time of onset)

Aspect score

CT perfusion

 

Ineligible for TPA

Time from wake up – 76hr stroke

Time = brain quality

Role of the acute stroke is:

Exclude contraindications/haemorrhage

Establish diagnosis

Other pathologies SAH SDH Abscess

 

CT pitfalls

Inaccurate at early stages

Insensitive for small lesions

Insensitive for old bleeds

Insensitive for posterior fossa

However enough to exclude

Hyperacute 0-6hrs

Late 6-12hrs

 

Hyperdense artery sign

Insular ribbon sign

Odema takes hrs

CT fogging?????

Vasculitis of the brain

 

What is vasculitis of the brain?

 

The brain and the spine make up the central nervous system.) CNS vasculitis often occurs in the following situations: accompanied by other autoimmune diseases such as systemic lupus erythematosus, dermatomyositis, and, rarely, rheumatoid arthritis. As well as infection, such as viral or bacterial.

 

The actual cause of these vasculitis diseases is usually not known. However, immune system abnormality and inflammation of blood vessels are common features. Each form of vasculitis has its own characteristic pattern of symptoms, much of which depends on what particular organs are affected.

 

Inflammatory brain disease, also referred to as inflammatory disease of the central nervous system (CNS), is a condition where the brain and/or spinal cord become inflamed. Inflammation in the brain causes irritation and swelling of brain tissue or blood vessels. Brain inflammation can occur for a variety of reasons.

 

Vasculitis is a condition that involves inflammation in the blood vessels. The condition occurs if your immune system attacks your blood vessels by mistake. This may happen as the result of an infection, a medicine, or another disease or condition.

Cerebral vasculitis or central nervous system vasculitis (sometimes the word angiitis is used instead of “vasculitis”) is vasculitis (inflammation of the blood vessel wall) involving the brain and occasionally the spinal cord. It affects all of the vessels: very small blood vessels (capillaries), medium-size blood vessels (arterioles and venules), or large blood vessels (arteries and veins). If blood flow in a vessel with vasculitis is reduced or stopped, the parts of the body that receive blood from that vessel begins to die. It may produce a wide range of neurological symptoms, such as headache, skin rashes, feeling very tired, joint pains, difficulty moving or coordinating part of the body, changes in sensation, and alterations in perception, thought or behavior, as well as the phenomena of a mass lesion in the brain leading to coma and herniation. Some of its signs and symptoms may resemble multiple sclerosis. 10% have associated bleeding in the brain.

“Inflammation” refers to the body’s response to injury, including injury to the blood vessels. Inflammation may involve pain, redness, warmth, swelling, and loss of function in the affected tissues.

In vasculitis, inflammation can lead to serious problems. Complications depend on which blood vessels, organs, or other body systems are affected.

Vasculitis can be caused by underlying pathologies:

Classifications + Pathophysiology

 

SLE (single organ vasculitis) RA

Immunosuppressed – ie; RA

Viral – ie; chicken pox

TB

Fungal

Drug related central nervous system (CNS) abnormality

 

It is best seen on digital subtraction imaging and can also be seen on an angio.

 

You get Arachnoid granulation in venous imaging

Cerebral venous sinus thrombosis

Usually 62 Hounsfield units

Delta sign (Empty delta sign)

 

https://images.radiopaedia.org/images/6778/1e73b0faaaee30a45c069951abaa4a_big_gallery.jpg

This is a filling defect on a venogram

Cord sign

dural venous sinus thrombosis.

https://radiopaedia.org/articles/cord-sign-dural-sinus-thrombosis

Cerebral Vasculitis

The disruption in blood flow caused by inflammation can damage the body’s organs. Signs and symptoms depend on which organs have been damaged and the extent of the damage.

Typical symptoms of inflammation, such as fever and general aches and pains, are common among people who have vasculitis.

Outlook

There are many types of vasculitis, but overall the condition is rare. If you have vasculitis, the outlook depends on:

• The type of vasculitis you have
• Which organs are affected
• How quickly the condition worsens
• The severity of the condition
• Treatment often works well if it’s started early. In some cases, vasculitis may go into remission. “Remission” means the condition isn’t active, but it can come back, or “flare,” at any time.

Sometimes vasculitis is chronic (ongoing) and never goes into remission. Long-term treatment with medicines often can control the signs and symptoms of chronic vasculitis.  Rarely, vasculitis doesn’t respond well to treatment. This can lead to disability and even death.

Much is still unknown about vasculitis. However, researchers continue to learn more about the condition and its various types, causes, and treatments.

 

Answers to Activity Pack.

Activity 1.

Due to being a diagnostic radiographer the above scenario does not apply to me. However having been in a situation where a patient did not want an x-ray even though the doctor requested one, I did not perform the examination. I feel that it is up to the individual patient. If someone expressly states they didn’t want to go ahead with what I have been asked to perform then it is up to the doctor to explain why the exam is needed and not for me to force the exam.

Activity 2

1: Systems in place to ensure my competencies are: mandatory training, CPD, eKSF, lectures reflective learning and on-line training.

2: The aspects of my code of conduct that I can apply to carrying out my role as a radiographer are, keep up to date with best practice and maintain my personal CPD portfolio. Maintain confidentiality, while complying with the Data Protection Act and update and record all necessary records. Follow infection control policies.

Acivity 3

1: I am accountably to my line manager for the development and maintenance of my clinical skills.

2: The code of conduct addresses accountability issues addressing patient care as being priority. Ensuring the practitioner complies to the Codes and Standards that regulate the professions making it clear that each practitioner is personally accountable for their actions and omissions when dealing with patients, carers and other members of the team.

As a practitioner I am accountable for my individual responsibility and awareness of your own competence and educational needs. This also applies to issues such as delegation and the skill mix of staff to ensure that staff are prepared and supported to deliver the necessary care service. As well as complying to the wider organisational issues such as having the appropriate policies, procedures, reporting and governance arrangements in place that include miscommunication or faults.

Acitvity 4

I would prevent skill fade by keeping reasonably up to date with major changes and developments with the use of electronic libraries, internet and by attending lectures. Comply with National Institute for Clinical Excellence (NICE) and Clinical Governance. Comply with Ionising Radiation (Medical Exposure) Regulations 2000 (IRMER) along with The Ionising Radiations Regulations 1999. Continue to follow lifelong learning, reflective practice, evidence based care, CPD and e-KSF.

Activity 5

Clinical Governance influences my skills and practices by providing clear guidelines of responsibility and accountability. Protocols are implemented with guidelines for skill mix. Guidance due to evidence based practice is supported and applied routinely from everyday practice, with risk assessment being done before new roles and working practices are implemented. Service failures are monitored to analyse and improve services.

Activity 6

Does not apply in my profession. As a radiographer I would never have to make the clinical decision for blood transfusion.

 Activity 7

Documentation difficulties in my clinical area are can be due to bad hand writing on a request card and this being interpreted wrongly and the wrong examination being performed. Another potential problem is someone mistakenly filling out the wrong examination or wrong body part on a request card.

Activity 8

Abbreviations are not permitted on the examination part of an x-ray request card. Any abbreviations on a card are discussed with the referrer who has requested the exam to get clear clarification on the meaning of the abbreviation being used.

Activity 9

N/A

Activity 10

As a health professional I am expected to keep reasonable up to date with evidence based practice and care and carrying out my duties following all the current protocols and procedures.

In the case of Hunter v Hanley the doctor was found to be negligent due to not carrying out a procedure not using the appropriate equipment. This case highlighted the need for a test for the standard of care which doctors and health professionals to adhere to. The Bolam case law stated a doctor is not negligent, if he is acting in accordance with a practice accepted as proper by a responsible body of medical men skilled in that particular art, merely because there is a body of such opinion that takes a contrary view”.

These two case highlight the need for clinical governance, so professionals are expected to continually update their skills and work in accordance to best practice.

 Activity 11

N/A

Ethical issues to consider are the benefits to the patient and the valuable help and treatment that may be delayed if a venous blood sample was not provided.

Follow the principles inherent within the code of conduct set out by the Society and College of Radiographers (SCoR) to give advice and guidance to radiographers.

This code of conduct is adjunct to the current Health Professions Council (HPC) Standards of Conduct, Performance and Ethics1 and must be used in conjunction with it and all other relevant HPC publications.

The standards of ethical behaviour which underpin and sustain professional and personal conduct:

1. Scope of Professional Practice
2. Relationships with Service Users
3. Relationships with Professional Staff
4. Personal and Professional Standards

 

Keep up to date with best practice and maintain my personal CPD portfolio.

Maintain confidentiality, while complying with the Data Protection Act and update and record all necessary records. Follow infection control policies.

Responsibilty – meet all the standards of proficiency

Maintain my knowledge, skills and experience to practise lawfully, safely and effectively.

•  practise safely and effectively within their scope of practice
• practise within the legal and ethical boundaries of their profession
• practise within the legal and ethical boundaries of their profession
• be able to practise as an autonomous professional, exercising their own professional judgement
• be aware of the impact of culture, equality, and diversity on practice
• be able to practise in a non-discriminatory manner
•  understand the importance of and be able to maintain confidentiality
• be able to communicate effectively
• be able to work appropriately with others
• be able to maintain records appropriately
• be able to reflect on and review practice
• be able to assure the quality of their practice

Fife Mulit Agency Adult Protection

 

This guidance outline the duties and responsibilities of all agencies concerned with the protection of adults, however, it is important to recognise that “Adult Protection is everyone’sbusiness”.

 

CPD Talk 4^th May 2014.

 

Following the Adult protection talk

I have recently read about an up and coming system for hospitals to alert them to children at risk. Announced by Dr Dan Poulter (Synergy News, 2013), this system will be an aid to alert Doctors and Health Care Professionals to children at risk or suffering from abuse and neglect.

Being introduced to the NHS Hospitals in 2015 and know as Child Protection Information System (CPIS), not to be confused with Computerised Radiology Information System (CRIS).

This system will immediately alert Doctors in an A&E department or minor injuries unit, of any frequent visits to the department. It also informs the Doctor that the child is in local authority care or registered with social work department under a protection plan.

This system is designed to help establish a better picture to any possible concerns or risks within the child life style. It can highlight numerous attendances at various Emergency Units. Highlighting numerous or suspicious injuries which might indicate abuse.

Following the talk I feel there may be a cross over hear and this may be a possible tool to help with the Adult protection System.

Reference:

Synergy News. (2013) New child abuse alert system for hospitals announced: [Online], Available: http://www.sor.org/ezines/scortalk/issue-3/new-child-abuse-alert-system-hospitals-announced [15 Jan 2013]

www.sor.org

I love my job. I love everything about radiography. It is such a vibrant world. It is a demanding environment (especially if you throw yourself into the workload as I tend to do) but the rewards are also there. The feeling of making a real difference to someone’s life when a nervous and frail patient puts their hand up as you shout their name and then difference in their demeanour as you talk them through the procedure and relax them and take a great dagnostic image. They leave feeling much better about the whole experience.

There’s also the difficult patients who through either substance abuse or nervousness can be aggressive or abusive but dealing with patients like that is also a really rewarding part of the job.

I am on the lookout for new and exciting challenges within this wonderful world of radiography…

Year 2 e-KSF   link to evidence.

No.	Dimension Name	Dimension Type	Foundation Outline Level	Full Outline Level	Current Level	Evidence
C1	COMMUNICATION	Work Related	2	2	…< 11234
C2	PERSONAL AND PEOPLE DEVELOPMENT	Work Related	1	2	…< 11234
C3	HEALTH, SAFETY AND SECURITY	Work Related	1	2	…< 11234
C4	SERVICE IMPROVEMENT	Work Related	1	1	…< 11234
C5	QUALITY	Work Related	1	1	…< 11234
C6	EQUALITY AND DIVERSITY	Work Related	1	2	…< 11234
HWB3	PROTECTION OF HEALTH AND WELLBEING	Work Related	1	1	…< 11234
HWB6	ASSESSMENT AND TREATMENT PLANNING	Work Related	1	3	…< 11234
IK1	INFORMATION PROCESSING	Work Related	1	1	…< 11234

Gateway

Year 1 e-KSF   link to evidence

No.	Dimension Name	Dimension Type	Foundation Outline Level	Full Outline Level	Current Level	Evidence
C1	COMMUNICATION	Work Related	2	2	…< 11234
C2	PERSONAL AND PEOPLE DEVELOPMENT	Work Related	1	2	…< 11234
C3	HEALTH, SAFETY AND SECURITY	Work Related	1	2	…< 11234
C4	SERVICE IMPROVEMENT	Work Related	1	1	…< 11234
C5	QUALITY	Work Related	1	1	…< 11234
C6	EQUALITY AND DIVERSITY	Work Related	1	2	…< 11234
HWB3	PROTECTION OF HEALTH AND WELLBEING	Work Related	1	1	…< 11234
HWB6	ASSESSMENT AND TREATMENT PLANNING	Work Related	1	3	…< 11234
IK1	INFORMATION PROCESSING	Work Related	1	1	…< 11234

Current Situation

The beginning of semester 2 of 4th year. This is my plan of action for my PDP. My aim for development is to continue to get as much hands on experience within the general department as possible. I still feel I haven’t had enough practice in adapting my technique in difficult situations. Although I had more of an opportunity in the last clinical block, I still feel I need more. There was one very busy week with very little staff on my last clinical block and I was allowed to carry out most examinations on my own without any interventions from other staff. This allowed me to perform examinations without feeling intimidated or nervous and this helped to increase my confidence.
However there are still examinations that I shy away from because I feel I am unable to perform them as well as some other examinations but this is an area that I am determined to work on.

Ideal Situation

An ideal situation would be to have the same opportunity again, especially because I have my fit to practice very soon. Confidence is a big problem for me and when I am working along side a member of staff that doesn’t know me I know it is going to take time before they allow me to work on my own. I like to perform the complete examination, from checking the patients previous history, to cleaning the room at the end. I feel this allows me to get into a routine knowing everything has been done. I enjoy working with others and completely understand when someone is helping me, however because our clinical placement are in blocks and you continually work with different staff members, I feel establishing a routine and being allowed to continually perform it helps to cement good practice and remove the possibility of errors.
My action plan for next block is to establish and maintain a routine that works for me and to tackle projections that I am not comfortable with, mainly axial shoulders, lateral scapulas and horizontal beam hips. I continually get told I am a good radiographer however until I feel I can perform to the level I think is acceptable then my confidence will always be low.

Steps to success

• Continue to have as much hands on within the general department.
• Tackle all examination that I am not confident in performing to help increase my performance and confidence.
• Perform more examinations that allows more hands on which allows me to adapt techniques.

Overall Completion Date

01 April 2011

SWOT analysis

Strengths

My strength is that I love the job and I strive to be as good as I can be. I as love the interaction with the patients and I am friendly and good at chatting to patients in a difficult situations.

Weaknesses

My biggest weakness is my confidence. Even though I know I am capable of most things that are asked of me I still question my ability. I know this will increase over time however with the little clinical time we receive it is difficult as there is never enough time to perform everything you would like to. My confidence begins to rise just as we are finishing our clinical placements.

Opportunities

On my last block I am at Queen Margaret Hospital. I would like to use this week to work alongside a member of staff who will advise and supervise me while I am performing the examinations I don’t feel comfortable with, mainly axial shoulders, lateral scapulas and horizontal beam hips, so I can overcome my nerves when performing them.

Threats

Threats to this situation can be working alongside a member of staff who interacts when you are performing an examination. This could be them checking your positioning of the patient. Some staff move the patient from there original position and then put them back to exactly the same position you had them in. Some radiographers do that through habit and are aware of it and apologise, however some do it all the time and don’t acknowledge they have done the exact same thing as you had done and this can be frustrating as a student. It also knocks your confidence and you end up questioning your ability, especially if your working alongside someone that does it continually.

Supporting Resources

Books / journals

Carver and Carver.
Clarks.

Web links

http://www.wikiradiography.com
http://www.e-radiography.net

Electronic resources

Presentations

Reflection

I have just finished my very last placement as a student. On reflection I feel I have had a very productive year. I also feel my confidence has increased dramatically over this last year, allowing me to gain the confidence to perform my “confidence to practice” in an out of hours placement. I really enjoy tackling the challenges of A & E situations as well as the challenges required for dealing with trauma patients which require me to think about the technicalities required when performing some examinations.
I also like the fact that as my confidence increases I relax and enjoy the job more. I do release I have so much more to learn and I look forward to doing this in the future.

Description

Schematic drawing of a tumorous lesion in the rectosigmoid junction traversed with a guidewire and catheter. C, Terumo guidewire (left) and angiographic catheters (right), Cobra and Headhunter types. D, Schematic drawing of the stent instrument advanced over the superstiff wire and the released stent in place.

Imaging consult colonic stenting.jpg

 

 

21 March 2011

This was my final week of placement as a student. It was quite daunting as I was very conscious of the fact that the next time I work in a radiography department I will be a qualified radiographer. It was also very exciting as, after 5 years, I can now see the end of the course in sight.
During the week I carried out a general practitioner (GP) request on a female patient who had presented to her GP with pain and tenderness in her forearm. The clinical history was brief so I asked the patient for more details. She showed the area of the pain which looked a little swollen but nothing remarkable. She informed me there had been no trauma and she didn’t understand why it was painful. I then continued with the examination of an AP and lateral forearm.
On processing the image it was very clear there was something obviously amiss with the patients’ ulnar. It looked as if something had taken a clean bite out of the patients’ bone, I had seen a similar case previously and thought it looked like osteosarcoma. I asked another radiographer for her opinion and we decided to get a radiologist to have a look before letting the patient leave. It was the opinion of the radiologist that the patient did have osteosarcoma and he was going to telephone her GP straight away so she could get an urgent referral to the osteosarcoma team.
I found the patients symptoms for this very surprising and I could understand why it took her so long to visit her doctor. The patient was 32 years of age with an 18 month old baby so it was understandable that she first thought she may have bumped it without realising and it would get better.
Osteosarcoma is a primary malignant tumour of bone and the cause of it is unknown. According to Shenoy at el (2007) osteosarcoma is the most common malignant bone tumour which conflicts with the opinion of Pretorius and Jeffrey (2006) who state osteosarcoma as being the second most common primary bone tumour after multiple myeloma. It is also the opinion of Pretorius and Jeffrey (2006) that sarcomas tend to undergo hematogenous spread, with pulmonary metastases being the most common.
According to Wang and Houston (2005) most osteosarcomas are sporadic, whereas inherited predisposition accounts for a small number of cases, along with this 20% of patients with osteosarcoma present clinically with overt metastatic disease, with the presence of metastatic disease being a strong predictor of a poor outcome. The disease is believed to originate from primitive mesenchymal cells but also may arise from pluripotential mesenchymal cells. Osteosarcoma is a deadly cancer and is commonly fatal when it metastasizes to the lungs. It usually forms as a single lesion on long bones, with the distal femur being the most common, then the proximal humerus and proximal tibia.
Several tests are necessary to diagnose osteosarcoma. Initially, a blood test followed by imaging tests to detect any other tumours and their location within the body. This can be performed by an X-ray, MRI, CT scan or bone scan. Confirmation of osteosarcoma can also be done by performing a biopsy to remove a piece of bone tissue.
Treatment for osteosarcoma depends on the location of the tumour and the severity of the illness. Treatments may include neoadjuvant therapy which is the administration of a therapeutic agent before the main treatment of chemotherapy to destroy cancerous cells and prevent the growth of new malignant cells. The aim of neoadjuvant therapy is to reduce the size or extent of the cancer before using radical treatment intervention, thus making procedures easier, more likely to succeed, and reducing the consequences of a more extensive treatment technique that would be required if the tumour wasn’t reduced in size or extent. Additionally, radiation therapy, which uses high-energy radiation beams to shrink tumours and destroy cancer cells may also be used to treat osteosarcoma. In advanced stages of osteosarcoma, doctors may suggest amputation to remove the affected limb. Advances in surgical techniques have allowed a reduction in the number of amputations associated with osteosarcoma. Tumours can now be removed from the affected bone without removing a limb, this is done by using artificial bones or bones from other parts of the body. These advances in surgical techniques to treat osteosarcoma have resulted in higher survival rates, and high limb salvage rates associated with this type of cancer. Attached to this writing are images taken from x-ray 2000 and the childrens specialist website.

Pretorius, E. S. and Jeffrey A. S. 2006. Radiology secrets. 2nd ed. Philadelphia: Mosby Elsevier

Shenoy, R. Pillai, A. Sokhi, K. Porter, D. Ried, R. 2008. Survival trends in osteosarcoma of humerus. European Journal of Cancer Care 17, pp. 261–269.

Wang, L. 2005. Biology of Osteogenic Sarcoma. Cancer Journal. pp. 294-305.

Ehow Health. 2011. How long are treatments for osteosarcoma. [online] Available at: http://www.ehow.com/how-does_5251031_long-treatments-osteosarcoma_.html [Accessed March 27]

Childrens Specialists. 2011. Musculoskeletal Tumors and Infections. [online] Available at: http://www.cssd.us/body.cfm?id=1238 [Accessed March 27]