Thrombolysis Stroke

October 10th, 2017

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?????

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Vasculitis

September 29th, 2017

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

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.

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Professional Issues

November 23rd, 2014

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:

Scope of Professional Practice
Relationships with Service Users
Relationships with Professional Staff
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

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Child Abuse Alert System Announced

September 7th, 2014

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

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