แนวทางรักษา stroke-fast-track

1. ·π«∑“ß°“√√—°…“π’È ‡ªìπ‡§√◊ËÕß¡◊Õ à߇ √‘¡§ÿ≥¿“æ¢Õß°“√∫√‘°“√¥â“π ÿ¢¿“æ
∑’ˇÀ¡“– ¡°—∫∑√—欓°√·≈–‡ß◊ËÕπ‰¢ —ߧ¡‰∑¬ ‚¥¬À«—ߺ≈„π°“√ √â“߇ √‘¡
·≈–·°â‰¢ªí≠À“ ÿ¢¿“æ¢Õߧπ‰∑¬Õ¬à“ß¡’ª√– ‘∑∏‘¿“æ·≈–§ÿâ¡§à“ ¢âÕ·π–π”µà“ßÊ
„π·π«∑“ß°“√√—°…“π’ȉ¡à„™à¢âÕ∫—ߧ—∫¢Õß°“√ªØ‘∫—µ‘ ºŸâ„™â “¡“√∂ªØ‘∫—µ‘·µ°µà“ß
‰ª®“°¢âÕ·π–π”‰¥â „π°√≥’∑’Ë ∂“π°“√≥å·µ°µà“ßÕÕ°‰ªÀ√◊Õ¡’‡Àµÿº≈∑’Ë ¡§«√
‚¥¬„™â«‘®“√≥≠“≥∑’ˇªìπ∑’ˬա√—∫„π —ߧ¡
✧ ✧ ✧ ✧ ✧ ✧ ✧ ✧
©∫—∫∑’Ë 1 æ.». 2549 (æ‘¡æå§√—Èß∑’Ë 1)
ISBN : 974-8133-47-8

2. §”π‘¬¡
‚√§À≈Õ¥‡≈◊Õ¥ ¡Õ߇ªìπ‚√§∑’Ëæ∫∫àÕ¬‚√§Àπ÷ËߢÕß‚√§∑“ß√–∫∫ª√– “∑ ·≈–‡ªì𠓇Àµÿ°“√µ“¬∑’Ë ”§—≠
„πÕ—π¥—∫µâπÊ ¢Õߪ√–‡∑» ‚√§π’ÈÀ“°‰¡à‰¥â√—∫°“√√—°…“∑—π∑à«ß∑’¡—°®–¡’§«“¡æ‘°“√µ“¡¡“‡ ¡Õ ªí®®ÿ∫—π¡’«‘∏’
°“√√—°…“„À¡à∑’ˉ¥âº≈¥’ ‰¥â·°à °“√©’¥¬“≈–≈“¬≈‘Ë¡‡≈◊Õ¥∑“ßÀ≈Õ¥‡≈◊Õ¥¥” ·¡â«à“«‘∏’°“√‰¡à¬ÿà߬“°·µà¡’¢âÕ®”°—¥
¥â“π‡«≈“ °≈à“«§◊Õ µâÕß«‘π‘®©—¬·≈–‡√‘Ë¡°“√„À⬓≈–≈“¬≈‘Ë¡‡≈◊Õ¥¿“¬„π 3 ™—Ë«‚¡ßÀ≈—߇°‘¥Õ“°“√ ¥—ßπ—Èπ ∂“π欓∫“≈
µà“ßÊ ®÷ßµâÕß¡’°“√‡µ√’¬¡§«“¡æ√âÕ¡„π¥â“π∫ÿ§≈“°√ Õ“§“√ ∂“π∑’Ë ·≈–√–∫∫°“√∫√‘°“√ ‡æ◊ËÕ„Àâ “¡“√∂√Õß√—∫
°“√√—°…“«‘∏’π’ȉ¥âÕ¬à“ß¡’ª√– ‘∑∏‘¿“æ ´÷Ëß„π¢≥–π’Ȫ√–‡∑»‰∑¬¬—߉¡à¡’·π«∑“ß„π°“√√—°…“‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßµ’∫
·≈–Õÿ¥µ—π¥â«¬°“√©’¥¬“≈–≈“¬≈‘Ë¡‡≈◊Õ¥∑“ßÀ≈Õ¥‡≈◊Õ¥¥” ∑’ˇªìπ¡“µ√∞“π‡¥’¬«°—π
∂“∫—πª√– “∑«‘∑¬“„π∞“π–∑’ˇªìπ ∂“∫—π‡©æ“–∑“ߥâ“π‚√§∑“ß√–∫∫ª√– “∑‰¥âµ√–Àπ—°∂÷ߪí≠À“¥—ß°≈à“«
®÷߉¥â¡’°“√¢Õ§«“¡√à«¡¡◊Õ°—∫ ∂“∫—π∑“ß«‘™“°“√µà“ßÊ ®—¥∑”·π«∑“ß°“√√—°…“‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßµ’∫·≈–Õÿ¥µ—π
¥â«¬°“√©’¥¬“≈–≈“¬≈‘Ë¡‡≈◊Õ¥∑“ßÀ≈Õ¥‡≈◊Õ¥¥” ‡æ◊ËÕ‡ªìπ·π«∑“ß„π°“√¥Ÿ·≈√—°…“‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßµ’∫·≈–
Õÿ¥µ—πœ „Àâ¡’ª√– ‘∑∏‘¿“æ ‚¥¬À«—ß„À⇰‘¥ª√–‚¬™πå·°à·æ∑¬å·≈–∫ÿ§≈“°√ºŸâ‡°’ˬ«¢âÕßÕ¬à“ß·∑â®√‘ß „π°“√∑’Ë®–π”
§«“¡√Ÿâ∑’ˉ¥â√—∫‰ªªØ‘∫—µ‘‰¥â∂Ÿ°µâÕß·≈–‡ªìπ¡“µ√∞“π‡¥’¬«°—π∑—Ë«ª√–‡∑» ‚¥¬¡’°“√¥”‡π‘π°“√ ¥—ßπ’È
1. ª√–™ÿ¡§≥–∑”ß“πºŸâ∑√ߧÿ≥«ÿ≤‘·≈–ºŸâ‡™’ˬ«™“≠ §√—Èß∑’Ë 1 „π«—π∑’Ë 3 ‡¡…“¬π 2549
2. ª√–™ÿ¡§≥–∑”ß“πºŸâ∑√ߧÿ≥«ÿ≤‘·≈–ºŸâ‡™’ˬ«™“≠ §√—Èß∑’Ë 2 „π«—π∑’Ë 20 ‡¡…“¬π 2549
3. ª√–™ÿ¡§≥–∑”ß“πºŸâ∑√ߧÿ≥«ÿ≤‘·≈–ºŸâ‡™’ˬ«™“≠ §√—Èß∑’Ë 3 „π«—π∑’Ë 2 情¿“§¡ 2549
4. ª√–™ÿ¡§≥–∑”ß“πºŸâ∑√ߧÿ≥«ÿ≤‘·≈–ºŸâ‡™’ˬ«™“≠ ‡æ◊ËÕæ‘®“√≥“·π«∑“ß°“√√—°…“‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßµ’∫
·≈–Õÿ¥µ—π¥â«¬°“√©’¥¬“≈–≈“¬≈‘Ë¡‡≈◊Õ¥œ „Àâ¡’§«“¡ ¡∫Ÿ√≥å „π«—π∑’Ë 16 ¡‘∂ÿπ“¬π 2549 ‡æ◊ËÕ®—¥æ‘¡æå§√—Èß∑’Ë 1
·≈–‡º¬·æ√àµàÕ‰ª
Õ¬à“߉√°Áµ“¡ ·π«∑“ß°“√√—°…“‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßµ’∫·≈–Õÿ¥µ—π¥â«¬°“√©’¥¬“≈–≈“¬≈‘Ë¡‡≈◊Õ¥œ ©∫—∫π’È ‡ªìπ
§”·π–π”„π ‘Ëß∑’˧«√·°à°“√ªØ‘∫—µ‘‡∑à“π—Èπ ∑—Èßπ’È „π°“√ªØ‘∫—µ‘®√‘ß®–¢÷Èπ°—∫¥ÿ≈¬æ‘π‘®¢Õß·æ∑¬åºŸâ¥Ÿ·≈ºŸâªÉ«¬¢≥–
π—Èπ‡ªì𠔧—≠
„π∑⓬π’È ∂“∫—πª√– “∑«‘∑¬“À«—߇ªìπÕ¬à“߬‘Ëß«à“ ·π«∑“ß°“√√—°…“‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßµ’∫·≈–Õÿ¥µ—π
¥â«¬°“√©’¥¬“≈–≈“¬≈‘Ë¡‡≈◊Õ¥œ©∫—∫π’È®—°‡°‘¥ª√–‚¬™πå ”À√—∫·æ∑¬å∑’Ë®–𔉪ª√–¬ÿ°µå„™â‡æ◊ËÕ„Àâª√–™“™π¡’§ÿ≥¿“æ
™’«‘µ∑’Ë¥’ „π‚Õ°“ π’È „§√à¢Õ¢Õ∫§ÿ≥ºŸâ‡™’ˬ«™“≠®“°§≥–·æ∑¬»“ µ√å¡À“«‘∑¬“≈—¬µà“ß Ê ¡“§¡ª√– “∑«‘∑¬“
·Ààߪ√–‡∑»‰∑¬ ¡“§¡‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß·Ààߪ√–‡∑»‰∑¬ ∑’ˉ¥â„À⧫“¡√à«¡¡◊Õ‡ªìπÕ¬à“ߥ’„π°“√®—¥∑”
√«¡∑—Èß°√¡°“√·æ∑¬å °√–∑√«ß “∏“√≥ ÿ¢ ∑’Ë π—∫ πÿπ°“√¥”‡π‘πß“π§√—Èßπ’ÈÕ¬à“ߥ’¬‘Ëß
(π“¬¡—¬∏—™ “¡‡ π)
ºŸâÕ”π«¬°“√ ∂“∫—πª√– “∑«‘∑¬“

3. √“¬π“¡§≥–ºŸâ®—¥∑”
·π«∑“ß°“√√—°…“‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßµ’∫·≈–Õÿ¥µ—π
¥â«¬°“√©’¥¬“≈–≈“¬≈‘Ë¡‡≈◊Õ¥∑“ßÀ≈Õ¥‡≈◊Õ¥¥”
1. π.æ. ÿ√«‘∑¬å ‡µ™∏ÿ«“π—π∑å ∑’˪√÷°…“
2. π.æ.¡—¬∏—™ “¡‡ π ª√–∏“π
3. π.æ. ¡™“¬ ‚µ«≥–∫ÿµ√ √Õߪ√–∏“π 1
4. π.æ. ÿ™“µ‘ À“≠‰™¬æ‘∫Ÿ≈¬å°ÿ≈ √Õߪ√–∏“π 2
5. æ.≠.∑—»π’¬å µ—𵑃∑∏‘»—°¥‘Ï √Õߪ√–∏“π 3
6. ».π.æ.π‘æπ∏å æ«ß«√‘π∑√å §≥–∑”ß“π
7. æ≈.µ.æ.≠.®‘µ∂πÕ¡ ÿ«√√≥‡µ¡’¬å §≥–∑”ß“π
8. æ.Õ.º».π.æ. “¡“√∂ π‘∏‘π—π∑πå §≥–∑”ß“π
9. ».æ.≠.¥‘…¬“ √—µπ“°√ §≥–∑”ß“π
10. √».æ.≠.π‘®»√’ ™“≠≥√ß§å §≥–∑”ß“π
11. π.æ.¬ß§å™—¬ π‘≈–ππ∑å §≥–∑”ß“π
12. π.æ. ¡“π µ—ÈßÕ√ÿ≥»‘≈ªá §≥–∑”ß“π
13. π.æ.摇™…∞ ‡¡∏“√—°…å™’æ §≥–∑”ß“π
14. æ.≠.æ√æ‘¡≈ ¡“» °ÿ≈æ√√≥ §≥–∑”ß“π
15. π.æ.Õ—§√«ÿ≤‘ «‘√‘¬‡«™°ÿ≈ §≥–∑”ß“π
16. π.æ. ÿ√»—°¥‘Ï ‚°¡≈®—π∑√å §≥–∑”ß“π
17. π.æ.°‘µµ‘™“µ‘ Õ‘π∑ÿ √ §≥–∑”ß“π
18. π.æ.‡¡∏“ Õ¿‘«—≤π“°ÿ≈ §≥–∑”ß“π
19. æ.≠.¢«—≠√—µπå À«—ߺ≈æ—≤π»‘√‘ §≥–∑”ß“π
20. π“ß ÿ≥’ ¿“≥ÿ‡√◊Õß√—»¡’ §≥–∑”ß“π
21. π“ß· ß∑» ¡ÿ ‘°∂“«√ §≥–∑”ß“π
22. æ.≠.°“≠®π“ Õ—Îπ«ß»å ‡≈¢“πÿ°“√
23. π. .Õ‘ √’ µ√’°¡≈ ºŸâ™à«¬‡≈¢“πÿ°“√·≈–ºŸâª√– “πß“π
§≥–∫√√≥“∏‘°“√ : π.æ. ¡™“¬ ‚µ«≥–∫ÿµ√
æ.≠.∑—»π’¬å µ—𵑃∑∏‘»—°¥‘Ï

4. §”π”
‚√§À≈Õ¥‡≈◊Õ¥ ¡Õ߇ªìπ‚√§∑’Ëæ∫∫àÕ¬‚√§Àπ÷ËߢÕß‚√§∑“ß√–∫∫ª√– “∑ ·≈–‡ªì𠓇Àµÿ°“√µ“¬
∑’Ë ”§—≠„πÕ—π¥—∫µâπÊ ¢Õߪ√–‡∑» ‚√§π’ÈÀ“°‰¥â√—∫°“√√—°…“‰¡à∑—π∑à«ß∑’¡—°®–¡’§«“¡æ‘°“√µ“¡¡“‡ ¡Õ ªí®®ÿ∫—π
¡’«‘∏’°“√√—°…“„À¡à∑’ˉ¥âº≈¥’ ‡™àπ °“√©’¥¬“≈–≈“¬≈‘Ë¡‡≈◊Õ¥∑“ßÀ≈Õ¥‡≈◊Õ¥¥” ·¡â«à“«‘∏’°“√‰¡à¬ÿà߬“°·µà¡’¢âÕ®”°—¥
¥â“π‡«≈“°≈à“«§◊ÕµâÕß«‘π‘®©—¬·≈–‡√‘Ë¡°“√„À⬓≈–≈“¬≈‘Ë¡‡≈◊Õ¥¿“¬„π3™—Ë«‚¡ßÀ≈—߇°‘¥Õ“°“√¥—ßπ—Èπ ∂“π欓∫“≈µà“ßÊ
®÷ßµâÕß¡’°“√‡µ√’¬¡§«“¡æ√âÕ¡„π¥â“π∫ÿ§≈“°√ Õ“§“√ ∂“π∑’Ë ·≈–√–∫∫°“√∫√‘°“√ ‡æ◊ËÕ„Àâ “¡“√∂√Õß√—∫
°“√√—°…“«‘∏’π’ȉ¥âÕ¬à“ß¡’ª√– ‘∑∏‘¿“æ ´÷Ëß„π¢≥–π’Ȫ√–‡∑»‰∑¬¬—߉¡à¡’·π«∑“ß„π°“√√—°…“‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßµ’∫
·≈–Õÿ¥µ—π¥â«¬°“√©’¥¬“≈–≈“¬≈‘Ë¡‡≈◊Õ¥∑“ßÀ≈Õ¥‡≈◊Õ¥¥” ∑’ˇªìπ¡“µ√∞“π‡¥’¬«°—π
∂“∫—πª√– “∑«‘∑¬“ „π∞“π–∑’ˇªìπ ∂“∫—π‡©æ“–∑“ߢÕß‚√§∑“ß√–∫∫ª√– “∑ ‰¥âµ√–Àπ—°∂÷ߪí≠À“¥—ß
°≈à“« ®÷߉¥â¡’°“√¢Õ§«“¡√à«¡¡◊Õ°—∫ ∂“∫—π∑“ß«‘™“°“√µà“ßÊ ®—¥∑”·π«∑“ß°“√√—°…“‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßµ’∫
·≈–Õÿ¥µ—π¥â«¬°“√©’¥¬“≈–≈“¬≈‘Ë¡‡≈◊Õ¥œ ‡æ◊ËÕ‡ªìπ·π«∑“ß„π°“√¥Ÿ·≈√—°…“‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßµ’∫·≈–Õÿ¥µ—πœ
„Àâ¡’ª√– ‘∑∏‘¿“æ °àÕ„À⇰‘¥ª√–‚¬™πå°—∫ ∂“π欓∫“≈µà“ßÊ „πÕ—π∑’Ë®–æ—≤π“°“√∫”∫—¥√—°…“„À⥒¢÷È𠇪ìπº≈
„Àâ°“√¥Ÿ·≈ºŸâªÉ«¬‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßµ’∫·≈–Õÿ¥µ—π„πª√–‡∑»‰∑¬¡’¡“µ√∞“π Ÿß¢÷Èπ ¬—ßª√–‚¬™πåµàÕª√–™“™π
∑’ˇ®Á∫ªÉ«¬Õ¬à“ß·∑â®√‘ß ∑”„ÀâÕ—µ√“°“√µ“¬®“°‚√§π’È≈¥≈ß ºŸâªÉ«¬∑’Ë√Õ¥™’«‘µ¡’§ÿ≥¿“æ™’«‘µ∑’Ë¥’·≈–‡ªìπª√–™“°√
∑’Ë¡’§ÿ≥¿“æ “¡“√∂ª√–°Õ∫Õ“™’æ √â“ß√“¬‰¥â ·≈–∑”ª√–‚¬™πå„Àâ·°à§√Õ∫§√—« —ߧ¡·≈–ª√–‡∑»™“µ‘ ”À√—∫
ºŸâ∑’Ë®–π”·π«∑“ß„π°“√¥Ÿ·≈√—°…“‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßµ’∫·≈–Õÿ¥µ—π¥â«¬°“√©’¥¬“≈–≈“¬≈‘Ë¡‡≈◊Õ¥œ ‰ª„™â®–µâÕß
µ√–Àπ—°«à“ ·π«∑“ßπ’ȇª√’¬∫‡ ¡◊Õ𧔷π–π” ”À√—∫°“√ªØ‘∫—µ‘√—°…“‡∑à“π—Èπ ∑—Èßπ’È ¢÷Èπ°—∫¥ÿ≈¬æ‘π‘®¢Õß·æ∑¬å
ºŸâ¥Ÿ·≈ºŸâªÉ«¬ „π°“√π”‡Õ“§”·π–π”‡À≈à“π’ȉªª√–¬ÿ°µå„™â„Àâ‡À¡“– ¡°—∫·µà≈–æ◊Èπ∑’˵àÕ‰ª
29 ¡‘∂ÿπ“¬π 2549
§≥–ºŸâ®—¥∑”

5. “√∫—≠
Àπâ“
∫∑π”
»—°¬¿“æ¢Õß‚√ß欓∫“≈∑’Ë “¡“√∂¥”‡π‘π°“√√—°…“‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßµ’∫·≈–Õÿ¥µ—π
¥â«¬°“√©’¥¬“≈–≈“¬≈‘Ë¡‡≈◊Õ¥∑“ßÀ≈Õ¥‡≈◊Õ¥¥” 2
·π«∑“ß°“√√—°…“ºŸâªÉ«¬‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßµ’∫·≈–Õÿ¥µ—π
¥â«¬°“√©’¥¬“≈–≈“¬≈‘Ë¡‡≈◊Õ¥∑“ßÀ≈Õ¥‡≈◊Õ¥¥” 3
¢âÕ∫àß™’È·≈–¢âÕÀâ“¡„π°“√√—°…“ºŸâªÉ«¬‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßµ’∫·≈–Õÿ¥µ—π
¥â«¬°“√©’¥¬“≈–≈“¬≈‘Ë¡‡≈◊Õ¥∑“ßÀ≈Õ¥‡≈◊Õ¥¥” 5
°“√∫√‘À“√¬“≈–≈“¬≈‘Ë¡‡≈◊Õ¥∑“ßÀ≈Õ¥‡≈◊Õ¥¥” 6
°“√√—°…“¿“«–·∑√°´âÕπ 8
Monitor and care during and after thrombolytic treatment 9
Elevated Blood Pressure Treatment Sheet for Thrombolytic Therapy 10
‡Õ° “√Õâ“ßÕ‘ß 11
¿“§ºπ«°
1. NIHSS score sheet 12
2. The Barthel Index, The Modified Rankin Scale 18
3. µ—«Õ¬à“ß Stroke fast track care maps and protocols 20
3.1 §≥–·æ∑¬»“ µ√å ®ÿÓ≈ß°√≥å¡À“«‘∑¬“≈—¬ 21
3.2 §≥–·æ∑¬»“ µ√å ‚√ß欓∫“≈√“¡“∏‘∫¥’ ¡À“«‘∑¬“≈—¬¡À‘¥≈ 27
3.3 §≥–·æ∑¬»“ µ√廑√‘√“™æ¬“∫“≈ ¡À“«‘∑¬“≈—¬¡À‘¥≈ 29
3.4 ∂“∫—πª√– “∑«‘∑¬“ °√¡°“√·æ∑¬å °√–∑√«ß “∏“√≥ ÿ¢ 37
4. CT scan examples for early signs of cerebral ischemia 43
5. Stroke Unit 46

6. “√∫—≠µ“√“ß
Àπâ“
µ“√“ß∑’Ë 1 Doctorûs orders 9
µ“√“ß∑’Ë 2 Elevated blood pressure treatment for thrombolytic therapy 10
µ“√“ß∑’Ë 3 The Modified National Institutes of Health Stroke Scale 16
µ“√“ß∑’Ë 4 The Barthel Index 18
µ“√“ß∑’Ë 5 The Modified Rankin Scale 19

7. ‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß (stroke, cerebrovascular disease) ‡ªìπ‚√§∑’Ëæ∫∫àÕ¬„πºŸâ ŸßÕ“¬ÿ∑—Ë«‚≈° „πª√–‡∑»
∑’Ëæ—≤π“·≈â« æ∫«à“‡ªì𠓇Àµÿ°“√µ“¬∑’Ë ”§—≠‡ªìπÕ—π¥—∫ 3 √Õß®“°‚√§À—«„®·≈–‚√§¡–‡√Áß ”À√—∫„πª√–‡∑»
®’π·≈–≠’˪ÿÉπ æ∫«à“‡ªì𠓇Àµÿ°“√µ“¬Õ—π¥—∫ 2 √Õß®“°‚√§À—«„®(1)
„πª√–‡∑»‰∑¬‰¥â¡’°“√»÷°…“Õ—µ√“§«“¡™ÿ°
¢Õß‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß„π™ÿ¡™π‡¡◊Õß ®”π«π 1,361 √“¬ „π°√ÿ߇∑æ¡À“π§√ ‡¡◊ËÕªï æ.». 2526 æ∫«à“¡’Õ—µ√“
‡∑à“°—∫ 690/100,000 ¢Õߪ√–™“°√∑’ËÕ“¬ÿ‡°‘π 20 ªï(2)
·≈–≈à“ ÿ¥„πªï æ.». 2541 ‰¥â¡’°“√»÷°…“«‘®—¬„πª√–™“°√
ºŸâ ŸßÕ“¬ÿ (‡°‘π 60 ªï) „π™π∫∑ 4 ¿“§∑—Ë«ª√–‡∑» 3,036 √“¬ æ∫«à“¡’Õ—µ√“§«“¡™ÿ°¢Õß‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß
„°≈⇧’¬ß°—∫ª√–™“°√„πª√–‡∑»µà“ßÊ ∑—Ë«‚≈°(1)
¥—ßπ—Èπ ‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß®÷߇ªìπ‚√§∑’Ë¡’§«“¡ ”§—≠¬‘Ëß
‚√§Àπ÷ËߢÕߪ√–™“°√‰∑¬ ·≈– ¡§«√®—¥∑”·π«∑“ß°“√√—°…“‚√§π’È
Õߧ尓√Õπ“¡—¬‚≈°‰¥â°”À𥧔®”°—¥§«“¡¢Õß‚√§À≈Õ¥‡≈◊Õ¥ ¡Õ߉«â¥—ßπ’È
çRapidly developed clinical signs of focal (global) disturbance of cerebral function lasting more than 24
hours or leading to death, with no apparent cause other than a vascular originé(3)
°“√«‘π‘®©—¬‚√§À≈Õ¥‡≈◊Õ¥ ¡Õ߬—ߧß∂◊Õ«à“ °“√«‘π‘®©—¬∑“ߧ≈‘π‘°‡ªìπ ‘Ëß ”§—≠ ºŸâªÉ«¬‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßπ—Èπ
à«π„À≠à®–¡’Õ“°“√∑“ß√–∫∫ª√– “∑‡ªìπ·∫∫‡©æ“–∑’Ë ‡™àπ ÕàÕπ·√ߧ√÷Ëß´’° °≈◊π≈”∫“° 查≈”∫“° ‡¥‘π‡´
µ“¡Õ߉¡à‡ÀÁπ ¡Õ߇ÀÁπ¿“æ´âÕ𠇫’¬π»’√…– ‚¥¬∑’ËÕ“°“√‡À≈à“π’È®–‡ªìπÕ¬à“߇©’¬∫æ≈—π Õ¬à“߉√°Áµ“¡ ºŸâªÉ«¬
∫“ß√“¬Õ“®¡’Õ“°“√·∫∫§àÕ¬‡ªìπ§àÕ¬‰ª„π 2 - 3 «—π À√◊Õ¥’¢÷Èπ·≈⫇≈«≈߉¥â(4)
·≈–∂⓺ŸâªÉ«¬¡’ªí®®—¬‡ ’ˬ߮–™à«¬
π—∫ πÿπ°“√«‘π‘®©—¬‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß¡“°¬‘Ëߢ÷È𠇙à𠧫“¡¥—π‚≈À‘µ Ÿß ‡∫“À«“π Ÿ∫∫ÿÀ√’Ë ‚√§À—«„® ‡ªìπµâπ
ªí®®ÿ∫—π«‘∏’°“√√—°…“ºŸâªÉ«¬‚√§À≈Õ¥‡≈◊Õ¥ ¡Õ߉¥âæ—≤π“¡“Õ¬à“ßµàÕ‡π◊ËÕß «‘∏’∑’ˉ¥â√—∫°“√¬Õ¡√—∫„πªí®®ÿ∫—π
«‘∏’Àπ÷Ëß ‰¥â·°à °“√„À⬓≈–≈“¬≈‘Ë¡‡≈◊Õ¥∑“ßÀ≈Õ¥‡≈◊Õ¥¥”„π‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßµ’∫·≈–Õÿ¥µ—π ´÷Ëß¡’¢âÕ®”°—¥
„π°“√¥”‡π‘π°“√À≈“¬ª√–°“√ ‡™àπ ¡’°“√«‘π‘®©—¬·≈–‡√‘Ë¡°“√„À⬓≈–≈“¬≈‘Ë¡‡≈◊Õ¥¿“¬„π 3 ™—Ë«‚¡ßÀ≈—߇°‘¥Õ“°“√
“¡“√∂ªØ‘∫—µ‘„π ∂“π欓∫“≈∑’Ë¡’§«“¡æ√âÕ¡∑“ߥâ“π∫ÿ§≈“°√ ÀâÕߪؑ∫—µ‘°“√ ·≈–Àπ૬√—∫ºŸâªÉ«¬„𠇪ìπµâπ
∂“π∫√‘°“√∫“ß·Ààß„πª√–‡∑»‰∑¬¬—߉¡àæ√âÕ¡∑’Ë®–‡ªî¥„Àâ∫√‘°“√©’¥¬“≈–≈“¬≈‘Ë¡‡≈◊Õ¥„πºŸâªÉ«¬‚√§À≈Õ¥‡≈◊Õ¥
¡Õßµ’∫·≈–Õÿ¥µ—π¿“¬„π 3 ™—Ë«‚¡ß Õ¬Ÿà 2 ¥â“π §◊Õ ¥â“πºŸâ„Àâ∫√‘°“√ ‚¥¬‰¡à¡’§«“¡æ√âÕ¡¢Õß ∂“π欓∫“≈
∑’Ë„Àâ∫√‘°“√ ∑—Èß„π¥â“π ∂“π∑’Ë·≈–∫ÿ§≈“°√∑’ˇ°’ˬ«¢âÕß ·≈–¥â“πºŸâ√—∫∫√‘°“√ ‚¥¬¬—ß¡’§«“¡‰¡à‡¢â“„®¢Õߪ√–™“™π
∑’Ë¡“√—∫∫√‘°“√ ∂÷ß·¡â«à“º≈°“√√—°…“«‘∏’¥—ß°≈à“«¢â“ßµâπ®–‡ªìπª√–‚¬™πå ·µà°ÁµâÕß¡’°“√ª√–™“ —¡æ—π∏å„Àâª√–™“™π
‡¢â“„®«à“ ‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß¡’Õ“°“√Õ¬à“߉√ ·≈–®–µâÕß¡“æ∫·æ∑¬å‚¥¬‡√Á«∑’Ë ÿ¥‡∑à“∑’Ë®–‡√Á«‰¥â ®÷ß®–‰¥âº≈¥’
√«¡∑—ÈßµâÕߪ√–™“ —¡æ—π∏å«à“Àπà«¬ß“π„¥ “¡“√∂„Àâ°“√√—°…“«‘∏’π’ȉ¥â
¥â«¬¢âÕ®”°—¥¥—ß°≈à“« ®÷ß∑”„Àâ ∂“π欓∫“≈®”π«π¡“°·¡â¡’∫ÿ§≈“°√®“° “¢“«‘™“™’æµà“ßÊ §√∫∂â«π
·≈–¡’‡§√◊ËÕß¡◊Õ∑“ß°“√·æ∑¬åÕ¬à“ßæÕ‡æ’¬ß ·µà‰¡à “¡“√∂¥”‡π‘π°“√‰¥â ¥—ßπ—Èπ ·π«∑“ß°“√√—°…“‚√§À≈Õ¥‡≈◊Õ¥
¡Õßµ’∫À√◊ÕÕÿ¥µ—π¥â«¬°“√©’¥¬“≈–≈“¬≈‘Ë¡‡≈◊Õ¥∑“ßÀ≈Õ¥‡≈◊Õ¥¥”π’È ®÷ß¡’¢÷Èπ‡æ◊ËÕ à߇ √‘¡»—°¬¿“æ¢ÕßÀπ૬ߓπ
„Àâ “¡“√∂„Àâ∫√‘°“√©’¥¬“≈–≈“¬≈‘Ë¡‡≈◊Õ¥¥—ß°≈à“«‰¥â Õ—π®–∑”„Àâ “¡“√∂≈¥Õ—µ√“µ“¬ Õ—µ√“æ‘°“√ µ≈Õ¥®π√–¬–
‡«≈“°“√√—°…“µ—«„π‚√ß欓∫“≈·≈–§à“„™â®à“¬„π¿“æ√«¡
∫∑π”

8. 8 ·π«∑“ß°“√√—°…“‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßµ’∫·≈–Õÿ¥µ—π¥â«¬°“√©’¥¬“≈–≈“¬≈‘Ë¡‡≈◊Õ¥∑“ßÀ≈Õ¥‡≈◊Õ¥¥”
»—°¬¿“æ¢Õß‚√ß欓∫“≈∑’Ë “¡“√∂¥”‡π‘π°“√√—°…“‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßµ’∫·≈–Õÿ¥µ—π
¥â«¬°“√©’¥¬“≈–≈“¬≈‘Ë¡‡≈◊Õ¥∑“ßÀ≈Õ¥‡≈◊Õ¥¥”
∂“π∫√‘°“√µâÕß “¡“√∂„Àâ∫√‘°“√ 24 ™—Ë«‚¡ß „πÀ—«¢âÕ¥—ßµàÕ‰ªπ’È
1. ª√– “∑·æ∑¬åÀ√◊Õ·æ∑¬å‡«™»“ µ√å©ÿ°‡©‘π/Õ“¬ÿ√·æ∑¬å∑’ˉ¥â√—∫ª√–°“»π’¬∫—µ√Ωñ°Õ∫√¡°“√„Àâ “√≈–≈“¬
≈‘Ë¡‡≈◊Õ¥ (rt-PA) „πºŸâªÉ«¬‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßµ’∫·≈–Õÿ¥µ—π„π√–¬–‡©’¬∫æ≈—π‚¥¬‰¥â√—∫°“√√—∫√Õß
®“° ∂“∫—π∑’ˉ¥â√—∫°“√¬Õ¡√—∫„π√–¥—∫™“µ‘
2. ª√– “∑»—≈¬·æ∑¬å
3. CT brain
4. ¡’ÀâÕߪؑ∫—µ‘°“√∑’Ë “¡“√∂µ√«® blood sugar, CBC, coagulogram, electrolyte, BUN, Cr
5. “¡“√∂À“‡≈◊Õ¥·≈– à«πª√–°Õ∫¢Õ߇≈◊Õ¥‰¥â ‡™àπ fresh frozen plasma, cryoprecipitate, platelet con-
centrate ·≈– pack red cell
6. ¡’ ICU À√◊Õ Stroke Unit (SU) (¥Ÿ¿“§ºπ«° 5)
7. ¡’°“√ ”√Õ߬“ rt-PA ‰«â∫√‘‡«≥∑’Ë„Àâ°“√√—°…“ ‡™àπ ER, ICU À√◊Õ SU
✧ ✧ ✧ ✧ ✧ ✧ ✧

9. ·π«∑“ß°“√√—°…“‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßµ’∫·≈–Õÿ¥µ—π¥â«¬°“√©’¥¬“≈–≈“¬≈‘Ë¡‡≈◊Õ¥∑“ßÀ≈Õ¥‡≈◊Õ¥¥” 9
▼
▼
▼
▼
▼
1. µ‘¥µàÕ·æ∑¬å* 2. «—¥ —≠≠“≥™’æ·≈– basic life support 3. µ‘¥µàÕ∑” CT brain 4. µ‘¥µàÕ ICU À√◊Õ SU
‡®“–‡≈◊Õ¥µ√«® blood sugar, CBC,
coagulogram, electrolyte, BUN, Cr.
·ºπ¿Ÿ¡‘∑’Ë 1
·π«∑“ß°“√√—°…“ºŸâªÉ«¬‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßµ’∫·≈–Õÿ¥µ—π
¥â«¬°“√©’¥¬“≈–≈“¬≈‘Ë¡‡≈◊Õ¥∑“ßÀ≈Õ¥‡≈◊Õ¥¥”
* ª√– “∑·æ∑¬å À√◊Õ ·æ∑¬å‡«™»“ µ√å©ÿ°‡©‘π/Õ“¬ÿ√·æ∑¬å∑’ˉ¥â√—∫ª√–°“»π’¬∫—µ√Ωñ°Õ∫√¡œ
æ∫‡≈◊Õ¥ÕÕ°„π ¡Õß
ª√÷°…“µ“¡√–∫∫
‰¡àæ∫‡≈◊Õ¥ÕÕ°„π ¡Õß
ᾷŒ*
1. µ√«® Õ∫¢âÕ∫àß™’È-¢âÕÀâ“¡°“√„À⬓ ¥Ÿ∑’ËÀπâ“ 5
2. ¢Õ§«“¡¬‘π¬Õ¡°“√„À⬓ ¥Ÿ∑’ËÀπâ“ 31, 40
3. µ‘¥µàÕª√– “∑»—≈¬·æ∑¬å°àÕπ„À⬓
4. “¡“√∂„À⬓‰¥â∑’Ë ER/ICU/SU
¥Ÿ·ºπ¿Ÿ¡‘∑’Ë 2
1. ·¢π¢“™“ ÕàÕπ·√ß ¢â“ß„¥¢â“ßÀπ÷Ëß∑—π∑’
2. 查‰¡à™—¥ 查‰¡à‰¥â À√◊Õøí߉¡à‡¢â“„®∑—π∑’
3. ‡¥‘π‡´ ‡«’¬π»’√…–∑—π∑’
4. µ“‡ÀÁπ¿“æ´âÕπÀ√◊Õ¡◊¥¡—«¢â“ß„¥¢â“ßÀπ÷Ëß∑—π∑’
欓∫“≈
´—°ª√–«—µ‘
▼
▼ ▼ ▼ ▼
▼ ▼
º≈ CT brain
ºŸâªÉ«¬∑’Ë¡’Õ“°“√ ß —¬‚√§À≈Õ¥
‡≈◊Õ¥ ¡Õß¿“¬„π 3 ™—Ë«‚¡ß

10. 10 ·π«∑“ß°“√√—°…“‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßµ’∫·≈–Õÿ¥µ—π¥â«¬°“√©’¥¬“≈–≈“¬≈‘Ë¡‡≈◊Õ¥∑“ßÀ≈Õ¥‡≈◊Õ¥¥”
▼
▼
·ºπ¿Ÿ¡‘∑’Ë 2
·π«∑“ß°“√√—°…“ºŸâªÉ«¬‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßµ’∫·≈–Õÿ¥µ—π
¥â«¬°“√©’¥¬“≈–≈“¬≈‘Ë¡‡≈◊Õ¥∑“ßÀ≈Õ¥‡≈◊Õ¥¥” ∑’Ë ER/ICU/SU
ER/ICU/SU ‡ΩÑ“√–«—ßÕ¬à“ß„°≈♑¥µ“¡ stroke fast track care map and protocal ¿“§ºπ«° 3
„Àâ°“√√—°…“¿“«–·∑√°´âÕπ
(¥Ÿ∑’ËÀπâ“ 8)
- —߇°µ¿“«–·∑√°´âÕπ¿“¬À≈—ß
°“√„À⬓ 48 ™¡.
- „Àâ°“√√—°…“µàÕµ“¡
CPG for ischemic stroke/
Stroke fast track care map*
‰¡à¡’ ¡’
▼
CT brain ´È” 24 ™¡. À≈—ß„À⬓
À√◊Õ‡¡◊ËÕ¡’Õ“°“√‡≈«≈ß
▼
¿“«–·∑√°´âÕπ
* “¡“√∂µ‘¥µàÕ¢Õ√—∫‰¥â∑’Ëß“π π—∫ πÿπ«‘™“°“√ ∂“∫—πª√– “∑«‘∑¬“

11. ·π«∑“ß°“√√—°…“‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßµ’∫·≈–Õÿ¥µ—π¥â«¬°“√©’¥¬“≈–≈“¬≈‘Ë¡‡≈◊Õ¥∑“ßÀ≈Õ¥‡≈◊Õ¥¥” 11
¢âÕ∫àß™’È·≈–¢âÕÀâ“¡„π°“√√—°…“ºŸâªÉ«¬‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßµ’∫·≈–Õÿ¥µ—π
¥â«¬°“√©’¥¬“≈–≈“¬≈‘Ë¡‡≈◊Õ¥∑“ßÀ≈Õ¥‡≈◊Õ¥¥”(5, 6, 7, 8)
¢âÕ∫àß™’È
1. ºŸâªÉ«¬‰¥â√—∫°“√«‘π‘®©—¬«à“‡ªìπ‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßµ’∫·≈–Õÿ¥µ—π¿“¬„π 3 ™—Ë«‚¡ß
2. Õ“¬ÿ¡“°°«à“ 18 ªï
3. ¡’Õ“°“√∑“ß√–∫∫ª√– “∑∑’Ë “¡“√∂«—¥‰¥â‚¥¬„™â NIHSS
4. º≈ CT scan ¢Õß ¡Õ߇∫◊ÈÕßµâπ‰¡àæ∫¿“«–‡≈◊Õ¥ÕÕ°
5. ºŸâªÉ«¬À√◊Õ≠“µ‘‡¢â“„®ª√–‚¬™πå·≈–‚∑…∑’Ë®–‡°‘¥¢÷Èπ®“°°“√√—°…“ ·≈–¬‘π¬Õ¡„Àâ°“√√—°…“ ‚¥¬„™â¬“≈–≈“¬
≈‘Ë¡‡≈◊Õ¥
¢âÕÀâ“¡
1. ¡’Õ“°“√¢Õß‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßµ’∫·≈–Õÿ¥µ—π∑’ˉ¡à∑√“∫‡«≈“∑’ˇ√‘Ë¡‡ªìπÕ¬à“ß™—¥‡®π À√◊Õ¡’Õ“°“√¿“¬À≈—ß
µ◊ËππÕπ
2. ¡’Õ“°“√¢Õß‚√§‡≈◊Õ¥ÕÕ°„µâ™—Èπ‡¬◊ËÕÀÿâ¡ ¡Õß (subarachnoid hemorrhage)
3. Õ“°“√∑“ß√–∫∫ª√– “∑¥’¢÷ÈπÕ¬à“ß√«¥‡√Á« À√◊Õ¡’Õ“°“√Õ¬à“߇¥’¬«·≈–‰¡à√ÿπ·√ß (NIHSS < 4)
4. ¡’Õ“°“√∑“ß√–∫∫ª√– “∑Õ¬à“ß√ÿπ·√ß (NIHSS > 18)
5. ¡’Õ“°“√™—°‡¡◊ËÕ‡√‘Ë¡¡’Õ“°“√‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßµ’∫·≈–Õÿ¥µ—π§√—Èßπ’È
6. §«“¡¥—π‚≈À‘µ„π™à«ß°àÕπ„Àâ°“√√—°…“ Ÿß (SBP > 185 mmHg, DBP > 110 mmHg)
7. ¡’ª√–«—µ‘‡≈◊Õ¥ÕÕ°„π ¡Õß¡“°àÕπ
8. ¡’ª√–«—µ‘‡ªìπ‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß À√◊Õ¡’∫“¥‡®Á∫∑’Ë»’√…–√ÿπ·√ß¿“¬„π 3 ‡¥◊Õπ
9. ‰¥â√—∫¬“µâ“π°“√·¢Áßµ—«¢Õ߇≈◊Õ¥ (heparin À√◊Õ warfarin) ¿“¬„π 48 ™—Ë«‚¡ß À√◊Õ¡’§à“ partial-thrombo-
plastin time º‘¥ª°µ‘ À√◊Õ¡’§à“ prothrombin time ¡“°°«à“ 15 «‘π“∑’ À√◊Õ¡’§à“ International
normalized ratio (INR) ¡“°°«à“ 1.5
10. ¡’ª√‘¡“≥‡°≈Á¥‡≈◊Õ¥πâÕ¬°«à“ 100,000/mm3
11. ¡’ª√–«—µ‘ºà“µ—¥„À≠à¿“¬„π 14 «—π
12. ¡’‡≈◊Õ¥ÕÕ°„π∑“߇¥‘πÕ“À“√À√◊Õ∑“߇¥‘πªí “«–¿“¬„π 21 «—π
13. ¡’√–¥—∫πÈ”µ“≈„π‡≈◊Õ¥µË”°«à“ 50 mg/dl (2.7 mmol/L) À√◊Õ Ÿß°«à“ 400 mg/dl (22.2 mmol/L)
§”π«≥‰¥â®“° Glucose (blood) 1 mg/dl = 0.05551 mmol/L9
14. ¡’ª√–«—µ‘ myocardial infarction ¿“¬„π 3 ‡¥◊Õπ
15. ¡’°“√‡®“–À≈Õ¥‡≈◊Õ¥·¥ß„πµ”·Àπàß∑’ˉ¡à “¡“√∂°¥Àâ“¡‡≈◊Õ¥‰¥â ¿“¬„π 7 «—π
16. æ∫¡’‡≈◊Õ¥ÕÕ°À√◊Õ¡’°“√∫“¥‡®Á∫ (°√–¥Ÿ°À—°) ®“°°“√µ√«®√à“ß°“¬
17. º≈ CT brain æ∫‡π◊ÈÕ ¡Õßµ“¬¡“°°«à“ 1 °≈’∫ (hypodensity > 1/3 cerebral hemisphere) À√◊Õæ∫°“√
‡ª≈’ˬπ·ª≈ß„π√–¬–·√°¢ÕßÀ≈Õ¥‡≈◊Õ¥ ¡Õßµ’∫¢π“¥„À≠à ‡™àπ æ∫ ¡Õß∫«¡ mass effect, sulcal
effacement

12. 12 ·π«∑“ß°“√√—°…“‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßµ’∫·≈–Õÿ¥µ—π¥â«¬°“√©’¥¬“≈–≈“¬≈‘Ë¡‡≈◊Õ¥∑“ßÀ≈Õ¥‡≈◊Õ¥¥”
°“√∫√‘À“√¬“≈–≈“¬≈‘Ë¡‡≈◊Õ¥∑“ßÀ≈Õ¥‡≈◊Õ¥¥”
ª√‘¡“≥·≈–«‘∏’°“√∫√‘À“√¬“
¬“ recombinant tissue-plasminogen activator (rt-PA) ∑’Ë¡’Õ¬Ÿà„πª√–‡∑»‰∑¬„πªí®®ÿ∫—π™◊ËÕ Actilyse(R)
´÷Ëß¡’ 2 ¢π“¥ §◊Õ 50 ¡°. À√◊Õ 100 ¡°. µàÕ 1 °≈àÕß ·≈–„π 1 °≈àÕß ª√–°Õ∫¥â«¬ ºß¬“ rt-PA 1 ¢«¥
πÈ”°≈—Ëπª√“»®“°‡™◊ÈÕ 50 ´’´’ 1 ¢«¥ ‡¢Á¡º ¡¢«¥¬“ºß·≈–¢«¥πÈ”°≈—Ëπ 1 Õ—π ‡¢Á¡ ”À√—∫¥Ÿ¥¬“ 2 Õ—π
‡¢Á¡æ‘‡»…„À⬓∑“ßÀ≈Õ¥‡≈◊Õ¥¥” 1 Õ—π syringe 10 ´’´’ 1 Õ—π ·≈–™ÿ¥„À⬓∑“ßÀ≈Õ¥‡≈◊Õ¥¥” 1 ™ÿ¥ (¥Ÿ√Ÿª∑’Ë 1
·≈– 2)
¢—ÈπµÕπ°“√∫√‘À“√¬“¡’¥—ßπ’È
- §”π«≥ª√‘¡“≥¬“µ“¡πÈ”Àπ—°µ—«ºŸâªÉ«¬ ‚¥¬¡’ª√‘¡“≥ 0.9 ¡°./°°. (¢π“¥¢Õ߬“ Ÿß ÿ¥‰¡à‡°‘π 90 ¡°.)
- ‡≈◊Õ°„™â¢«¥¬“ rt-PA ∑’ˇÀ¡“– ¡µ“¡∑’˧”π«≥‰¥â
- º ¡¢«¥πÈ”°≈—Ëπ·≈–¢«¥¬“ºß‚¥¬„™â‡¢Á¡∑’Ë¡’Õ¬Ÿà„π™ÿ¥ ‚¥¬„ÀâπÈ”°≈—Ëπ‰À≈‰ªº ¡Õ¬Ÿà„π¢«¥¬“ºß
- „™â syringe ¥Ÿ¥¬“∑’˺ ¡·≈â« ª√‘¡“≥ 10% ¢Õß¢π“¥¬“∑’˧”π«≥‰¥â·≈â«©’¥‡¢â“À≈Õ¥‡≈◊Õ¥¥”
„π 1 π“∑’
- µàÕ¢«¥¬“∑’ˇÀ≈◊Õ‡¢â“°—∫™ÿ¥„À⬓∑“ßÀ≈Õ¥‡≈◊Õ¥¥”∑’Ë¡’¡“°—∫¬“·≈–À¬¥‡¢â“À≈Õ¥‡≈◊Õ¥¥”„π 60 π“∑’
‡¡◊ËÕµâÕß°“√„Àâ “√≈–≈“¬Õ◊Ëπ∑“ßÀ≈Õ¥‡≈◊Õ¥¥”¢≥–„À⬓≈–≈“¬≈‘Ë¡‡≈◊Õ¥ §«√„Àâ∑“ßÀ≈Õ¥‡≈◊Õ¥¥”‡ âπÕ◊Ëπ
¢âÕ§«√√–«—ß
1. À≈’°‡≈’ˬ߰“√„À⬓µâ“π‡°≈Á¥‡≈◊Õ¥ À√◊Õ¬“µâ“π°“√·¢Áßµ—«¢Õ߇≈◊Õ¥ ¿“¬„π 24 ™—Ë«‚¡ß¢Õß°“√√—°…“
2. µâÕßÀ¬ÿ¥„Àâ rt-PA ∑—π∑’∑’Ë ß —¬«à“¡’¿“«–‡≈◊Õ¥ÕÕ°„π ¡Õß ·≈–√’∫∑”°“√µ√«®«‘π‘®©—¬ æ√âÕ¡∑—Èߪ√÷°…“
ª√– “∑»—≈¬·æ∑¬å∑—π∑’
3. ‰¡à§«√„ àÀ≈Õ¥„ÀâÕ“À“√ √«¡∑—Èß·∑ßÀ≈Õ¥‡≈◊Õ¥¥”„À≠à (central venous access) À√◊Õ·∑ßÀ≈Õ¥‡≈◊Õ¥·¥ß
¿“¬„π 24 ™—Ë«‚¡ßÀ≈—ß„Àâ rt-PA
4. À≈’°‡≈’ˬ߰“√„ à “¬ «πªí “«–„π™à«ß‡«≈“∑’Ë„À⬓À√◊Õ¿“¬À≈—ß°“√„À⬓ 30 π“∑’
5. §«∫§ÿ¡§«“¡¥—π‚≈À‘µ‰¡à„Àâ Ÿß ‚¥¬„Àâ SBP < 185 mmHg, DBP < 110 mmHg ‡π◊ËÕß®“°§«“¡
¥—π‚≈À‘µ Ÿß ®–‡ ’ˬߵàÕ°“√‡°‘¥‡≈◊Õ¥ÕÕ°„π ¡Õ߉¥â

13. ·π«∑“ß°“√√—°…“‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßµ’∫·≈–Õÿ¥µ—π¥â«¬°“√©’¥¬“≈–≈“¬≈‘Ë¡‡≈◊Õ¥∑“ßÀ≈Õ¥‡≈◊Õ¥¥” 13
√Ÿª∑’Ë 1 ¬“ recombinant tissue-plasminogen activator (rt-PA)
√Ÿª∑’Ë 2 «— ¥ÿÕÿª°√≥å°“√„À⬓ recombinant tissue-plasminogen activator (rt-PA)

14. 14 ·π«∑“ß°“√√—°…“‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßµ’∫·≈–Õÿ¥µ—π¥â«¬°“√©’¥¬“≈–≈“¬≈‘Ë¡‡≈◊Õ¥∑“ßÀ≈Õ¥‡≈◊Õ¥¥”
°“√√—°…“¿“«–·∑√°´âÕπ
°“√√—°…“¿“«–∑’Ë¡’‡≈◊Õ¥ÕÕ°„π ¡Õß„πºŸâªÉ«¬∑’ˉ¥â√—∫¬“≈–≈“¬≈‘Ë¡‡≈◊Õ¥
1. Õ“°“√·≈–Õ“°“√· ¥ß∑’Ë ß —¬«à“¡’‡≈◊Õ¥ÕÕ°„π ¡Õß
- Õ“°“√∑“ß√–∫∫ª√– “∑∑’ˇ≈«≈ßÕ¬à“ß©—∫æ≈—π
- ª«¥»’√…–
- §«“¡¥—π‚≈À‘µ Ÿß¢÷ÈπÕ¬à“ß©—∫æ≈—π
- §≈◊Ëπ‰ âÕ“‡®’¬π
2. §«√ªØ‘∫—µ‘¥—ßπ’È
- À¬ÿ¥„À⬓ rt-PA
- àߺŸâªÉ«¬∑” CT brain ∑—π∑’
- ‡®“–‡≈◊Õ¥µ√«® PT, aPTT ·≈– platelet count
- ‡µ√’¬¡ FFP ª√–¡“≥ 10 cc/kg
- ·®âß·æ∑¬åª√– “∑«‘∑¬“ À√◊Õ·æ∑¬åºŸâ¥Ÿ·≈
3. ‡¡◊ËÕ¡’‡≈◊Õ¥ÕÕ°„π ¡Õß
- µ√«® Õ∫º≈°“√µ√«® PT, aPTT ·≈– platelet count
- ª√÷°…“ª√– “∑»—≈¬·æ∑¬å∑—π∑’
- „Àâ FFP 10 cc/kg
- ª√–™ÿ¡ª√÷°…“·π«∑“ß°“√√—°…“√à«¡°—π∑“ߥâ“π»—≈¬°√√¡·≈–Õ“¬ÿ√°√√¡
- æ‘®“√≥“∑” CT scan ´È” ‡æ◊ËÕ¥Ÿ«à“¡’°“√‡ª≈’ˬπ·ª≈ߢÕß¢π“¥¢Õß°âÕπ‡≈◊Õ¥À√◊Õ‰¡à ¿“¬„π 24 ™—Ë«‚¡ß

15. ·π«∑“ß°“√√—°…“‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßµ’∫·≈–Õÿ¥µ—π¥â«¬°“√©’¥¬“≈–≈“¬≈‘Ë¡‡≈◊Õ¥∑“ßÀ≈Õ¥‡≈◊Õ¥¥” 15
q
q
q
MONITOR AND CARE DURING AND AFTER THROMBOLYTIC TREATMENT
µ“√“ß∑’Ë 1 Doctorûs orders
ORDER FOR ONE DAY ORDER FOR CONTINUATION
- rt-PA _____mg IV bolus in 1 minute then - NPO except medications for 24 hrs
- rt-PA _____mg IV drip in 60 minutes - Bed rest
- Check vital signs, neurological sign & NIHSS - IV fluid as appropriate
after infusion - Record I/O
15 mins. for 2 hrs. - Medication consider
then 30 mins. for 6 hrs. 1. H2
receptor blocker/proton pump inhibitor
then 60 mins. until 24 hrs. 2. Antihypertensive drugs if BP > 185/110
- If SBP > 185 or < 110 mm Hg, mmHg (¥ŸÀπâ“ 10)
DBP > 110 or < 60 mm Hg
please notify doctor
- Within 24 hrs after rt-PA infusion, Avoid
insertion Foley catheter, NG tube,
central venous access, arterial puncture &
intramuscular injection
If intracranial hemorrhage is suspected
1. Stop infusion of the thrombolytic drug.
2. Repeat CBC, platelet, INR, PTT, PT
3. Emergency CT brain
4. Consult neurosurgeon
5. Cross matching for FFP 6 to 8 units
(or 10 cc/kg)

16. 16 ·π«∑“ß°“√√—°…“‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßµ’∫·≈–Õÿ¥µ—π¥â«¬°“√©’¥¬“≈–≈“¬≈‘Ë¡‡≈◊Õ¥∑“ßÀ≈Õ¥‡≈◊Õ¥¥”
Elevated Blood Pressure Treatment Sheet
for Thrombolytic Therapy
Desired BP : SBP not more than 180 mmHg and DBP not more than 105 mmHg
Check BP 15 min. for 2 hrs, then 30 min. for 6 hrs and finally hr for 16 hrs
µ“√“ß∑’Ë 2 Elevated blood pressure treatment for thrombolytic therapy
q qq
q
BP level
If DBP > 140 mmHg
If SBP > 180 or
DBP > 105 but < 140 mmHg
Treatment
Sodium nitroprusside 0.5 ug/kg/min. IV infusion as
initial dose and titrate to desired BP
Nicardipine 5 mg/h IV infusion as initial dose and titrate
to desired effect by increasing 2.5 mg/h 5 min to
maximum of 15 mg/h; If BP is not controlled,
consider sodium nitroprusside

17. ·π«∑“ß°“√√—°…“‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßµ’∫·≈–Õÿ¥µ—π¥â«¬°“√©’¥¬“≈–≈“¬≈‘Ë¡‡≈◊Õ¥∑“ßÀ≈Õ¥‡≈◊Õ¥¥” 17
‡Õ° “√Õâ“ßÕ‘ß
1. π‘æπ∏å æ«ß«√‘π∑√å. Epidemiology of stroke. „π : π‘æπ∏å æ«ß«√‘π∑√å, ∫°.‚√§À≈Õ¥‡≈◊Õ¥ ¡Õß
(Stroke) ©∫—∫‡√’¬∫‡√’¬ß§√—Èß∑’Ë 2 °√ÿ߇∑æ¡À“π§√ : ‡√◊Õπ·°â«°“√æ‘¡æå, 2544: 1 - 37.
2. Viriyavejakul A, Poungvarin N, Vannasaeng S. The prevalence of stroke in urban community of
Thailand. J Neurology 1985; 232 (suppl): 93.
3. World Health Organization Meeting on Community Control of Stroke and Hypertension. Control of
stroke in the community: methodological considerations and protocol of WHO stroke register.
CVD/s/73.6 Geneva: WHO, 1973.
4. Adams H P Jr, Brott TG, Crowell RM, et al. Guidelines for the management of patients with acute
ischemic stroke. A statement for healthcare professionals from a special writing group of the
Stroke Council, American Heart Association. Stroke 1994; 25: 1901-14.
5. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Tissue
plasminogen activator for acute ischemic stroke. N Engl J Med 1995; 333: 1581-7.
6. Adams HP, Brott TG, Furlan AJ, et al. Guidelines for thrombolytic therapy for acute stroke: a
supplement to the guidelines for the management of patients with acute ischemic stroke: a
statement of healthcare professionals from a special writing group of the Stroke Council,
American Heart Association. Circulation. 1996; 94: 1167-74.
7. Adams HP, Adams RJ, Brott T, et al. Guidelines for the early management of patients with ischemic
stroke: a scientific statement from the Stroke Council of the American Stroke Association.
Stroke 2003; 34: 1056-83.
8. The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. Tissue
Plasminogen Activator for Acute Ischemic Stroke CT, computed tomography; NIHSS, National
Institute of Health Stroke Scale; NINDS, National Institute of Neurological Disorders and stroke.
N Engl J Med 1995; 333(24): 1581-7.
9. Henry JB. Clinical diagnosis and management by laboratory methods. 18th
ed., WB Saunders Co.
1991.
10. Masur H, Papke K, Althoff S, et al. Scales and Scores in Neurology: Quantification of Neurological
Deficits in Research and Practice, Druckhaus Gotz. Ludwigsburg. 2004; 149 - 50.
11. Herndo RM. Handbook of Neurologic Rating Scales, Demos Vermande: 386 Park Avenue South.
New York. 1997; 163 - 164, 178, 180.
12. Hacke W, Lees K, Toni D, et al. Acute stroke treatment. Update 2006 (An educational slide kit),
product by infill Kommunikation through an educational grant from Boehringer Ingelheim GmbH.
(Actilyse). 2006; 50.
13. Royal College of physician of London, National clinical guidelines for stroke. Second edition, The
Lavenham Press Ltd. London. 2004; 13 - 7.

18. 18 ·π«∑“ß°“√√—°…“‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßµ’∫·≈–Õÿ¥µ—π¥â«¬°“√©’¥¬“≈–≈“¬≈‘Ë¡‡≈◊Õ¥∑“ßÀ≈Õ¥‡≈◊Õ¥¥”
¿“§ºπ«° 1
NIHSS score sheet
The National Institutes of Health (NIH) Stroke Scale10
Application: Stroke
Area: Scientific studies
Duration: 10 - 15 minutes
Range of results: 0 - 36; the more points, the more sever the stroke sequelae
References: Brott T, Adams HP, Olinger CP et al. Measurements of acute cerebral infarction: a clinical
examination scale. Stroke 1989; 20: 864 - 70.
Level of consciousness
0 Alert, keenly responsive
1 Drowsy, but arousable by minor stimulation to obey, answer, or respond
2 Stuporous, requires repeated stimulation to attend, or lethargic or obtunded,
requiring strong or painful stimulation to make movements
3 Coma, responds only with reflex motor or autonomic effects, or unresponsive
Level of consciousness-questions
Ask patient the month and his/her age. Score first answer.
0 Answers both correctly
1 Answers one correctly
2 Incorrect
Level of consciousness-commands
Ask patient to open/close hand and eyes. Score if he or she makes unequivocal attempt.
0 Obeys both correctly
1 Obeys one correctly
2 Incorrect
Pupillary response
0 Both reactive
1 One reactive
2 Neither reactive

19. ·π«∑“ß°“√√—°…“‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßµ’∫·≈–Õÿ¥µ—π¥â«¬°“√©’¥¬“≈–≈“¬≈‘Ë¡‡≈◊Õ¥∑“ßÀ≈Õ¥‡≈◊Õ¥¥” 19
Best gaze
0 Normal
1 Partial gaze palsy; abnormal but not forced deviation
2 Forced deviation (total gaze paresis)
Confrontation testing using finger movements, inculding double simultaneous stimulation. Use visual theat if
consciousness or comprehension limit testing, scoring ç1é for any asymmetry demonstrated.
Best visual
0 No visual loss
1 Partial hemianopia
2 Complete hemianopia, to within 5 degrees of fixation
Facial palsy
0 Normal
1 Minor
2 Partial
3 Complete
Best motor-arm
Arms held for 10 sec at 90 degrees if sitting, 45 degree if lying. Grade weaker arm. Place arms in position
if comprehension reduced.
0 No drift in 10 sec
1 Drift, after brief hold
2 Cannot resist gravity, falling immediately but some effort made
3 No effort against gravity
Best motor-leg
While lying, patient to hold weaker leg raised 30 degrees for 5 sec. Place leg if comprehension reduced.
0 No drift in 5 sec
1 Drift, lowering within 5 sec
2 Cannot resist gravity, falling to bed but some effort made
3 No effort against gravity

20. 20 ·π«∑“ß°“√√—°…“‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßµ’∫·≈–Õÿ¥µ—π¥â«¬°“√©’¥¬“≈–≈“¬≈‘Ë¡‡≈◊Õ¥∑“ßÀ≈Õ¥‡≈◊Õ¥¥”
Plantar reflex
0 Normal
1 Equivocal
2 One extensor
3 Bilateral extensor
Limb ataxia
Finger-nose and heel-to-shin tests performed; ataxia is scored only if out of proportion to weakness. If total
paralysis, score as absent.
0 Absent
1 Present in arm or leg
2 Present in arm and leg
Sensory
Tested with pin; only hemisensory loss scored. If comprehension or consciousness reduced, only score if
obvious evidence.
0 Normal
1 Partial loss, subjectively different but still felt
2 Dense loss, unaware of being touched
Neglect
0 No neglect
1 Partial neglect, visual, tactile, or auditory
2 Complete neglect, affecting more than one modality
Dysarthria
0 Normal articulation
1 Mild to moderate dysarthria, slurring some words
2 Near unintelligible or worse

21. ·π«∑“ß°“√√—°…“‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßµ’∫·≈–Õÿ¥µ—π¥â«¬°“√©’¥¬“≈–≈“¬≈‘Ë¡‡≈◊Õ¥∑“ßÀ≈Õ¥‡≈◊Õ¥¥” 21
Best language
Assessed from response during evaluation.
0 No aphasia
1 Mild to moderate aphasia; naming errors, paraphasia, etc.
2 Severe aphasia
3 Mute

22. 22 ·π«∑“ß°“√√—°…“‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßµ’∫·≈–Õÿ¥µ—π¥â«¬°“√©’¥¬“≈–≈“¬≈‘Ë¡‡≈◊Õ¥∑“ßÀ≈Õ¥‡≈◊Õ¥¥”
The Modified National Institutes of Health Stroke Scale11
µ“√“ß∑’Ë 3 The Modified National Institutes of Health Stroke Scale
Item Name Response
1A Level of consciousness 0 = Alert
1 = Not alert, but arousable easily
2 = Not alert, obtunded
3 = Unresponsive
1B Questions 0 = Answers both correctly
1 = Answers one correctly
2 = Answers neither correctly
1C Commands 0 = Performs both tasks correctly
1 = Performs one task correctly
2 = Performs neither task correctly
2 Gaze 0 = Normal
1 = Partial gaze palsy
2 = Total gaze palsy
3 Visual fields 0 = No visual loss
1 = Partial hemianopsia
2 = Complete hemianopsia
3 = Bilateral hemianopsia
4 Facial palsy 0 = Normal
1 = Minor paralysis
2 = Partial paralysis
3 = Complete paralysis
5 Motor arm 0 = No drift
a. Left 1 = Drift before 10 seconds
b. Right 2 = Falls before 10 seconds
3 = No effort against gravity
4 = No movement
6 Motor leg 0 = No drift
a. Left 1 = Drift before 5 seconds
b. Right 2 = Falls before 5 seconds
3 = No effort against gravity
4 = No movement

23. ·π«∑“ß°“√√—°…“‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßµ’∫·≈–Õÿ¥µ—π¥â«¬°“√©’¥¬“≈–≈“¬≈‘Ë¡‡≈◊Õ¥∑“ßÀ≈Õ¥‡≈◊Õ¥¥” 23
µ“√“ß∑’Ë 3 The Modified National Institutes of Health Stroke Scale (µàÕ)
Item Name Response
7 Ataxia 0 = Absent
1 = One limb
2 = Two limbs
8 Sensory 0 = Normal
1 = Mild loss
2 = Severe loss
9 Language 0 = Normal
1 = Mild aphasia
2 = Severe aphasia
3 = Mute or global aphasia
10 Dysarthria 0 = Normal
1 = Mild
2 = Severe
11 Extinction/inattention 0 = Normal
1 = Mild
2 = Severe
There are 15 items in this version of the NIHSS. Complete scale with instructions can be obtained from the
National Institute of Neurological Disorders and Stroke (Lyden et al., 1994).

24. 24 ·π«∑“ß°“√√—°…“‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßµ’∫·≈–Õÿ¥µ—π¥â«¬°“√©’¥¬“≈–≈“¬≈‘Ë¡‡≈◊Õ¥∑“ßÀ≈Õ¥‡≈◊Õ¥¥”
¿“§ºπ«° 2
The Barthel Index
µ“√“ß∑’Ë 4 The Barthel Index
1. Feeding 10 = Independent. Able to apply any necessary device. Feeds in reasonable time.
5 = Needs help, i.e., for cutting.
0 = Inferior performance.
2. Bathing 5 = Performs without assistance.
0 = Inferior performance.
3. Personal Toilet 5 = Washes face, combs hair, brushes teeth, shaves (manages plug if electric razor)
(grooming) 0 = Inferior performance.
4. Dressing 10 = Independent. Ties shoes, fastens fasteners, applies braces.
5 = Needs help but does at least half of task within reasonable time.
0 = Inferior performance.
5. Bowel Control 10 = No accidents. Able to use enema or suppository if needed.
5 = Occasional accidents or needs help with enema or suppository.
0 = Inferior performance.
6. Bladder Control 10 = No accidents. Able to care for collecting device if used.
5 = Occasional accidents or needs help with device.
0 = Inferior performance.
7. Toilet Transfers 10 = Independent with toilet or bedpan. Handles clothes, wipes, flushes,
or cleans pan.
5 = Needs help for balance, handling clothes or toilet paper.
0 = Inferior performance.
8. Chair/Bed 15 = Independent, including locks of wheelchair and lifting footrests.
Transfers 10 = Minimum assistance or supervision.
5 = Able to sit, but needs maximum assistance to transfer.
0 = Inferior performance.
9. Ambulation 15 = Independent for 50 yards. May use assistive devices, except for rolling walker.
10 = With help for 50 yards.
5 = Independent with wheelchair for 50 yards, only if unable to walk.
0 = Inferior performance.
10. Stair Climbing 10 = Independent. May use assistive devices.
5 = Needs help or supervision.
0 = Inferior performance.

25. ·π«∑“ß°“√√—°…“‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßµ’∫·≈–Õÿ¥µ—π¥â«¬°“√©’¥¬“≈–≈“¬≈‘Ë¡‡≈◊Õ¥∑“ßÀ≈Õ¥‡≈◊Õ¥¥” 25
µ“√“ß∑’Ë 5 The Modified Rankin Scale
Grade Description
0 No symptoms at all.
1 No significant disability despite symptoms: able to carry out all usual duties and activities.
2 Slight disability: unable to carry out all previous activities but able to look after own affairs
without assistance.
3 Moderate disability: requiring some help, but able to walk without assistance.
4 Moderately severe disability: unable to walk without assistance, and unable to attend
to own bodily needs without assistance.
5 Severe disability: bedridden, incontinent, and requiring constant nursing care and attention.

26. 26 ·π«∑“ß°“√√—°…“‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßµ’∫·≈–Õÿ¥µ—π¥â«¬°“√©’¥¬“≈–≈“¬≈‘Ë¡‡≈◊Õ¥∑“ßÀ≈Õ¥‡≈◊Õ¥¥”
¿“§ºπ«° 3
µ—«Õ¬à“ß Stroke fast track care maps and protocols
1. §≥–·æ∑¬»“ µ√å ®ÿÓ≈ß°√≥å¡À“«‘∑¬“≈—¬
ª√–°Õ∫¥â«¬
1. Stroke fast track protocol
2. The National Institute of Health Stroke Scale (0 - 42) (NIHSS)
3. Barthel Index
4. Rankin Scale
5. Stroke discharge summary sheet
2. §≥–·æ∑¬»“ µ√å ‚√ß欓∫“≈√“¡“∏‘∫¥’
ª√–°Õ∫¥â«¬ Doctorûs order sheet: orders for acute stroke patients
3. §≥–·æ∑¬»“ µ√廑√‘√“™æ¬“∫“≈
ª√–°Õ∫¥â«¬
1. Siriraj acute stroke protocol
2. Àπ—ß ◊Õ· ¥ß‡®µπ“¢Õ√—∫°“√√—°…“¿“«– ¡Õߢ“¥‡≈◊Õ¥‡©’¬∫æ≈—π ‚¥¬°“√„™â¬“≈–≈“¬≈‘Ë¡‡≈◊Õ¥
3. Dose t-PA (mg)
4. Checklist for intravenous thrombolysis in acute stroke
4. ∂“∫—πª√– “∑«‘∑¬“
ª√–°Õ∫¥â«¬
1. Stroke fast track care map
2. Thrombolysis check list
3. Àπ—ß ◊Õ· ¥ß§«“¡¬‘π¬Õ¡©’¥¬“≈–≈“¬≈‘Ë¡‡≈◊Õ¥rt-PA∑“ßÀ≈Õ¥‡≈◊Õ¥¥”„πºŸâªÉ«¬‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßµ’∫
·≈–Õÿ¥µ—π
4. Doctorûs orders sheet
5. NIHSS score sheet (1)

27. ·π«∑“ß°“√√—°…“‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßµ’∫·≈–Õÿ¥µ—π¥â«¬°“√©’¥¬“≈–≈“¬≈‘Ë¡‡≈◊Õ¥∑“ßÀ≈Õ¥‡≈◊Õ¥¥” 27
µ—«Õ¬à“ß Stroke fast track care map and protocol
§≥–·æ∑¬»“ µ√å ®ÿÓ≈ß°√≥å¡À“«‘∑¬“≈—¬

28. §≥–·æ∑¬»“ µ√å ®ÿÓ≈ß°√≥å¡À“«‘∑¬“≈—¬
µâÕ߉¥â rt-PA °àÕπ ............ π. ‡À≈◊Õ‡«≈“Õ’° ....................
STROKE FAST TRACK !
µ“√“߇«≈“ ”À√—∫ºŸâªÉ«¬∑’Ë¡“¥â«¬Õ“°“√ ß —¬ stroke ¡’Õ“°“√¡“‰¡à‡°‘π 3 ™—Ë«‚¡ß
™◊ËÕºŸâªÉ«¬............................................. ‡æ» ™“¬ À≠‘ß Õ“¬ÿ............. ªï HN.................. «—π∑’Ë................
ᾷŒ R med 2 ...................... R neuro 2.......................... R neuro 3...................... Time Signature
Symptoms at onset ÕàÕπ·√ß ™“ ‡¥‘π‡´ æŸ¥‰¡à™—¥ µ“¡—« Õ◊Ëπ Ê...........................
Time of arrival
Primary doctor Acute stroke Y N
Request blood test, CT scan
Neurologist Fast track Y N
The patient is transfered to CT at
History screening for exclusion
No Hx of head trauma or stroke within 3 mo
No Hx of major Sx or serious trauma within 14 days
No Hx of ICH, AVM or aneurysm
No Hx of GI or urinary tract hemorrhage within 21 days
No Hx of arterial puncture at non compressible site or LP within 7 days
No seizure at onset
No symptom suggests SAH
NIHSS .................................. BP..................................
Laboratory screening for exclusion
CT scan result ............................................................................................
No evidence of ICH No edema or brain shifting
Blood test results BS............ PT................ PTT.................... PLT......................
BS > 50 < 400 mg/dl Plt > 100,000
INR < 1.7 PTT not prolonged
Immediate physical examination before rt-PA infusion
No rapid spontaneous improvement SBP < 185, DBP < 110 mmHg
Consent form is signed
NIHSS ..............BP.................DOOR TO NEEDLE TIME............................
rt-PA Given Y N
Departure time from ER
Arrival time to stroke unit
Total time
Thrombolytic is not given
Reasons not to use thrombolytic drug
Excluded by clinical Minimal neurological deficit Excluded by history
Abnormal blood test Spontaneous improve Hemorrhagic stroke
Consent form was not signed High blood pressure Delayed processes
Note
28 ·π«∑“ß°“√√—°…“‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßµ’∫·≈–Õÿ¥µ—π¥â«¬°“√©’¥¬“≈–≈“¬≈‘Ë¡‡≈◊Õ¥∑“ßÀ≈Õ¥‡≈◊Õ¥¥”

29. §≥–·æ∑¬»“ µ√å ®ÿÓ≈ß°√≥å¡À“«‘∑¬“≈—¬
™◊ËÕ.......................................... °ÿ≈................................. HN.................................
The National Institute of Health Stroke Scale (0 - 42) (NIHSS)
Date of examination
Level of consciousness Alert 0
Drowsy 1
Stuporous 2
Coma 3
Two questions ∂“¡Õ“¬ÿ·≈–‡¥◊Õπ Both correct 0
One correct 1
None correct 2
Two commands À≈—∫µ“ ≈◊¡µ“·≈–°”¡◊Õ·∫¡◊Õ Obeys both 0
Obeys none 2
Best gaze ¡Õߥâ“π¢â“ß Normal 0
Partial gaze palsy 1
Forced deviation 2
Best visual (visual field) No visual loss 0
Partial hemianopia 1
Complete hemianopia 2
Bilateral hemianopia 3
Facial palsy Normal 0
Minor 1
Partial 2
Complete 3
Best Motor Lt arm π—Ë߬°·¢π 90 Õß»“ 10 «‘π“∑’ No drift 0
Drift 1
Fall in 10 secs 2
No effort against gra 3
No movement 4
Best Motor Rt arm π—Ë߬°·¢π 90 Õß»“ 10 «‘π“∑’ No drift 0
Drift 1
Fall in 10 secs 2
No effort against gra 3
No movement 4
Best Motor Lt leg πÕπ¬°¢“ 45 Õß»“ 5 «‘π“∑’ No drift 0
Drift 1
Fall in 5 secs 2
No effort against gra 3
No movement 4
Best Motor Rt leg πÕπ¬°¢“ 45 Õß»“ 5 «‘π“∑’ No drift 0
Drift 1
Fall in 5 secs 2
No effort against gra 3
No movement 4
Limb Ataxia Absent 0
Upper or lower limb 1
Upper & lower limbs 2
Sensory Normal 0
Partial loss 1
Dense loss 2
Neglect No neglect 0
Sensory or visual 1
Sensory & visual 2
Dysarthria Normal articulation 0
Mild to moderate 1
Severe 2
Best language Aphasia No aphasia 0
Mild to moderate 1
Severe 2
Mute 3
Total
·π«∑“ß°“√√—°…“‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßµ’∫·≈–Õÿ¥µ—π¥â«¬°“√©’¥¬“≈–≈“¬≈‘Ë¡‡≈◊Õ¥∑“ßÀ≈Õ¥‡≈◊Õ¥¥” 29

30. §≥–·æ∑¬»“ µ√å ®ÿÓ≈ß°√≥å¡À“«‘∑¬“≈—¬
ON ADMISSION
™◊ËÕ............................ °ÿ≈............................ HN............................
BARTHEL INDEX
WITH HELP INDEPENDENT
1. Feeding 5 10
2. Moving from wheelchair to bed and return
(includes sitting up in bed) 5 or 10 15
3. Personal toilet (wash face, comb hair, shave, clean teeth) 0 5
4. Getting on and off toilet (handing clothes, wipe, flush) 5 10
5. Bathing self 0 5
6. Walking on level surface (if unable propel wheelchair) 10 15
* Score only if unable to walk 0* 5*
7. Ascend and descend stairs 5 10
8. Dressing (includes tying shoes, fastening fasteners) 5 10
9. Controlling bowel 5 10
10. Controlling bladder 5 10
Total score
RANKIN SCALE
No symptoms at all 0
No significant disability despite symptoms: able carry out
all usual duties and activities. 1
Slight disability: unable to carry out all previous activities
but able to look after own affairs without assistance. 2
Moderate disability: requiring some help; but able to walk
without assistance. 3
Moderately severe disability: unable to walk without
assistance and unable to attend to own bodily needs without
assistance. 4
Severe disability: bedridden, incontinent, and requiring constant
nursing care and attention 5
30 ·π«∑“ß°“√√—°…“‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßµ’∫·≈–Õÿ¥µ—π¥â«¬°“√©’¥¬“≈–≈“¬≈‘Ë¡‡≈◊Õ¥∑“ßÀ≈Õ¥‡≈◊Õ¥¥”

31. §≥–·æ∑¬»“ µ√å ®ÿÓ≈ß°√≥å¡À“«‘∑¬“≈—¬
™◊ËÕ........................ °ÿ≈..................... Õ“¬ÿ............... HN....................................
Stroke Discharge Summary Sheet
Date of admission .................................................................. Date of discharge .....................................................................
Final Diagnosis Hemorrhagic stroke type............................
Ischemic Stroke
Vessel: Anterior circulation: ACA/MCA
Posterior circulation: PCA/VB/AICA/PICA/SCA
Cause Emboli : cardiac Type Total anterior circulation infarct
Emboli : artery Partial anterior circulation infarct
Emboli : unknown Posterior circulation infarct
Large vessel thrombosis Lacunar
Lacunar stroke : type........................................
Others...............................................................
Risk of stroke HT AF DM Smoking Alc Dyslipid Others......................................
Complication: Intracerebral hemorrhage Brain edema Others.............................................................
Other diagnosis
1. .......................................................................................................
2. ....................................................................................................... CT
3. .......................................................................................................
Investigations
Lab: Hct.............. WBC............. PMN.............% L.............% Eo...........% B..............% Plt............. ESR.........................mm/hr
VDRL.......... FPG........... BUN........... Cr.......... Chol........... TG........... HDL........... LDL................ Stool occ bl............
CT scan.......................................................................................... EKG...............................................................................................
MRI not done done scheduled on.........................................................................................................................
MRI brain result....................................................................................................................................................................................
MRA brainresult....................................................................................................................................................................................
MRA neck result....................................................................................................................................................................................
CDUS not done done result.............................................................................................................................................
Echocardiogram not done done result..................................................................................................................
Condition on discharge BP...................... mmHg
Result : improved stable worse dead cause............................................................................................
NIHSS on admission................................................ NIHSS on discharge.........................................................................................
Barthel Index............................................................. Rankin Scale....................................................................................................
Hospital meds.........................................................................................................................................................................................
Discharge meds......................................................................................................................................................................................
·æ∑¬åºŸâµ√«®.................................................................
·π«∑“ß°“√√—°…“‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßµ’∫·≈–Õÿ¥µ—π¥â«¬°“√©’¥¬“≈–≈“¬≈‘Ë¡‡≈◊Õ¥∑“ßÀ≈Õ¥‡≈◊Õ¥¥” 31

32. §≥–·æ∑¬»“ µ√å ®ÿÓ≈ß°√≥å¡À“«‘∑¬“≈—¬
ON DISCHARGE
™◊ËÕ...................................................... °ÿ≈................................................. HN............................
BARTHEL INDEX
WITH HELP INDEPENDENT
1. Feeding 5 10
2. Moving from wheelchair to bed and return
(includes sitting up in bed) 5 or 10 15
3. Personal toilet (wash face, comb hair, shave, clean teeth) 0 5
4. Getting on and off toilet (handing clothes, wipe, flush) 5 10
5. Bathing self 0 5
6. Walking on level surface (if unable propel wheelchair) 10 15
* Score only if unable to walk 0* 5*
7. Ascend and descend stairs 5 10
8. Dressing (includes tying shoes, fastening fasteners) 5 10
9. Controlling bowel 5 10
10. Controlling bladder 5 10
Total score
RANKIN SCALE
No symptoms at all 0
No significant disability despite symptoms: able carry out
all usual duties and activities. 1
Slight disability: unable to carry out all previous activities
but able to look after own affairs without assistance. 2
Moderate disability: requiring some help; but able to walk
without assistance. 3
Moderately severe disability: unable to walk without
assistance and unable to attend to own bodily needs without
assistance. 4
Severe disability: bedridden, incontinent, and requiring constant
nursing care and attention 5
32 ·π«∑“ß°“√√—°…“‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßµ’∫·≈–Õÿ¥µ—π¥â«¬°“√©’¥¬“≈–≈“¬≈‘Ë¡‡≈◊Õ¥∑“ßÀ≈Õ¥‡≈◊Õ¥¥”

33. ·π«∑“ß°“√√—°…“‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßµ’∫·≈–Õÿ¥µ—π¥â«¬°“√©’¥¬“≈–≈“¬≈‘Ë¡‡≈◊Õ¥∑“ßÀ≈Õ¥‡≈◊Õ¥¥” 33
µ—«Õ¬à“ß Stroke fast track care map and protocol
§≥–·æ∑¬»“ µ√å ‚√ß欓∫“≈√“¡“∏‘∫¥’
¡À“«‘∑¬“≈—¬¡À‘¥≈

34. 34 ·π«∑“ß°“√√—°…“‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßµ’∫·≈–Õÿ¥µ—π¥â«¬°“√©’¥¬“≈–≈“¬≈‘Ë¡‡≈◊Õ¥∑“ßÀ≈Õ¥‡≈◊Õ¥¥”
™◊ËÕ..............................................................................................
H.N...........................................................................................
Õ“¬ÿ................................................... ·ºàπ∑’Ë..........................
Date
Hour
Admit to Stroke Unit/ICU
Dx : ................................................................
Vitals : Q 4 hours, I/O
Activity : Bed rest
Head flat (< 30)
Fall precaution
Aspiration precaution
Diet : NPO until cleared by M.D.or
swallowing assessment
Medications:-
- Paracetamol 500 mg po/NG
prn pain of fever Q 4 hours
- MOM 30 ml po/NG prn
constipation QD
Sign.........................code...........................
Date
Hour
Date
Hour
§≥–·æ∑¬»“ µ√å‚√ß欓∫“≈√“¡“∏‘∫¥’ ¡À“«‘∑¬“≈—¬¡À‘¥≈
RAMATHIBODI HOSPITAL
Department Division Ward
Attending Staff Resident
DOCTORûS ORDER SHEET
Orders for 1 day only Orders for Continuation OFF
CBC, PT/INR, PTT
BUN/Cr, Electrolytes, glucose
Capillary blood glucose
0.9% NSS..................ml/h IV drip
O2 nasal cannula 2 LPM
CT brain without contrast
Notify neurology resident on call
12-lead EKG
Chest X-ray
Please check
Foley catheter placement
NG tube placement if at high risk of aspiration
tPA and post-tPA orders
NPO except meds
Obtain another IV line (hepLock)
Keep SBP < 185 and DBP < 110 mmHg
May give Nicardipine IV drip
Obtain Actilyse (t-PA)
(Do not mix until told to do so)
Total dose =..................mg (0.9 mg/kg, max 90 mg)
- 10% of total dose in 1 min
- the remaining in 60 min
Record BP as follows:-
Q 15 mins ✕ 2 hours
Q 30 mins ✕ 6 hours
Q 1 hour ✕ 16 hours
Q 4 hours if stable
Record neuro-signs (GCS) Q 1 hour ✕ 24 hours
Notify acute stroke on call Neurology resident if BP > 180/110 mmHg
or decline in Neuro status or decrease in GCS
No arterial puncture
No aspirin, aspirin/dipyridamole (Aggrenox®),
ticlopidine (Ticlid®), clopidogrel (Plavix®), cilostazole (Pletaal®)
heparin, warfarin (Coumadin), Enoxaprarin (Clexane), Nadroparin (Fraxiparine)
or any other antithrombotic for first 24 hrs. Post t-PA administration
CT scan after t-PA administration 24 hours
Sign..........................code..........................

35. ·π«∑“ß°“√√—°…“‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßµ’∫·≈–Õÿ¥µ—π¥â«¬°“√©’¥¬“≈–≈“¬≈‘Ë¡‡≈◊Õ¥∑“ßÀ≈Õ¥‡≈◊Õ¥¥” 35
µ—«Õ¬à“ß Stroke fast track care map and protocol
§≥–·æ∑¬»“ µ√廑√‘√“™æ¬“∫“≈
¡À“«‘∑¬“≈—¬¡À‘¥≈

36. 10. Consent form
(Resident/Staff neurology)
§≥–·æ∑¬»“ µ√廑√‘√“™æ¬“∫“≈ ¡À“«‘∑¬“≈—¬¡À‘¥≈
Siriraj Acute Stroke Protocol
1. ‡«≈“¢≥–‡√‘Ë¡¡’Õ“°“√..........................
ºŸâ∫—π∑÷° ....................................
2. ¡“∂÷ß∑’Ë ER
‡«≈“ .............................
ºŸâ∫—π∑÷° ..............................
3. 欓∫“≈§—¥°√Õß
‡«≈“ ................................
ºŸâ∫—π∑÷° ................................
(ER nurse)
4. ·æ∑¬å‡«√ ER
‡√‘Ë¡´—°ª√–«—µ‘/µ√«®√à“ß°“¬
‡«≈“ ................................
ºŸâ∫—π∑÷° ................................
7. ‡®“– CBC, BS, electrolyte, BUN,
Cr, Coagulogram, INR
‡«≈“ ...............................
ºŸâ∫—π∑÷° ...............................
(ER physician)
6. Activate Siriraj acute stroke team
‡«≈“ ......................................
ºŸâ∫—π∑÷° ......................................
(ER physician)
5. µ‘¥µàÕ√—ß ’·æ∑¬å (7308, 7309)
‡«≈“ ...............................
ºŸâ∫—π∑÷° ...............................
(ER physician)
9. Non-contrast CT brain
‡«≈“ ...............................
ºŸâ∫—π∑÷° ...............................
8. ‡«√‡ª≈ àߺŸâªÉ«¬‡æ◊ËÕµ√«® CT brain
‡«≈“ ........................................
ºŸâ∫—π∑÷° ........................................
(ER nurse)
Cerebral infarct Cerebral hemorrhage Stroke mimics ◊∫§âπ‡æ‘Ë¡‡µ‘¡ À√◊Õ admit
µ“¡§«“¡‡À¡“– ¡
æ‘®“√≥“„À⬓„π°√≥’µàÕ‰ªπ’È ‰¡à„À⬓‡æ√“–
- ¡’Õ“°“√¿“¬„π 3 ™—Ë«‚¡ß
- Õ“¬ÿ >18 ªï
- º≈ CT ‰¡àæ∫‡≈◊Õ¥
- º≈ Coagulogram ª°µ‘
11. Onset 0 - 90 π“∑’
Dose 0.9 mg/kg „Àâ 10% iv bolus,
90% iv drip in 1hr
‡«≈“ ................................................
ºŸâ„Àâ ................................................
(Resident/Staff neurology on call)
11. Onset 91 - 150 π“∑’
Dose 0.75 mg/kg „Àâ 10% iv bolus,
90% iv drip in 1hr
‡«≈“ ................................................
ºŸâ„Àâ ................................................
(Resident/Staff neurology on call)
11. Onset 151 - 180 π“∑’
Dose 0.60 mg/kg „Àâ 10% iv bolus,
90% iv drip in 1hr
‡«≈“ .................................................
ºŸâ„Àâ .................................................
(Resident/Staff neurology on call)
12. ºŸâªÉ«¬ admit ∑’Ë Siriraj Acute Stroke
Unit (8613, 8614)
‡«≈“ ...............................
ºŸâ∫—π∑÷° ...............................
(Stroke unit nurse)
·®âß neurosurgeon ‡«√«à“ºŸâªÉ«¬‰¥â√—∫¬“
thrombolysis admit ∑’Ë Word
(Resident/Staff neurology on call)
* À¡“¬‡Àµÿ πÕ°‡«≈“√“™°“√„Àâ by pass ºŸâÕ”π«¬°“√πÕ°‡«≈“√“™°“√ ‚¥¬µ‘¥µàÕºŸâÕ”π«¬°“√‚√ß欓∫“≈»‘√‘√“™ (». π.æ.ª√– ‘∑∏‘Ï «—≤π“¿“) ‚¥¬µ√ß
1. .............................................................................
2. .............................................................................
3. .............................................................................

36 ·π«∑“ß°“√√—°…“‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßµ’∫·≈–Õÿ¥µ—π¥â«¬°“√©’¥¬“≈–≈“¬≈‘Ë¡‡≈◊Õ¥∑“ßÀ≈Õ¥‡≈◊Õ¥¥”

37. §≥–·æ∑¬»“ µ√廑√‘√“™æ¬“∫“≈
Àπ—ß ◊Õ· ¥ß‡®µπ“¢Õ√—∫°“√√—°…“¿“«– ¡Õߢ“¥‡≈◊Õ¥‡©’¬∫æ≈—π
‚¥¬°“√„™â¬“≈–≈“¬≈‘Ë¡‡≈◊Õ¥
„À⺟âªÉ«¬À√◊ÕºŸâ¡’Õ”π“®°√–∑”°“√·∑πºŸâªÉ«¬‡ªìπºŸâ°√Õ°¢âÕ§«“¡·≈–°“‡§√◊ËÕßÀ¡“¬/„π™àÕß
‚¥¬Àπ—ß ◊Õ©∫—∫π’È ¢â“懮ⓠπ“¬/π“ß/π“ß “« ..................................................................Õ“¬ÿ................ ªï
∫—µ√ª√–®”µ—«ª√–™“™π ∫—µ√¢â“√“™°“√ ∫—µ√æπ—°ß“π√—∞«‘ “À°‘® ∫√‘…—∑ ‡≈¢∑’Ë.........................
—ß°—¥............................................................................„π∞“𖇪ìπ ºŸâªÉ«¬ ºŸâ¡’Õ”π“®°√–∑”°“√·∑π
„π∞“π–........................¢ÕߺŸâªÉ«¬™◊ËÕ π“¬/π“ß/π“ß “«..................................................................................................
H.N. ................................................................................A.N. .......................................................................................
¢â“懮Ⓣ¥â√—∫∑√“∫∂÷ß√“¬≈–‡Õ’¬¥¢Õß°“√√—°…“¿“«– ¡Õߢ“¥‡≈◊Õ¥‡©’¬∫æ≈—π‚¥¬°“√„À⬓≈–≈“¬≈‘Ë¡‡≈◊Õ¥
∑“ßÀ≈Õ¥‡≈◊Õ¥¥”®“°·æ∑¬å¢Õߧ≥–·æ∑¬»“ µ√廑√‘√“™æ¬“∫“≈ ¥—ßµàÕ‰ªπ’È
¢âÕ 1 °“√„À⬓≈–≈“¬≈‘Ë¡‡≈◊Õ¥„πºŸâªÉ«¬¿“«– ¡Õߢ“¥‡≈◊Õ¥‡©’¬∫æ≈—π¿“¬„π 3 ™—Ë«‚¡ß®–∑”„À⺟âªÉ«¬¡’
‚Õ°“ ∑’Ë®–øóôπµ—«®“°§«“¡æ‘°“√ Ÿß°«à“°≈ÿà¡∑’ˉ¡à‰¥â√—∫¬“ª√–¡“≥ 30%
¢âÕ 2 ¢â“懮Ⓡ¢â“„®¢âÕ∫àß™’È·≈–√“¬≈–‡Õ’¬¥¢Õß°“√√—°…“¥—ß°≈à“«¢â“ßµâπ√«¡∑—Èß√—∫∑√“∫∂÷ߺ≈·∑√°´âÕπ
¢Õß°“√„™â¬“π’ȧ◊Õ
2.1 ¿“«–‡≈◊Õ¥ÕÕ°„π ¡Õß·≈–‡≈◊Õ¥ÕÕ°„π∫√‘‡«≥µà“ß Ê ¢Õß√à“ß°“¬‚¥¬®–¡’Õ—µ√“‡ ’ˬߢÕß
¢âÕ·∑√°´âÕππ’Ȫ√–¡“≥ 7%
2.2 Õ—µ√“°“√·æ⬓™π‘¥√ÿπ·√ß (Anaphylactic, Angioedema) ª√–¡“≥ 0.1%
ºŸâ„Àâ¢âÕ¡Ÿ≈°“√√—°…“
≈ß™◊ËÕ.............................................................. ≈ß™◊ËÕ.................................................................
(...........................................................) (..............................................................)
µ”·Àπàß......................................................... ºŸâªÉ«¬ / ºŸâ¡’Õ”π“®°√–∑”°“√·∑πºŸâªÉ«¬
≈ß™◊ËÕ..............................................................欓π ≈ß™◊ËÕ.................................................................欓π
(...........................................................) (..............................................................)
µ”·Àπàß......................................................... µ”·Àπàß...........................................................
«—π∑’Ë.............../................./................. ‡«≈“.............π.
·π«∑“ß°“√√—°…“‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßµ’∫·≈–Õÿ¥µ—π¥â«¬°“√©’¥¬“≈–≈“¬≈‘Ë¡‡≈◊Õ¥∑“ßÀ≈Õ¥‡≈◊Õ¥¥” 37

38. BODY WEIGHT
(KG)
Dose t-PA (mg)
Onset 0 - 90 min. 91 - 150 min. 151 - 180 min.
0.9 (mg/kg) 0.75 (mg/kg) 0.6 (mg/kg)
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
54.9
55.8
56.7
57.6
58.5
59.4
60.3
61.2
62.1
63.0
63.9
64.8
65.7
66.6
67.5
68.4
69.3
70.2
71.1
72.0
45.75
46.50
47.25
48.00
48.75
49.50
50.25
51.00
51.75
52.50
53.25
54.00
54.75
55.50
56.25
57.00
57.75
58.50
59.25
60.00
36.6
37.2
37.8
38.4
39.0
39.6
40.2
40.8
41.4
42.0
42.6
43.2
43.8
44.4
45.0
45.6
46.2
46.8
47.4
48.0
§≥–·æ∑¬»“ µ√廑√‘√“™æ¬“∫“≈ ¡À“«‘∑¬“≈—¬¡À‘¥≈
38 ·π«∑“ß°“√√—°…“‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßµ’∫·≈–Õÿ¥µ—π¥â«¬°“√©’¥¬“≈–≈“¬≈‘Ë¡‡≈◊Õ¥∑“ßÀ≈Õ¥‡≈◊Õ¥¥”

39. §≥–·æ∑¬»“ µ√廑√‘√“™æ¬“∫“≈ ¡À“«‘∑¬“≈—¬¡À‘¥≈
Checklist for intravenous thrombolysis in acute stroke
Initial assessment
Onset of stroke clearly established < 3 hours prior to presentation
Unequivocal diagnosis of stroke; no seizure at onset
Urgent blood work (Blood glucose, CBC, electrolyte, Coagulogram, INR)
Emergency non-contrast CT brain
Acute Stroke Team notified
Urgently request family members to be present
ECG
Consider insert urinary catheter and NG tube prior to thrombolysis
CT assessment
Non-contrast CT assessment within 3 hours of stroke
No signs of neoplasm, SAH or aneurysm
Final assessment
At least moderate deficit remaining (NIHSS > 4)
2nd
canula inserted
BP below 185/110, may give a single dose of i.v. metoprolol or nicardipine if required
2.7 < blood sugar level < 22
Platelet count > 100,000/mm3, INR < 1.7, normal APTT
No suspicion of septic emboli, SAH or pregnancy at present time
No previous intracranial haemorrhage/SAH, cerebral neoplasm
No AMI, stroke or head trauma in previous 3 months
No history of haemorrhage in previous 30 days, that might lead to unmanageable haemorrhage with TPA
Patient or responsible person provide informed consent (specific information sheet and consent form for
rtPA)
Sticker ™◊ËÕºŸâªÉ«¬
·π«∑“ß°“√√—°…“‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßµ’∫·≈–Õÿ¥µ—π¥â«¬°“√©’¥¬“≈–≈“¬≈‘Ë¡‡≈◊Õ¥∑“ßÀ≈Õ¥‡≈◊Õ¥¥” 39

40. Date
Time
1A Consciousness 0 = Alert
1 = Sleepiness
2 = Stupor
3 = Coma
1B Question 0 = Answers both questions
1 = Answers only one question
2 = Answers neither question
1C Commands 0 = Performs both tasks
1 = Performs only one task
2 = Performs neither task
2 Gaze 0 = Normal
1 = Partial gaze plasy
2 = Total gaze palsy
3 Visual field 0 = No visual loss
1 = Partial hemianopsia
2 = Total hemianopsia
3 = Bilateral hemianopsia
4 Facial Palsy 0 = Without facial paralysis
1 = Minor facial paralysis
2 = Partial facial paralysis
3 = Complete facial paralysis
5 Arm Strength 0 = Normal
1 = Drifts down after 10 seconds
2 = Fall before 10 seconds
3 = No effort against gravity
4 = No movement
9 = Limb amputated
6 Leg Strength 0 = Normal
1 = Drifts down after 5 seconds
2 = Fall before 5 seconds
3 = No effort against gravity
4 = No movement
9 = Limb amputated
7 Ataxia 0 = Does not present ataxia
1 = Ataxia in only one limb
2 = Ataxia in 2 limbs
9 = Limb amputated
8 Sensory 0 = Without sensory alteration
1 = Mild to moderate sensory loss
2 = Severe or complete sensory loss
9 Language 0 = Without language alteration
1 = Mild to moderate aphasia
2 = Severe aphasia
3 = Mute or global aphasia
10 Dysarthria 0 = Without dysarthria
1 = Mild or moderate dysarthria
2 = Severe dysarthria or anarthria
9 = Intubation
11 Inattention 0 = Without inattention
1 = Mild inattention
2 = Severe inattention
Total
Signature
§≥–·æ∑¬»“ µ√廑√‘√“™æ¬“∫“≈ ¡À“«‘∑¬“≈—¬¡À‘¥≈
Left Left Left Left
Right Right Right Right
Left Left Left Left
Right Right Right Right
40 ·π«∑“ß°“√√—°…“‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßµ’∫·≈–Õÿ¥µ—π¥â«¬°“√©’¥¬“≈–≈“¬≈‘Ë¡‡≈◊Õ¥∑“ßÀ≈Õ¥‡≈◊Õ¥¥”

41. §≥–·æ∑¬»“ µ√廑√‘√“™æ¬“∫“≈ ¡À“«‘∑¬“≈—¬¡À‘¥≈
Inclusion and Exclusion Criteria of the National Institute of Neurological Disorders and Stroke
(NINDS) study*
Inclusion Criteria of NINDS
Ischemic stroke of defined onset < 3 hours
Deficit measurable on NIHSS
Baseline CT of the brain without evidence of hemorrhage
Exclusion Criteria of NINDS
A prior stroke within the last 3 months prior to presentation (PTP)
Major surgery within the last 14 days PTP
Serious head trauma within the last 3 months PTP
History of intracranial hemorrhage (ICH)
Systolic blood pressure (BP) > 185 mmHg or diastolic BP >110 mmHg or if aggressive treatment was required
to lower the BP to below these limits
Rapidly improving or minor symptoms
Symptoms suggestive of subarachnoid hemorrhage (SAH)
Gastrointestinal bleeding or urinary tract hemorrhage within the 3 weeks PTP
Arterial puncture at a non-compressible site within the last 7 days PTP
Seizure at the onset of symptoms
Anticoagulants or heparin within 48 hours before stroke onset or elevated PTT
(patial thromboplastin time), or elevated PT (prothrombin time) > 15 sec
Platelet count < 100,000/ml
Blood glucose < 50 mg/dL or above 400 mg/dL
*Tissue Plasminogen Activator for Acute Ischemic Stroke CT, computed tomography; NIHSS, National
Institutes of Health Stroke Scale; NINDS, National Institute of Neurological Disorders and Stroke
The National Institute of Neurological Disorders and Stroke rt-PA Stroke Study Group. N Engl J Med
333(24):1581 - 1587, 1995.
·π«∑“ß°“√√—°…“‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßµ’∫·≈–Õÿ¥µ—π¥â«¬°“√©’¥¬“≈–≈“¬≈‘Ë¡‡≈◊Õ¥∑“ßÀ≈Õ¥‡≈◊Õ¥¥” 41

42. 42 ·π«∑“ß°“√√—°…“‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßµ’∫·≈–Õÿ¥µ—π¥â«¬°“√©’¥¬“≈–≈“¬≈‘Ë¡‡≈◊Õ¥∑“ßÀ≈Õ¥‡≈◊Õ¥¥”

43. ·π«∑“ß°“√√—°…“‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßµ’∫·≈–Õÿ¥µ—π¥â«¬°“√©’¥¬“≈–≈“¬≈‘Ë¡‡≈◊Õ¥∑“ßÀ≈Õ¥‡≈◊Õ¥¥” 43
µ—«Õ¬à“ß Stroke fast track care map and protocol
∂“∫—πª√– “∑«‘∑¬“
°√¡°“√·æ∑¬å °√–∑√«ß “∏“√≥ ÿ¢

44. ∂“∫—πª√– “∑«‘∑¬“°√¡°“√·æ∑¬å
STROKEFASTTRACKCAREMAP
DATETIMEATARRIVALNAMEAGEHNAN
1.Continuepreviousmonitorofvitalsignsandneurosignsq15minuntil
2hrsthenq30min.for6hrsthen60min.for16hrs
2.IfsuspectforintracranialhemorrhagegotoICHmanagementsheet
3.IfSBP>185orDBP>110mmHg,gotoelevatedBPtreatmentsheet
4.Cardiacmonitoring(ifneeded)
5.Checkinput&output
1.After24hrsCTscantoexcludeintracranialhemorrhageifhemorrhage
presentgotoICHmanagementsheet
1.Continuert-PAinfusionthenIVNSSatrate60cc/hr
2.Oxygencanula(ifneeded)
3.Noantiplatelet&anticoagulantagentfor24hrspostrt-PA
4.Pepticulcerprophylaxis
(H2-blocker/Protonpumpinhibitor)
5.Continuepatientûsregularmedicationprescribed
(ifappropriated)
1.Checkbleeding&hematomafrompuncturesites,checkurine,stoolemesis
orothersforblood
2.Notifyphysiciansimmediatelyforevidenceof
*bleeding
*neurologicaldeterioration
*SBP>185or<100mmHg
*DBP>105or<60
*pulse<50/min
*respiration>24/min
1.RecordTIMEATONSET________
2.Checkvitalsignsonce&BPq15min.
3.AssessNIHSS
4.Checkinclusion&exclusioncriteria
1.StatblooddrawforCBC,PT,aPTT,BS
2.Statnon-contrastCTscanofbrain
TIMEATCTSCAN_______
1.IVassessNSSkeepatrate40cc/hr
2.Noantiplatelet&anticoagulantagent
3.Avoidofurinarycatheterizationand
nasogastrictubeinsertion
1.Activatestrokefasttrackpathway
2.Recordvitalsignsonce&BPq15min.
3.Immediatelyfollowdoctorûsorder
1.RecordresultsofCTscan&labs
2.Checkvitalsigns&neurosigns(inNIHSSsheet)
3.q15min.for2hrs
4.IfSBP>185orDBP>110mmHg,goto
elevatedBPtreatmentsheet
5.Recordpatientweightinkg
1.Statstooloccultblood(bedsidekit)
1.SecondIVassess:NSSlockinoppositearm
2.PrepareIVrt-PA(concentration1mg:1cc)
3.Totaldose:____mg(0.9mg/kg,maxdose90mg)
Administer____mg(10%oftotaldose)IVover1min.
Administer____mg(90%oftotaldose)
IVinfusionover60min.
TIMEATNEEDLE_______
4.TransfertoICUTIMETOICU________
5.Avoidarterialpunctures,frequentvenouspunctures
andurinarycatheterizationfor24hrspostrt-PA
6.Noantiplatelet&anticoagulantagentfor24hrs
postrt-PA
1.Recordvitalsigns&neurosignsq15min.for
2hrspostrt-PA
2.NotifyphysiciansforSBP>185&DBP>110mmHg
Department/EmergencydepartmentEmergencydepartmentIntensivecareunit
Aspectof(preliminaryevaluation)(thrombolytictherapy)
care
Assessment
Labs&Tests
Medication&
Intervention
Nursing
intervention
NutritionNPONPONPO
ActivityBedrestStrictbedrestStrictbedrest
44 ·π«∑“ß°“√√—°…“‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßµ’∫·≈–Õÿ¥µ—π¥â«¬°“√©’¥¬“≈–≈“¬≈‘Ë¡‡≈◊Õ¥∑“ßÀ≈Õ¥‡≈◊Õ¥¥”

45. ∂“∫—πª√– “∑«‘∑¬“ °√¡°“√·æ∑¬å
THROMBOLYSIS CHECK LIST
Name_______________________________ Age_____ HN_________ AN_________ Date:_______________
Attending staff______________________ Time: Symptom Onset ______ rtPA given:_______NIHSS_________
INCLUSION criteria (must all be YES)
* Age 18 years or older Yes No
* Time of onset well established to be less than 3 hours Yes No
* Clinical diagnosis of ischemic stroke causing a measurable neurological deficit Yes No
* CT without hemorrhage or significant edema Yes No
EXCLUSION criteria (must all be NO)
* SBP > 185 or DBP > 110 Yes No
* Symptoms rapidly improving or minor symptoms (NIHSS = 0 - 6) Yes No
* Coma or severe obtundation (or NIHSS > 25) Yes No
* Seizure at onset Yes No
* Symptoms of subarachnoid hemorrhage (diffuse headache, stiffness of neck) Yes No
* Prior stroke or head trauma within 3 months Yes No
* Major surgery within 14 days Yes No
* Prior intracranial hemorrhage Yes No
* GI hemorrhage or urinary tract hemorrhage within 21 days Yes No
* Arterial puncture at a noncompressible site or LP within 7 days Yes No
* Recent Myocardial infarction Yes No
* Patients receiving heparin within 48 hrs and with an elevated PTT Yes No
* PT >15 or INR > 1.7 Yes No
* Platelet count < 100,000 Yes No
* Plasma glucose < 50 or > 400 Yes No
* Hematocrit < 25% Yes No
* Pregnant (Note: menstruation is NOT a contraindication) Yes No
TREATMENT
Total dose to be given (0.9mg/kg)
Weight (kg): ____ x 0.9 mg = _____ mg (maximum 90 mg)
Give 10% bolus over 1 minute ___ mg (= ml)
Give remaining 90% constant infusion over 60 minutes ___ mg (= ml)
.................................................M.D.
Physicianûs Signature
·π«∑“ß°“√√—°…“‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßµ’∫·≈–Õÿ¥µ—π¥â«¬°“√©’¥¬“≈–≈“¬≈‘Ë¡‡≈◊Õ¥∑“ßÀ≈Õ¥‡≈◊Õ¥¥” 45

46. ∂“∫—πª√– “∑«‘∑¬“ °√¡°“√·æ∑¬å
Àπ—ß ◊Õ· ¥ß§«“¡¬‘π¬Õ¡©’¥¬“≈–≈“¬≈‘Ë¡‡≈◊Õ¥ rt-PA ∑“ßÀ≈Õ¥‡≈◊Õ¥¥”
„πºŸâªÉ«¬‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßµ’∫·≈–Õÿ¥µ—π
°≈ÿà¡ß“πª√– “∑«‘∑¬“ ∂“∫—πª√– “∑«‘∑¬“
«—π∑’Ë..........‡¥◊Õπ......................æ.». ................
°“√√—°…“‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßµ’∫À√◊ÕÕÿ¥µ—π‡©’¬∫æ≈—π¥â«¬°“√„À⬓≈–≈“¬≈‘Ë¡‡≈◊Õ¥∑“ßÀ≈Õ¥‡≈◊Õ¥¥”
‡ªìπ°“√√—°…“¡“µ√∞“π∑’Ë„™â„π°“√√—°…“ºŸâªÉ«¬ ‚¥¬¡’‚Õ°“ ∑’Ë®–„™â¬“¿“¬„π 3 ™—Ë«‚¡ß π—∫µ—Èß·µà‡√‘Ë¡¡’Õ“°“√®π∂÷ß
‡√‘Ë¡„À⬓∑“ß°≈ÿà¡ß“πª√– “∑«‘∑¬“¢Õ™’È·®ßª√–‚¬™πå·≈–¿“«–·∑√°´âÕπ∑’ËÕ“®‡°‘¥¢÷Èπ®“°°“√©’¥¬“≈–≈“¬≈‘Ë¡‡≈◊Õ¥
∑“ßÀ≈Õ¥‡≈◊Õ¥¥” ¥—ßπ’È
ª√–‚¬™πå∑’ˉ¥â√—∫ ®“°°“√»÷°…“æ∫«à“ºŸâªÉ«¬∑’ˉ¥â¬“≈–≈“¬≈‘Ë¡‡≈◊Õ¥ 31 - 50% ®–¡’Õ“°“√¥’¢÷Èπ¿“¬À≈—ß
‰¥â√—∫¬“ 24 ™—Ë«‚¡ß ·≈–¡’Õ“°“√‡°◊Õ∫‡ªìπª°µ‘‡«≈“ 3 ‡¥◊Õπ À≈—߉¥â√—∫¬“ ‡∑’¬∫°—∫°≈ÿà¡∑’ˉ¡à‰¥â„À⬓ ®–¡’Õ“°“√¥’¢÷Èπ
À≈—ß 24 ™—Ë«‚¡ß À√◊Õ¡’Õ“°“√‡°◊Õ∫ª°µ‘∑’Ë 3 ‡¥◊Õπ ‡æ’¬ß·§à 20 - 30%
¿“«–·∑√°´âÕπ∑’ËÕ“®‡°‘¥¢÷Èπ ®“°°“√»÷°…“æ∫«à“ºŸâªÉ«¬¡’‚Õ°“ ‡°‘¥¿“«–·∑√°´âÕπÕ◊Ëπ Ê ‰¥â·°à ¿“«–
‡≈◊Õ¥ÕÕ°„π ¡Õ߉¥â 6.4% √«¡∂÷ß¿“«–·∑√°´âÕπÕ◊Ëπ Ê ‰¥â·°à ¿“«–‡≈◊Õ¥ÕÕ°∑’Ë√à“ß°“¬ à«πÕ◊Ëπ Ê °“√·æ⬓
·µàÕ¬à“߉√°Áµ“¡ °“√§—¥‡≈◊Õ° ¿“«–ºŸâªÉ«¬∑’ˇÀ¡“– ¡°Á®– “¡“√∂™à«¬≈¥‚Õ°“ ‡°‘¥¿“«–·∑√°´âÕπ‰¥â
Àπ—ß ◊Õ· ¥ß§«“¡¬‘π¬Õ¡©∫—∫π’È¢â“懮â“........................................................................ºŸâªÉ«¬À√◊ÕºŸâÕπÿ≠“µ*
(¡’§«“¡ —¡æ—π∏å°—∫ºŸâªÉ«¬‡ªìπ.......................¢ÕߺŸâªÉ«¬™◊ËÕ..............................................) HN..................................
‰¥âÕà“π·≈–µ√«® Õ∫¥Ÿ‚¥¬≈–‡Õ’¬¥∂’Ë∂â«π·≈â«
¢Õ¬‘π¬Õ¡„Àâ©’¥¬“≈–≈“¬≈‘Ë¡‡≈◊Õ¥∑“ßÀ≈Õ¥‡≈◊Õ¥¥” À“°¡’‡Àµÿ ÿ¥«‘ —¬Õ—π‡°‘¥®“°¿“«–·∑√°´âÕπ
¢â“懮⓮–‰¡à∂◊Õ‡ªì𧫓¡º‘¥¢Õß°≈ÿà¡ß“πª√– “∑«‘∑¬“ ∂“∫—πª√– “∑«‘∑¬“ ·≈–®–‰¡à‡√’¬°√âÕßÀ√◊ÕøÑÕß√âÕß
¥”‡π‘𧥒°—∫∫ÿ§≈“°√·≈– à«π√“™°“√µâπ —ß°—¥¢Õß ∂“∫—πª√– “∑«‘∑¬“·µàÕ¬à“ß„¥ æ√âÕ¡°—ππ’ȉ¥â≈ß≈“¬¡◊Õ™◊ËÕ
‰«â‡ªìπÀ≈—°∞“𠔧—≠
‰¡à¬‘π¬Õ¡„Àâ©’¥¬“≈–≈“¬≈‘Ë¡‡≈◊Õ¥∑“ßÀ≈Õ¥‡≈◊Õ¥¥”
≈ß™◊ËÕ...........................................................ºŸâ¬‘π¬Õ¡*/ºŸâ‰¡à¬‘π¬Õ¡*
(.........................................................)
¡’§«“¡‡°’ˬ«¢âÕ߇ªìπ.....................¢ÕߺŸâªÉ«¬*
≈ß™◊ËÕ...........................................................欓π
(.........................................................)
≈ß™◊ËÕ...........................................................欓π
(.........................................................)
«—π∑’Ë...............‡¥◊Õπ............................æ.».............
46 ·π«∑“ß°“√√—°…“‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßµ’∫·≈–Õÿ¥µ—π¥â«¬°“√©’¥¬“≈–≈“¬≈‘Ë¡‡≈◊Õ¥∑“ßÀ≈Õ¥‡≈◊Õ¥¥”

47. µ÷°.............................
‘∑∏‘..........................
..................................
™◊ËÕ.............................
π“¡ °ÿ≈...................
Õ“¬ÿ............................
HN............................
Diagnosis..................
..................................
·æ⬓.........................
..................................
µ÷°.............................
‘∑∏‘..........................
..................................
™◊ËÕ.............................
π“¡ °ÿ≈...................
Õ“¬ÿ............................
HN............................
Diagnosis..................
..................................
·æ⬓.........................
..................................
µ÷°.............................
‘∑∏‘..........................
..................................
™◊ËÕ.............................
π“¡ °ÿ≈...................
Õ“¬ÿ............................
HN............................
Diagnosis..................
..................................
·æ⬓.........................
..................................
Doctorûs orders
∂“∫—πª√– “∑«‘∑¬“
312 ∂ππ√“™«‘∂’ ‡¢µ√“™‡∑«’ °∑¡. 10400
DATE ONE DAY DATE CONTINUATION
- Check vital & neuroûs signs
after infusion
15 mins. for 2 hrs
then 30 mins. for 6 hrs
then 60 mins. until 24 hrs
- Maintain BP 185/110 mmHg,
if BP out of ranges please notify
- Avoid after infusion
insertion Foley catheter within 2 hrs
insertion NG tube within 24 hrs
entral venous access, arterial puncture &
intramuscular injection
- UA, Stool occult blood
If hemorrahage is suspected
1. Stop infusion of the thrombolytic drug.
2. Repeat CBC, platelet, INR, PTT, PT
(fibrinogen, D-dimer)
3. CT brain stat
4. Prepare for administration of
6 to 8 FFP
5. Notify neurosurgeon
q
q
q
- NPO except meds for
24 hrs
- Bed rest
- Record I/O
- Medication
1. H2
blocker/PPI
Prophylaxis
·π«∑“ß°“√√—°…“‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßµ’∫·≈–Õÿ¥µ—π¥â«¬°“√©’¥¬“≈–≈“¬≈‘Ë¡‡≈◊Õ¥∑“ßÀ≈Õ¥‡≈◊Õ¥¥” 47

48. 48 ·π«∑“ß°“√√—°…“‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßµ’∫·≈–Õÿ¥µ—π¥â«¬°“√©’¥¬“≈–≈“¬≈‘Ë¡‡≈◊Õ¥∑“ßÀ≈Õ¥‡≈◊Õ¥¥”
1a. Level of 0 = Alert and responsive
Consciousness 1 = Response to minor stimuli
2 = Response to painful stimuli
3 = Reflex response or unresponse
1b. Questions 0 = Both correct
ask ptûs age 1 = One correct
and month 2 = Neither correct
1c. Commands 0 = Both correct
open/close eyes 1 = One correct
grip/release hand 2 = Neither correct
2. Best Gaze 0 = Normal
horizontal EOM by 1 = Partial gaze palsy
voluntary or Dollûs 2 = Forced eye deviation
total paresis
3. Visual Field 0 = No visual loss R/L
field of good eye 1 = Partial hemianopia,
2 = Complete hemianopia
3 = Bilateral hemianopia
4. Facial Palsy 0 = Normal R/L
check symmetry of 1 = Minor paralysis (flat NLF)
grimace to pain. 2 = Partial paralysis (UMN)
3 = Complete paralysis (U & LMN)
5. Motor Arm 0 = No drift R
arms outstretched 1 = Drift
90*(sitting) or 2 = Some antigravity effort
45*(supine) for 10 secs. 3 = No antigravity effort L
4 = No movement at all
X = Unable to assess (amputation)
6. Motor Leg 0 = No drift R
raise leg to 30* 1 = Drift
(supine) for 5 secs. 2 = Some antigravity effort
3 = No antigravity effort L
4 = No movement at all
X = Unable to assess (amputation)
7. Limb Ataxia 0 = No ataxia R/L
finger to nose 1 = Ataxia in upper or lower ext.
or heel to shin 2 = Ataxia in upper & lower ext.
X = Unable to assess (amputation)
8. Sensory 0 = Normal R/L
only stroke-related loss 1 = Mild-mod unilateral loss
2 = Total loss, Coma, bilateral loss
9. Best Language 0 = Normal
name objects, 1 = Mild-mod aphasia
read sentences, 2 = Severe aphasia
writing 3 = Mute, global aphasia, coma
10. Dysarthria 0 = Normal
1 = Mild-mod; slurred
2 = Severe; unintelligible or mute
X = Intubation
11. Extinction/Neglect 0 = Normal
simultaneous touch & 1 = Neglect to double simultaneous
visual field test stimulation in any modality
2 = Both neglect
TOTAL SCORE
∂“∫—πª√– “∑«‘∑¬“ °√¡°“√·æ∑¬å
NIHSS SCORE SHEET (1)
Patient Name________________________ Unit #______________ Date___/___/___ TOTAL______________
Date/Time of Stroke Onset_____________ Stroke Type___________ Examiner_________________________
DATE/SCORE
NIHSS ITEM SCORE DEFINITIONS

49. ·π«∑“ß°“√√—°…“‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßµ’∫·≈–Õÿ¥µ—π¥â«¬°“√©’¥¬“≈–≈“¬≈‘Ë¡‡≈◊Õ¥∑“ßÀ≈Õ¥‡≈◊Õ¥¥” 49
¿“§ºπ«° 4
CT scan examples for early signs of cerebral ischemia12
√Ÿª∑’Ë 1 Hyperdense MCA sign (arrow).
√Ÿª∑’Ë 2 Loss of the anterior half of the insular ribbon (arrow).

50. 50 ·π«∑“ß°“√√—°…“‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßµ’∫·≈–Õÿ¥µ—π¥â«¬°“√©’¥¬“≈–≈“¬≈‘Ë¡‡≈◊Õ¥∑“ßÀ≈Õ¥‡≈◊Õ¥¥”
√Ÿª∑’Ë 3 Loss of the insular ribbon on the right side (arrows)
and hypodensity of the basal ganglia (short arrows).
√Ÿª∑’Ë 4 Sulcal effacement right frontal lobe (arrow).

51. ·π«∑“ß°“√√—°…“‚√§À≈Õ¥‡≈◊Õ¥ ¡Õßµ’∫·≈–Õÿ¥µ—π¥â«¬°“√©’¥¬“≈–≈“¬≈‘Ë¡‡≈◊Õ¥∑“ßÀ≈Õ¥‡≈◊Õ¥¥” 51
√Ÿª∑’Ë 5 Early signs of a > 2/3 MCA infarction.
This patient should not be treated with thrombolysis

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