JCPSLP July 2014_Vol16_no2

Table 1. Logan Hospital Dysphagia Clinical Protocol for Thrombolysed Patients

Implication for speech pathologist management

Speech pathologist recommendations

Timeframe

Identified risks/ contraindications/for swallow assessment Urgent medical management/ admission

Presentation – 60min post-thrombolysis

Not for non-urgent assessments

Remain NBM awaiting swallow assessment and medical consent for intervention by speech pathologist

Other factors to consider between presentation – 60 min post-thrombolysis • Establishment of type of stroke (ischaemic vs hemorrhagic) ° As hemorrhagic stroke patients should preferably remain NBM pending neurosurgical review (in case of need for urgent surgical intervention) it is recommended to delay swallow assessment until haemorrhage has been excluded – Recommend patients remain NBM awaiting determination of stroke type and medical consent for intervention by speech pathologist • Medical establishment for suitability for rt-PA ° Due to the time limited opportunity for patients to be considered for thrombolysis, it is recommended that non-urgent assessments be delayed until this decision has been reached – Recommend patients remain NBM awaiting swallow assessment and medical consent for intervention by speech pathologist

60min – 4hours post- thrombolysis

Acute phase post-thrombolysis

Not for CBE during acute phase post- thrombolysis

Remain NBM awaiting swallow assessment and medical consent for intervention by speech pathologist

Other factors to consider in 60 min–4 hours post-thrombolysis • Highest risk of bleeding occurs in the first 2 hours post-thrombolysis ° Avoid all unnecessary movement and examinations, especially during this time period – Recommended that patients remain NBM pending swallow assessment • To be nursed at 30 degrees–45 degrees (not safe to be sat upright) ° As patients are required to be sat upright in order to complete swallow assessment (SPA dysphagia position paper), swallow assessment is recommend to be delayed until 4 hours post rt-PA, when the patient can safely be sat upright. – Recommended that patients remain NBM pending swallow assessment • All non-urgent assessments to be avoided ° Commencement of oral intake is not usually considered urgent, unless stated specifically in individual cases by treatment medical officers ° Should a medical request for swallow assessment due to need for oral medications / intake be received, completion of a swallow assessment on fluids (thick or thin) only is recommended, to avoid mastication and risk of oral trauma. Medically documented consent for early swallow assessment is recommended should this occur – Recommended that patients remain NBM pending swallow assessment • Insertion of lines, catheters, feeding tubes and injections remains contraindicated ° Insertion of NGT/venous cannulae is contraindicated during this time period ° Intramuscular injections or subcutaneous injections contraindicated during this time – Recommended that patients remain NBM pending swallow assessment and that NGT/IV/subcutaneous fluids not be inserted until 24 hours post-thrombolysis – Utilisation of already insitu line access is not contraindicated • Not for mobilisation ° Patients are at times sat out of bed for swallow assessment. It must be noted that should urgent swallow assessment be requested by medical staff and documented in the medical chart, in this timeframe patients are not to be sat out of bed during CBE. Should early dysphagia assessment be completed, the patient should remain in bed during this assessment

4 hrs–6 hrs post- thrombolysis

Continued heightened risk of haemorrhage

Swallow assessment may be completed; however, caution required

Seek consent from medical team for speech pathologist CBE. Complete swallow assessment if consent gained, using the below factors to guide assessment specifics

Other factors to consider in the 4 hours–6 hours post-thrombolysis • Continued heightened risk of haemorrhage ° CBE can be completed with caution; however, seek medical consent for same prior to assessment – Recommend seeking medical consent prior to speech pathology review, to ensure patent medical safe for assessment • Patients not for mobilisation within 6 hours post-thrombolysis ° Although a CBE can be completed, it is not safe for patient to be sat out of bed until over 6 hours post-thrombolysis. – Recommend that should a dysphagia assessment be completed in this timeframe, the patient must remain in bed for swallow assessment of fluids and soft solids

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JCPSLP Volume 16, Number 2 2014

Journal of Clinical Practice in Speech-Language Pathology