Stroke Consults

Stroke Consults

Welcome to the Vascular/Stroke Neurology consult service!  This will consist of you, the service fellow and the consult attending.

Guidelines for Stroke Fellows

Extended Thrombectomy Guidelines

Inpatient Stroke Codes – tPA for Inpatient Stroke worksheet

When an inpatient stroke is activated, the ICU pharmacy is NOT automatically notified.  Please follow these steps to notify them:

  1. Phone call #1: The stroke team is always responsible for calling the pharmacy (M4 satellite: 305-7130) for a heads up that tPA may be needed– before the CT scan
  2. The stroke team at that point will provide the patient’s MRN and weight if not in allscripts
  3. In the meantime, the pharmacist will have time to calculate the dose and review the patient’s profile
  4. Phone call #2: The stroke team will call the pharmacy to state if patient will need or not need Tpa
  5. Pharmacy will mix the tPA at that time and someone from the stroke team will need to pick the drug from the M4 pharmacy

Schedule:

8:00am – Get signout from CNF for any new consults to present. Grab a stroke pager from the

NI1 call room. Check-in with the stroke fellow on call join AM general consult rounds if

you’re able.

9:00am – See follow-ups in ICU preferentially, any new consults and stroke codes

12:00pm – 1pm – Noon conference*

     *Mon-Thurs: stroke fellow will cover stroke codes to protect resident during noon

       conference.  If there is a second stroke code, the resident will run the code.

     *Fridays: resident will remain 1st call to protect Stroke Fellow

       during Stroke conference

2:00pm – Rounds in the afternoon with fellow and attending.  You will decide which follow-up

patients need to be seen.

      *For Dr. Mohr, call/email Karen Lord to coordinate rounds

        (kl285@cumc.columbia.edu; 212-305-8033)

      *For other attendings, can text with them or fellows to coordinate rounds.

4:00pm – New consults, stroke codes

6:00pm – Stroke consult resident covers stroke codes and stroke consults until 6 PM,

      then signout active patients to the general consult resident.

General Logistics

  • Please note that you are to add patients to the new “Neuro Stroke Consult Service” list with the order “Add to Neuro Stroke Consult Service List”

  • Residents will see all new consults, but follow-up patients are split.  Fellow will follow and see all patients in ICUs (MICU, SICU, CCU, CTICU).

  • RAVEN Eligibility will be determined by criteria posted on Niresidents.org, and final decision is by stroke attending.

  • If patient is determined to be RAVEN eligible, email neuroravenclinic@columbia.eduwith patient MRN, one-liner, and tests needed (usually Dopplers +/- TCDs). Copy resident on RAVEN clinic, if there is one (Mon, Tues, Fri).

  • All consults on patients with LVAD or ECMO should be staffed with Dr. Wiley.  All consults on pregnant and recent post-partum patients should be staffed with Eliza Miller.

Responders for concurrent stroke codes (running the code)

Weekday 7:30 AM – 6 PM* See 12-1 PM coverage above

     1) Stroke Consult resident

     2) Stroke fellow

     3) General consult resident

Weeknights 6 PM – 7:30 AM

     1) Consult Night Float

     2) ANF

     3) NICU fellow

Saturday 7:30 AM – 7 PM

     1) Weekend Consult Junior

     2) Stroke service senior until 5 PM

     3) NICU fellow

Saturday and Sunday night 7 PM – 8 AM Sun/7:30 AM Mon

     1) Sat Weekend Consult Junior/Sun Consult Night Float

     2) ANF

     3) NICU fellow

 

Staffing (who to call first to discuss tpa/Thrombectomy)

Weekdays 7:30 AM -5:30 PM                 Stroke Fellow

Weeknights 5:30 PM – 7:30 AM             NICU Fellow

Saturday 7:30 AM – 3 PM                      Stroke ATTENDING

Sunday 7:30 AM – 3 PM                         Stroke Fellow

Saturday and Sunday 3 PM -7:30 AM   NICU Fellow

  • If you cannot reach the stroke fellow on Weekdays, second call is stroke consult attending, third call is stroke service If you cannot reach the NICU fellow overnight, second call is stroke service attending.  If you cannot reach either attending, escalate to Dr. Marshall.

  • When fellow is in Attending clinic Wednesday afternoons, Stroke consult attending will staff stroke codes.

  • All stroke consults (stroke code and non-urgent consults) planned for discharge from ED MUST be staffed with an attending, even if already discussed with fellow. In the weekdays, you can all Stroke Consult attending to staff, and on nights/weekends, you call the Stroke  (Putnam) service attending.

CHONY Stroke codes:

  • If you are called to a CHONY stroke code for a Pediatric patient, you are still the primary responder.

  • The peds neuro fellow will also be present, but you have more experience evaluating for stroke codes.  If none of the Peds Neuro team is present, call them and make sure they are the way.  The exception to this is overnight, where they will come in only if you feel the stroke code is “real”.

  • Remember, you should get a CT head if you have any suspicion for stroke, but you should avoid radiation if you feel there is a very low likelihood of stroke.

Extended window (“6-24” hr) Strokes:

Please see separate document about strokes with last known normal 6-24 hours (link above).