Stroke algorithm?
- Identify signs and symptoms of possible stroke and activate the emergency response system
- Critical EMS assessments and actions:
- Support ABCs, given O2 if <94%
- Perform pre-hospital stroke assessment
- Establish time of symptom onset (last normal)
- Triage to stroke center
- Alert hospital, consider direct transfer to CT scan
- Check glucose if possible; consider MI, seizures as well - Immediate general assessment and stabilization on arrival to ED
- ABCs, vitals, O2 if hypoxemic
- Obtain IV access, labs (CBC, lytes, coags)
- Check glucose, treat if indicated
- Neuro screening assessment
- Activate stroke team
- Order emergent CT or MRI
- Obtain 12-lead EKG (do not delay CT unless high suspicion for ACS) - Immediate neurologic assessment by stroke team or designee
- Review patient history
- Establish last known normal
- Perform neuro exam (NIH Stroke Scale or Canadian Neuro Scale) - CT scan within 25 minutes after arrival to ED; evaluate scan immediately (within 45 minutes of arrival)
6A - if hemorrhage, consult neurologist or neurosurgeon, consider transfer if not available, begin stroke or hemorrhage pathway, admit to stroke unit/ICU
6B - if no hemorrhage, probable acute ischemic stroke
- Fibrinolytic checklist
- Repeat neuro exam (are deficits rapidly improving to normal?)
7A. If still a candidate for fibrinolytic therapy, review risks/benefits, then give rTPA. No anticoagulants or antiplatelet therapy for 24 hours
7B. If not a candidate, give ASA, then begin stroke or hemorrhage pathway/admit to stroke unit/ICU - If giving tPA, begin post-rTPA stroke pathway, aggressively monitor BP per protocol and for neuro deterioration, emergent admission to stroke unit/ICU
- BP <185/110 (labetalol 10 mg)
- Other options - endovascular therapy (intra-arterial rTPA, mechanical clot disruption/retrieval; must meet inclusion criteria, up to 6 hours from symptom onset)
- Control BG levels, temperature, BP
8 D’s of stroke
Detection (facial droop, arm drift, speech abnormality, sudden weakness/numbness, confusion, trouble speaking or understanding, trouble seeing in one or both eyes, trouble walking, dizziness or loss of balance or coordination, sudden severe headache) Dispatch Delivery Door Data Decision Drug/Device Disposition
How should potential arrhythmias with stroke be managed?
EKG does not take priority over CT. No arrhythmias are specific for stroke, although EKG may identify recent AMI or arrhythmias like AFib that can cause an embolic stroke.
Most arrhythmias do not require treatment if patient is hemodynamically stable
Cardiac monitoring during the first 24 hours in patients with acute ischemic stroke
Drugs involved in stroke management?
- Approved fibrinolytic agent (rTPA)
- Glucose (D50)
- Labetalol
- Nicardipine
- Enalaprilat
- ASA
- Nitroprusside
Timing goals for provision of fibrinolytic treatment in stroke? Endovascular therapy?
Within 3 hours of symptom onset or 4.5 hours for select patients
Within 6 hours of onet of symptoms
In-hospital time goals for assessment and management of patients with suspected stroke?
- Immediate general assessment by expert within 10 minutes of arrival + order urgent non-contrast CT
- Neuro assessment by stroke team or designee + CT scan within 25 minutes of arrival
- Interpretation of CT scan within 45 minutes of arrival
- Initiation of fibrinolytic therapy within 1 hour of arrival and 3 hours from symptom onset
- Door-to-admission time of 3 hours
Cincinnati Prehospital Stroke Scale?
Facial droop (smile or show teeth) Arm drift (close eyes and hold both arms out with palms up for 10 seconds) Abnormal speech (have the patient say, "You can't teach an old dog new tricks.")
Inclusion criteria for fibrinolytics?
- Dx of ischemic stroke causing measurable neurologic deficit
- Onset of symptoms <3 hours before beginning treatment
- Age 18+ y/o
Exclusion criteria for fibrinolytics?
- Significant head trauma or prior stroke in previous 3 months
- Symptoms suggesting SAH
- Arterial puncture at noncompressible site in previous 7 days
- Hx of previous ICH
- Intracranial neoplasm, AVM, or aneurysm
- Recent intracranial or intraspinal surgery
- Elevated BP (systolic >185 or diastolic >110)
- Active internal bleeding
- Acute bleeding diathesis, including but not limited to:
- Platelets <100,000
- Heparin received within 48 hours, resulting in aPTT greater than the upper limit of normal
- Current use of anticoagulant with INR >1.7 or PT >15 seconds
- Current use of direct thrombin inhibitors or direct factor Xa inhibitors with elevated sensitive laboratory tests such as aPTT, INR platelet, and ECT; TT; or appropraite factor Xa activity assays
BG <50
CT w/multilobar infarct (hypodensity > 1/2 cerebral hemisphere)
Relative exclusion criteria for fibrinolytics?
- Only minor or rapidly improving stroke symptoms (clearing spontaneously)
- Pregnancy
- Seizure at onset w/postictal residual neuro impairments
- Major surgery or serious trauma w/in previous 14 days
- Recent GI or urinary tract hemorrhage w/in 21 days
- Recent acute MI w/in 3 months
Inclusion criteria for endovascular therapy?
Prestroke mRS score of 0 to 1
Acute ischemic troke receiving IV tPA within 4.5 hours of onset
Causative occlusion of the ICA or proximal MCA (M1)
Age 18+
NIHSS score 6+
ASPECTS of 6+
Rx can be initiation (groin puncture) within 6 hours of symptom onset
The general care of all patients with stroke includes the following:
- Begin stroke pathway (admit to stroke unit, careful observation)
- Support ABCs
- Monitor BG
- Monitor BP (give NS to maintain intravascular volume if needed - eg, ~75-100 mL/hr)
- Monitor temperature
- Perform dysphagia screening
- Monitor for complications of stroke and fibrinolytic therapy (if worsening, order an emergent CT to evaluate for cerebral edema or hemorrhage)
- Transfer to general intensive care if indicated
Why should BG be monitored carefully?
Hyperglycemia is associated with worse clinical outcome in patients w/acute ischemic stroke (although there is no evidence that active glucose control improves clinical outcome)
Consider giving IV or subcutaneous insulin to lower BG in patients w/acute ischemic stroke when the serum glucose level is >185
Should prophylaxis for seizures be given?
No, although if they occur, they should be treated
How should HTN be managed in rTPA candidates?
Lowers the risk of ICH after rTPA administration
BP must be 185 or less/110 or less
Labetalol 10-20 mg IV over 1-2 minutes, may repeat x1 time
Nicardipine IV 5 mg/hr, titrate up by 2.5 mg/hr every 5-15 minutes, maximum 15 mg/hr; adjust to maintain proper limits once desired BP is reached Other agents (hydralazine, enalaprilat, etc. may be considered)
Management of BP during and after rTPA or other acute reperfusion therapy?
Monitor Q15 minutes for 2 hours from the start of therapy, then Q30 minutes for 6 hours, then Q1hr for 16 hours
If 180-230/105-120 ->
Labetalol 10 mg IV followed by a continuous IV infusion 2-8 mg/min or
Nicardipine IV 5 mg/hr, titrate to desired effect by 2.5 mg/hr Q5-15 minutes, maximum 15 mg/hr
If not controlled or diastolic >140, consider sodium nitroprusside
Management of arterial HTN in patients not undergoing reperfusion?
Data are inconclusive or conflicting; many have spontaneous declines in BP during the first 24 hours after onset of stroke. The benefit of treating is not well established. Those with malignant HTN or other medical indications for aggressive BP treatment should be treated accordingly
