ACLS: Acute Stroke

Cardiac Monitoring post-stroke

Cardiac monitoring is recommended during the first 24 hrs after an acute ischemic stroke to detect atrial fibrillation and potentially life-threatening arrhythmia's

CT Scan - Shows Hemorrhage

Consult neurologist or neurosurgeon Begin stroke hemmorrhage pathway Admit to stroke/neuro unit

How to manage BP in ischemic stroke post TPA

Monitor BP Q15 mins for 2 hrs form the start of TPA therapy, then Q30 mins for 6 hrs and then Q1hr for 16 hrs. *If SBP >180-230 or Diastolic 105-120?* Labetolol: 10 mg IV followed by cont. IV infusion 2-8mg/min *OR * Nicardipine: 5 mg/hr; titrate up by 2.5 mg/hr Q5-15 mins; max 15 mg/hr *If BP not controlled of DBP >140* Consider sodium nitroprusside

8 D's of Stroke Care

*Detection:* rapid recognition of stroke symptoms *Dispatch:* early activation in dispatch of EMS via 911 Delivery:* rapid EMS identification, management, and transport *Door:* appropriate triage to Stroke center *Data:* wrap in triage, evaluation, and management within the ED *Decision:* stroke expertise in therapy selection *Drug/Device:* fibrinolytic or endovascular therapy *Disposition:* rapid admission to the stroke unit or critical care unit

Cincinnati Prehospital Stroke Scale

*Facial Droop* *Arm Drift* *Abnormal Speech* Have patient state "Can you teach an old dog new tricks?"

Critical time periods from hospital arrival

*General Assessment* 10 mins *Neuro Assessment* 25 mins *CT Head Scan* 25 mins *Interpretation of CT head* 45 mins *Admin of fibrinolytic therapy, from ED arrival* 60 mins *Admin of fibrinolytic therapy, from symptom onset*3 hrs OR 4.5 hrs in selected patients *Admin of endovascular therapy, from symptom onset* 6 hrs in selected patients *Admin to a monitored bed* 3 hrs

CT Scan - No Hemorrhage

*Probable acute ischemic stroke; consider fibrinolytic therapy* -check for fibrinolytic exclusions -Repeat neuro exam; are deficits rapidly improving to normal? *Candidate for therapy?* -Yes? Review risk/benefits with family; admin TPA, No anticoagulants or antiplatlet treatments for 24 hrs. Begin post TPA pathway. Monitor BP, Monitor for neuro deterioration, Admit to stroke unit. -No? Administer ASA

DO NT give what medications until CT scan has ruled out intracranial hemorrhage

ASA, heparin, TPA

Respiratory Risks

Acute Stroke puts pt at risk for respiratory compromise from aspiration, upper airway obstruction, hyperventilation and neurogenic pulmonary edema. The combination of poor perfusion and hypoxemia will exacerbate and extend ischemic brain injury, and it has been associated with worse outcome from stroke.

Immediate Genera Assessment and Stabilization

Assess ABCs, VS Provide O2, if needed IV access & Labs Glucose check Neuro check Activate Stroke Code Order emergent CT or MRI Obtain EKG

General Stroke Care

Begin stroke pathway Support ABCs Monitor blood glucose Monitor BP Monitor Temp Preform dysphagia screen Monitor for complications of stroke and fibrinolytic therapy Transfer to ICU

Drugs for Stroke

Fibrinolytic agent Glucose Labeltolol Nicardipine Enalaprilat Aspirin Nitroprusside

TPA Exclusion criteria

Head trauma prior to stroke in past 3 months Symptoms of subarachnoid hemorrhage Arterial puncture at noncompressable site in previous 7 days Hx of previous intracranial hemorrhage (intracranial neoplasm, AV malformation, aneurysm, recent intracranial/intraspinal inury) Elevated BP (SBP >185 or DBP >110) Active internal bleeding Acute bleeding diathesis, including but not limited to (platelet count <100,000, heparin received within 48 hrs resulting in a high PTT than normal, current anticouagulant use with INR >1.7 or PT >15 seconds, use of thrombin inhibitors or direct factor Xa inhibitors) Blood glucose <50 Ct demonstrates multilobar infarction

Hyperglycemia and stroke

Hyperglycemia is associated with worse clinical outcome in patients with acute ischemic stroke May need to use insulin to lower blood sugar if serum is >185

Hemorrhagic Stroke

a blood vessel in the brain suddenly ruptures into the surrounding tissue. Fibrinolytic therapy is contraindicated in this type of stroke. Avoid anticoagulants.

Ischemic Stroke

caused by an occlusion of an artery to a region of the brain

Endovascular therapy timing

should be given within 6 hrs of onset of symptoms

Critical in-hospital time periods

1. Immediate general assessment by the stroke team, emergency physican , or other expert within *10 mins* of arival; order urgent non-contrast CT scan 2. Neurologic assessment by the stroke team or designee and CT scan preformed within *25 mins* of hospital arrival 3. Interpretation of the CT scan within *45 mins* of ED arrival 4. Initiation of fibrinolytic therapy in appropriate patients (those without contraindications) within 1 hr of hospital arrival and *3 hrs* from symptom onset 5. Door to admission time of *3 hrs*

TPA inclusion criteria

Diagnosis of ischemic stroke causing measurable neuro deficits Onset of symptoms (<3 hrs) before beginning of treatment Age >18 years old

2 types of stroke

Ischemic Stroke Hemorrhagic Stroke

How to manage BP in ischemic stroke prior to TPA

Labatelol (10-20 mg IV over 1-2 mins, may repeat 1X time) Nicardipine (5 mg/hr; titrate up by 2.5 mg/hr Q5-15 mins; max 15 mg/hr) Others (hydralizine, enalaprilat, etc) If BP is not (SBP: <185;DBP: <100) Do not give TPA

Relative Exclusion Criteria/Risk benefit

Only minor or rapidly improving stroke symptoms (clearing spontaneously) Pregnancy Seizure at onset with posictal residual neuro impairments Major surgery or serious trauma within previous 14 days Recent GI or urinary tract hemorrhage (within 21 days) Recent MI (within 3 months)

Patients should receive endovascular therapy with a stent retriever if they meet all the following criteria

Pre-stroke MRS score of 0-1 Acute ischemic stroke receiving TPA within 4.5 hr of onset Causative occlusion of the internal carotid artery or proximal MCA 18 years or older NIHSS score of 6+ ASPECTS score of 6+ Treatment can e initiated (groin puncture) within 6 hrs of symptom onset

BP control

Pts who are candidates for fibrinolytic therapy should have their BP controlled to lower the risk of intracerebral hemorrhage after the admin of TPA BP should be kept: SBP: <185 DBP: <100

Immediate neurological assessment by Stroke team or designee

Review pt history Establish last known normal Neuro exam

Stroke Algorithm

See card

IV Fibrinolytic Therapy timing

Should be given within 3 hrs of onset of symptoms or within 4.5 hrs in selected patients.

S/S of Stroke

Sudden weakness or numbness in the face, arm, leg, esp unilateral Sudden confusion Trouble speaking or understanding Sudden trouble seeing in one or both eyes Sudden trouble walking Dizziness or loss of balance or coordination

EMS assessment and intervention

Support ABcs; give O2 Stroke assessment Establish "last normal" Triage to stroke center Alert hospital; direct transfer to CT scanner Glucose check