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