Stroke Algorithm

Question 1

Time frame of initial stroke steps

Answer 1

• Immediate general assessment with 10 minutes
• Neuro assessment and CT scan within 25 minutes of arrival at hospital
• Interp of CT within 45 minutes
• Admin of fibrinolytic within 1st hour of hospital and 3 hours from onset of symptoms

Question 2

Stroke algorithm step 1

Answer 2

Identify signs and symptoms of possible stroke

Active emergency response

Question 3

Stroke algorithm step 2, EMS

Answer 3

EMS assessment of actions

• Support ABC’s and O2 if necessary
• Pre hospital stroke assessment
• Establish time of onset of symptoms
• Triage to stroke center
• Alert hospital
• Check glucose if possible

Question 4

Stroke algorithm step 3

Immediate general assessment and stabilization

Answer 4

• Assess ABCs, vitals
• Provide O2 if hypoxemic
• Obtain IV access (blood count, coag, glucose)
• Check glucose, treat if indicated
• Perform neuro screening
• Activate stroke team
• Order CT
• Obtain ECG

Question 5

Stroke algorithm step 4

After assessment and stabilization

Answer 5

Neuro assessment:

• Review patient history
• Establish time of symptom onset
• Perform neuro exam

Question 6

Stroke algorithm step 5

After neuro assessment:

Answer 6

Does CT show hemorrhage?

Question 7

If CT scan shows no hemorrhage (Step 6 Left side)

Answer 7

Probable ischemic stroke

• Check for fibrinolysis exclusions
• Repeat neuro exam, are deficits rapidly improving to normal?

Question 8

If CT show hemorrhage (Step 6 right side)

Answer 8

Consult neurologist or neurosurgeon

Question 9

Stroke algorithm: if not candidate for fibrinolytics?

Answer 9

Administer aspirin

Question 10

Stroke algorithm: if candidate for fibrinolytics

Answer 10

• Review risks with family
• Give rtPA
• No anticoagulants or anti-platelets for next 24 hours

Question 11

After giving rtPA for stroke?

Answer 11

Begin post rtPA pathway

- aggressively monitor

Question 12

Signs of stroke

Answer 12

Sudden:

• Weakness or numbness of face, arm, leg, especially on one side of the body
• Confusion
• Trouble speaking or understanding
• Trouble seeing out of one or both eyes.
• Sudden trouble walking
• Dizziness
• Severe HA

Question 13

Cincinnati prehospital stroke scale

Answer 13

• Facial droop
• Arm drift
• Abnormal speech

Question 14

rtPA exclusion criteria

Answer 14

• Significant head trauma or prior stroke last 3 months
• S/sx suggesting subarachnoid hemorrhage
• Arterial puncture at non-compressable site in last 7 days
• Hx of previous intracranial hemorrhage
• Elevated BP SBP>185 or DBP>110
• Active internal bleeding
• Bleeding diathesis
• Blood glucose concentration

Question 15

Bleeding diathesis (exclusion criteria for rtPA)

Answer 15

• Platelet count upper limit of normal
• Current use of antiCoag with INR > 1.7 or PT >15
• Current use of direct thrombin inhibitors
• Blood glucose concentration

Question 16

Time window for using rtPA for stroke?

Answer 16

FDA: by 3 hours from symptom onset
AHA: advise up to 4.5 hours from symptom onset

Question 17

Treating hypertension when considering rtPA treatment

Answer 17

BP cutoff: > 185/110

• Labetalol 10-20 mg IV over 1-2 minutes, may repeat 1x
• Nicardipine IV 5 mg/h, titrate up by 2.5 mg/h, every 5-15 minutes, max 15 mg/hr

Question 18

8 D’s of stroke care

Answer 18

Detection
Dispatch
Delivery
Door
Data
Decision
Drug/device
Disposition

Question 19

Time frame of initial stroke steps

Answer 19

General assessment with in 10 minutes
Neuro assessment and CT scan within 25 minutes
Interpretation of CT scan within 45 mintues
rtPA within 1 hour in hospital and 3 hours from onset of symptoms