Acute Ischemic Stroke
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Pretest
God Knows
Stroke is the 2nd leading cause of death in the U. S. and the leading cause of brain injury in adults.  Each year approximately 750,000 Americans suffer a new or recurrent stroke.

Main change in treatment is the use of thrombolytic therapy for ischemic stroke.

Need to identify the type of stroke:  ischemic-occlusion of an artery in the brain or hemorrhagic-arterial bleed in the brain.

Education to patients and families as to what to look for will reduce the time to get patient to the Emergency Room.
God Knows
8 Ds:

Detection
Dispatch
Delivery
Door
Data
Decision
Drug
Disposition
Carotid (Anterior) Circ.
(Signs and Symptoms):

Unilateral paralysis - arms, hands, face,
                             one sided numbness
Sensory loss
Language disturbance - trouble selecting
                                 appropriate words,
                                 slurred speech
Visual disturbance - blurred vision
Monocular blindness - loss of vision in
                                one eye
Vertebrobasilar (Posterior) Circ. (Signs and Symptoms):
 
Vertigo - sense of spinning
Visual disturbance - blurred
Diplopia - 2 images seen
Paralysis - weakness
Numbness - sensory loss
Dysarthria - slurred speach
Ataxia - poor balance, stumbling gate
Use the Cincinnati Prehospital Scale to check for possible stroke:

*check for facial droop by having pt show teeth or smile
*check for arm drift by having pt hold their arms out in front of them palms up and close their eyes- normal is both move or none move, abnormal is one stays and the other drifts away
*check speech by having patient repeat, "You can't teach an old dog new tricks." normal is correct words and no slurring, abnormal is slurring of words and/or wrong words
2.  Dispatch - Early activation and dispatch of emergency medical services
(EMS) system by calling 911


3.  Delivery -  Rapid EMS identification, management, and transport
Goal is to identify a stroke quickly and transport quickly to a hospital with
a CT scanner, rapid transport! 
Notify the stroke team at the hospital ASAP for possible stroke.  Note:  check
a blood glucose in route if possible. 

4.  Door - Appropriate triage to stroke center
Immediate general assessment < 10 minutes after arrival to hospital
Assess ABGs,
O2, IV, Monitor
VS, lab
Check blood glucose if not done already
Assess neurological function - Review history and neuro exam:  Glascow Coma
Scale for level of consciousness (LOC), NIH stroke scale or Hunt and
Hess scale
Activate stroke team

CT scan < 25 minutes after arrival to hospital
CT read < 45 minutes after arrival to hospital

5.  Data - Rapid triage, evaluation, and management within the emergency
department (ED)
Question: Does CT scan show intracerebral or subarachnoid hemorrhage?
If yes, then consult neurosurgery.
If no, then review CT exclusions

Repeat neuro exam: check for increasing deficits or improvements

Review thrombolytic exclusions: If hemorrage still suspected despite negative
CT scan, then lumbar puncture may be ordered; if no blood on L.P., then
support pt. If yes blood on L.P., then consult neurosurgery.

6.  Decision - Stroke expertise and therapy selection
If pt remains a candidate and < 3 hours from 1st symptoms, consider
Thrombolytic Therapy

7.  Drug - Fibrinolytic therapy, intra-arterial strategies
Review risk and benefits with pt and family
Thrombolytic tx goal is to treat < 60 minutes from arrival to the hospital

Exclusion criteria:
Age > 80
NIHSS > 25 (National Institutes of Health Stroke Scale)
Taken oral anticoagulant regardless of INR
Combination of hx of diabetes and previous stroke

8.  Disposition: Rapid admission to stroke unit, critical-care unit

*Monitor neurological status
*Emergency CT if neurologic deterioration occurs
*Monitor BP
  *Patient otherwise eligible for acute reperfusion therapy except that blood
pressure is >185/110 mm Hg
  *Labetalol 10–20 mg IV over 1–2 minutes, may repeat ×1, or
  *Nicardipine IV 5 mg/hr, titrate up by 2.5 mg/hr every 5–15 minutes,
maximum 15 mg/hr; when desired blood pressure reached, lower to 3
mg/hr, or
  *Other agents (hydralazine, enalaprilat, etc) may be considered when
appropriate
  *If blood pressure is not maintained at or below 185/110 mm Hg, do not
administer rtPA
  *Management of blood pressure during and after rtPA or other acute
reperfusion therapy:
*Monitor blood pressure every 15 minutes for 2 hours from the start of
  rtPA therapy; then every 30 minutes for 6 hours; and then every hour for
  16 hours
  *If systolic BP 180–230 mm Hg or diastolic BP 105–120 mm Hg
  *Labetalol 10 mg IV followed by continuous IV infusion 2–8 mg/min, or
  *Nicardipine IV 5 mg/h, titrate up to desired effect by 2.5 mg/hr every 5–15
minutes, maximum 15 mg/h
  *If blood pressure not controlled or diastolic BP >140 mm Hg, consider
sodium nitroprusside

*No anticoagulants or antiplatelets tx x 24 hours unless not a candidate for
fibrinolytic therapy - then consider Aspirin
*Labetalol is favored for controlling BP because it does not cause cerebral
vasodilation
*Nitroprusside causes cerebral vasodilation and can increase ICP (intracranial
pressure)
*tPA (Tissue Plasminogen Activator) is currently the only FDA approved drug
for ischemic stroke.

*Suggested dosing only-follow your own policy and procedures:
- 0.9mg/kg max 90mg (Give 10% as bolus and rest over 1 hour)
- Give only if < 3 hrs of onset of symptoms
- Make sure you establish 2 large bore IVs #18g or greater before starting, so no sticks are required after giving TPA and so blood can be given if pt bleeds.
- Listed in the AHA's ACLS book the chapter on stroke is a checklist.  All yes and all no boxes must be checked to proceed.  Although TPA is short acting, a vessel that goes from being ischemic from a clot to bleeding can happen suddenly and quickly.  Monitor very closely.


1.  Prehospital Detection - Rapid recognition of stroke symptoms Note:  time is of the essence, so find out when the symptoms started exactly! Timeline is within 3 - 4.5 hours of onset of symptoms for thrombolytic therapy, IV and intra-arterial for 6 hours longer, although this longer time frame is not currently approved by the FDA.