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
O2, IV, Monitor
Check blood glucose if not done already
Assess neurological function - Review history and neuro exam: Glasgow 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
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 hemorrhage 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
7. Drug - Fibrinolytic therapy, intra-arterial strategies
Review risk and benefits with patient and family
Thrombolytic tx goal is to treat < 60 minutes from arrival to the hospital
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
*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, enalapril, etc.) may be considered when
*If blood pressure is not maintained at or below 185/110 mm Hg, do not
*Management of blood pressure during and after tPA or other acute perfusion
Monitor blood pressure every 15 minutes for 2 hours from the start of tPA
therapy; then every 30 minutes for 6 hours; and then every hour for remainder
*If systolic BP 185–230 mm Hg or diastolic BP 110–120 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
*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
*Nitroprusside causes cerebral vasodilation and can increase ICP (intracranial
*tPA (Tissue Plasminogen Activator) is currently the only FDA approved
drug for ischemic stroke.
*Suggested dosing only-follow your own policy and procedures:
- 0.9 mg/kg max 90 mg (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 patient 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.