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ACUTE STROKE

Stroke describes a condition in which normal blood flow to the brain is interrupted. Strokes can occur in two variations. In ischemic stroke, a clot lodges in one of the brain’s blood vessels, blocking blood flow through the blood vessel. In hemorrhagic stroke, a blood vessel in the brain ruptures, spilling blood into the brain tissue. Ischemic stroke and hemorrhagic stroke account for 87% and 13% of the total incidence, respectively. In general, the symptoms of ischemic and hemorrhagic strokes are similar. The treatments, however, are very different.


SYMPTOMS OF STROKE

  • Weakness in the arm and leg or face
  • Vision problems
  • Confusion
  • Nausea or vomiting
  • Trouble speaking or forming the correct words
  • Problems walking or moving
  • Severe headache (hemorrhagic)

acute stroke chart

Clinical signs of stroke depend on the region of the brain affected by decreased or blocked blood flow. Signs and symptoms can include: weakness or numbness of the face, arm or leg, difficulty walking, difficulty with balance, vision loss, slurred speech or absent speech, facial droop, headache, vomiting or change in level of consciousness. Not all of the above symptoms are present and the exam findings depend on the cerebral artery affected.

The Cincinnati Prehospital Stroke Scale (CPSS) is used to diagnose the presence of stroke in a patient if any of the following physical findings is seen: facial droop, arm drift, or abnormal speech. Patients with one of these three findings as a new event have a 72% probability of an ischemic stroke. If all three findings are present, the probability of an acute stroke is more than 85%. Becoming familiar and proficient with the tool utilized by the rescuers’ EMS system is recommended. Mock scenarios and practice will facilitate use of these valuable screening tools.

Patients with ischemic stroke who are not candidates for fibrinolytic therapy should receive aspirin unless contraindicated by true allergy to aspirin. All patients with confirmed stroke should be admitted to Neurologic Intensive Care Unit if available. Stroke treatment includes blood pressure monitoring and regulation per protocol, seizure precautions, frequent neurological checks, airway support as needed, physical/occupational/speech therapy evaluation, body temperature, and blood glucose monitoring. Patients who received fibrinolytic therapy should be followed for signs of bleeding or hemorrhage. Certain patients (age 18-79 with mild to moderate stroke) may be able to receive tPA up to 4.5 hours after symptom onset. Under certain circumstances, intra-arterial tPA is possible up to 6 hours after symptom onset. When the time of symptom onset is unknown, it is considered an automatic exclusion for tPA. If time of symptom onset is known, the National Institute of Neurological Disorders and Stroke (NINDS) has established time goals seen below.

10 MINUTES OF ARRIVAL

  • General assessment by expert
  • Order urgent CT scan without contrast

25 MINUTES OF ARRIVAL

  • Perform CT scan without contrast
  • Neurological assessment
  • Read CT scan within 45 minutes

60 MINUTES OF ARRIVAL

  • Evaluate criteria for use and administer fibrinolytic therapy ("clot buster")
  • Fibrinolytic therapy may be used within 3 hrs of SYMPTOM ONSET (4.5 hrs in some cases)

180 MINUTES OF ARRIVAL

  • Admission to stroke unit
  • TIME IS BRAIN!
  • Before giving anything (medication or food) by mouth, you MUST perform a bedside swallow screening. All acute stroke patients are considered NPO on admission.
  • The goal of the stroke team, emergency physician, or other experts should be to assess the patient with suspected stroke within 10 minutes of arrival in ED.
  • The CT scan should be completed within 25 minutes of patient’s arrival in the ED and should be read within 45 minutes.
emergency department staff

ABSOLUTE EXCLUSIONS

RELATIVE EXCLUSIONS

INCLUSION CRITERIA

  • Head trauma in last three months
  • Stroke in last three months
  • Subarachnoid hemorrhage
  • Arterial puncture in last seven days
  • Previous Intracranial Hemorrhage (ICH)
  • Active bleeding
  • Heparin in last two days
  • Elevated INR
  • Hypoglycemia
  • Very large brain infarct (multilobe)
  • Platelets < 100,000/mm3
  • Very minor/resolving symptoms
  • Seizure may be affecting neurological exam
  • Surgery or trauma in last 14 days
  • Major hemorrhage in last 21 days
  • Myocardial Infarction in last three months
  • Symptom onset within the last three hours (unless special circumstances)
  • 18 years or older
  • Ischemic stroke with neurologic defect
NO FIBRINOLYTIC CONSIDER FIBRINOLYTIC IF BENEFIT OUTWEIGHS RISK. ADMINISTER FIBRINOLYTIC