Stroke is the 3rd leading cause of death in the U. S. and the leading cause of brain injury in adults. Each year approximately 500,000 Americans suffer a new or recurrent stroke and nearly 25% die.
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.
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 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 - notify EMS, stat!
3. Delivery - 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 - Immediate general assessment < 10 minutes after arrival to hospital
Assess ABGs,
O2, IV, Monitor
VS
Check blood glucose if not done already
Assess neurological function
Alert stroke team
Review history and neuro exam: Glascow Coma Scale for level of consciousness (LOC), NIH stroke scale or Hunt and Hess scale
CT scan < 25 minutes after arrival to hospital
CT read < 45 minutes after arrival to hospital
5. Data - 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 - If pt remains a candidate and < 3 hours from 1st symptoms, consider Thrombolytic Therapy
7. Drug - Review risk and benefits with pt and family
Thrombolytic tx goal is to treat < 60 minutes from arrival to the hospital
Monitor neurological status
Emergency CT if deterioration occurs
Monitor BP
Admit to critical care
No anticoagulants or antiplatelets tx x 24 hours
Labetalol is favored for controlling BP because it does not cause cerebral vasodilation
Nitroprusside causes cerebral vasodilation and can increase ICP (intracranial pressure)
TPA 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.
