Stroke Algorithm

 

What is a Stroke

The word stroke refers to an acute neurologic impairment following interruption of blood supply to a specific area of tissue in the brain.

Two major types of stroke are:

• Ischemic stroke
  • Accounts for almost 87% of all strokes
  • Usually caused by an embolism, which occludes an artery, affecting the subsequent tissue of the brain of which that particular artery affects
• Hemorrhagic stroke
  • Accounts for close to 13% of strokes
  • Occurs when a blood vessel in the brain ruptures and bleeds into the surrounding tissue, causing damage
  • In the cases of suspected or confirmed hemorrhagic stroke, fibrinolytic therapy is contraindicated and anticoagulants should not be used

Stroke Treatment

Stroke remains a leading cause of death in the United States. Early recognition and treatment of acute ischemic stroke is important, because IV fibrinolytic treatment should be provided as soon as possible.

In stroke cases, an ECG should not take priority over obtaining a computed tomography (CT) scan. There is no arrhythmia specific for or related to stroke, but an ECG may help identify evidence of the cause of an embolic-type stroke.

Many stroke patients demonstrate arrhythmias, but if the patient is hemodynamically stable, treatment of such arrhythmia is usually not indicated. Cardiac monitoring should be maintained during the first 24 hours of observation for patients who have experienced acute ischemic stroke so that atrial fibrillation and other potentially life-threatening arrhythmias may be detected.

The goal of stroke care is to minimize brain injury and maximize the recovery. The American Heart Association (AHA) and American Stroke Association have developed a Stroke Chain of Survival. It correlates actions to be taken by patients, family members, and healthcare providers in order to maximize stroke recovery.

The following are the established links:

1. Rapid recognition and reaction to stroke warning signs
2. Rapid EMS dispatch
3. Rapid EMS system transport and pre-arrival notification to the receiving hospital
4. Rapid diagnosis and treatment upon arrival to the appropriate hospital

Patients with acute ischemic stroke have a “time-dependent benefit” for fibrinolytic therapy. The critical time period for administration of IV fibrinolytic therapy begins with the onset of symptoms.

Critical time periods from hospital arrival are as follows:

• Immediate general assessment should be 10 minutes  
• Immediate neurologic assessment performed within 25 minutes  
• Acquisition of CT of the head is to be within 25 minutes, while interpretation of the CT scan should be complete within 45 minutes
• Administration of fibrinolytic therapy should be within 60 minutes from the time of  Emergency Department arrival
• Administration of fibrinolytic therapy may be delivered as late as 3 to 4.5 hours timed from onset of select patients’ symptoms
• Administration of endovascular therapy should be 6 hours timed from onset of select patients’ symptom
• Admission to a monitored bed should be within 3 hours

Adult Suspected Stroke Algorithm