ACLS Suspected Stroke Algorithm (Acute Ischemic Stroke)
Using the Suspected Stroke Algorithm for Managing Acute Ischemic Stroke
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The ACLS Suspected Stroke Algorithm emphasizes critical actions for out-of-hospital and in-hospital care and treatment.
National Institute of Neurological Disorders and Stroke Critical Time Goals
Included in the algorithm are critical time goals set by the National Institute of Neurological Disorders (NINDS) for in-hospital assessment and management. These time goals are based on findings from large studies of stroke victims:
- Immediate general assessment by a stoke team, emergency physician, or other expertwithin 10 minutes of arrival, including the order for an urgent CT scan
- Neurologic assessment by stroke team and CT scan performed within 25 minutes of arrival
- Interpretation of CT scan within 45 minutes of ED arrival
- Initiation of fibrinolytic therapy, if appropriate, within 1 hour of hospital arrival and 3 hours from onset of symptoms
- Door-to-admission time of 3 hours
Step 1:Identify signs of a possible stroke.
Step 2:Call 911 immediately (activate EMS system).
This is an important step because EMS responders can transport the patient to a hospital that provides acute stroke care and notify the hospital that the patient is coming. The hospital staff can then prepare for efficient evaluation and management of the patient. Currently, half of all stroke victims are driven to the ED by family members or friends.
EMS Assessments and Actions
Step 3:Complete the following assessments and actions:
|Define and recognize the signs of stroke.||Support the ABCs (airway, breathing, and circulation).|
|Assess the patient using the CPSS or the LAPSS.||Give oxygen as needed.|
|Establish time zero.||Time Zero: set the time when the patient was last known to be neurologically normal. If the patient was sleeping and wakes up with symptoms, time zero is the last time the patient was seen to be normal.|
|Consider triage at a stroke center, if possible.||Transport the patient quickly.|
|Assess neurologic status while the patient is being transported.||Bring a family member or witness to confirm time zero.|
|Alert the receiving hospital.|
|Check glucose levels.|
General Assessment in the ED
NINDS time goal: 10 min
Step 4.Within 10 minutes of the patient's arrival in the ED, take the following actions:
|Assess ABCs and evaluate vital signs.|
|Give oxygen if patient is hypoxemic (less than 92% saturation). Consider oxygen is patient is not hypoxemic.|
|Make sure that an IV has been established.|
|Take blood samples for blood count, coagulation studies, and blood glucose. Check the patient's blood glucose and treat if indicated. Give dextrose if the patient is hypoglycemic. Give insulin if the patient's serum glucose is more than 300. Give thiamine if the patient is an alcoholic or malnourished.|
|Assess the patient using a neurologic screening assessment, such as the NIH Stroke Scale (NIHSS).|
|Order a CT brain scan and have it read quickly by a qualified specialist.|
|Obtain a 12-lead ECG and assess for arrhythmias.|
|Do not delay the CT scan to obtain the ECG. The ECG is taken to identify a recent or ongoing acute MI or arrhythmia (such as atrial fibrillation) as a cause of embolic stroke. Life-threatening arrhythmias can happen with or follow a stroke.|
Immediate Neurologic Assessment by Stroke Team
NINDS time goal: 25 min
Step 5.Within 25 minutes of the patient's arrival, take the following actions:
|Review the patient's history, including past medical history.|
|Perform a physical exam.|
|Establish time zero, if not already done.|
|Perform a neurological exam to assess patient's status using the NIHSS or the Canadian Neurological Scale.|
The CT scan should be completed within 25 minutes from the patient's arrival in the ED and should be read within 45 minutes.
Treatment Decisions by Specialist
NINDS time goal: 45 min
Step 6.Within 45 minutes of the patient's arrival, the specialist must decide, based on the CT scan or MRI, if a hemorrhage is present.
Take these actions if a hemorrhage is present
Take these actions if a hemorrhage is NOT present
|Note that the patient is not a candidate for fibrinolytics.||Decide if the patient is a candidate for fibrinolytic therapy.|
|Arrange for a consultation with a neurologist or neurosurgeon.||Review criteria for IV fibrinolytic therapy by using the fibrinolytic checklist (see Figure 1).|
|Consider transfer, if available.||Repeat the neurologic exam (NIHSS or Canadian Neurological Scale).|
If the patient is rapidly improving and moving to normal, fibrinolytics may not be necessary.
NINDS time goal: 60 min
If thepatient is a candidatefor fibrinolytic therapy, review the risks and benefits of therapy with the patient and family (the main complication of IV tPA is intracranial hemorrhage) and give tissue plasminogen activator (tPA).
Do not give anticoagulants or antiplatelet treatment for 24 hours after tPA until a follow-up CT scan at 24 hrs does not show intracranial hemorrhage.
If thepatient is NOT a candidatefor fibrinolytic therapy, give the patient aspirin.
For both groups (those treated with tPA and those given aspirin), give the following basic stroke care:
|Begin stroke pathway.|
|Support patient's airway, breathing, and circulation.|
|Check blood glucose.|
|Watch for complications of stroke and fibrinolytic therapy.|
|Transfer patient to intensive care if indicated.|
Patients with acute ischemic stroke who are hypoglycemic tend to have worse clinical outcomes, but there is no direct evidence that active glucose control improves outcomes. Consider giving IV or subcutaneous insulin to patients whose serum glucose levels are greater than 10 mmol/L (about 200 mg/dL).
|Inclusion criteria||Exclusion criteria||Exclusion criteria|
|Age: 18 yrs or older||Evidence of intracranial hemorrhage from CT scan||Active internal bleeding or acute trauma, such as a fracture|
|Diagnosis of an ischemic stroke with neurologic deficit||Clinical presentation suggestive of a subarachnoid hemorrhage, even with normal CT||Acute bleeding diathesis, including the following but may include other manifestations:
|Time from onset of symptoms is within 3 hours||Evidence of multilobar infarction in more than one-third of the cerebral hemisphere on CT||Intraspinal surgery, serious head trauma, or previous stroke within the past 3 months|
|History of intracranial hemorrhage||Arterial puncture at a noncompressible site within the past 7 days|
|Uncontrolled hypertension based on repeated measurements of > 185 mm Hg systolic pressure or > 110 mm Hg diastolic pressure|
|Known AV malformation, neoplasm, or aneurysm|
|Witnessed seizure at stroke onset|
|Minor or rapidly improving stroke symptoms|
|Major surgery or serious trauma within the past 14 days|
|Recent gastrointestinal or urinary tract hemorrhage within the past 3 weeks|
|Post-myocardial infarction pericarditis|
|Recent acute myocardial infarction within the past 3 months|
|Abnormal blood sugar level < 50 mg/dl or > 400 mg/dl|
Complications.The major complication of IV tPA is intracranial hemorrhage. Other bleeding complications, ranging from minor to severe, may also happen. Angioderma and transient hypotension also can occur.
Research.Several studies have shown that good to excellent outcomes are more likely when tPA is given to adults with acute ischemic stroke within 3 hrs of onset of symptoms. However, these results happened when tPA was given in hospitals with a stroke protocol that adheres closely to the therapeutic regimen and eligibility requirements of the NINDS protocol. Evidence from prospective randomized studies in adults documented a greater likelihood of benefit the earlier treatment begins.
Managing Hypertension in tPA Candidates
For patients who are candidates for fibrinolytic therapy, you need to control their blood pressure to lower their risk of intracerebral hemorrhage following administration of tPA. See the general guidelines in Figure 2.
Figure 2.Management guidelines for elevated blood pressure in patients with acute ischemic stroke
Candidates NOT eligible for fibrinolytic therapy
|Blood pressure level, mm Hg||Treatment|
|Systolic ≤220 or diastolic ≤120||Observe patient unless there is other end-organ involvement. Treat the patient's other symptoms of stroke (headache, pain, nausea, etc). Treat other acute complications of stroke, including hypoxia, increased intracranial pressure, seizures, or hypoglycemia.|
|Systolic > 220 or diastolic 121 to 140||Labetalol 10 to 20 mg IV for 1–2 min—may repeat or double every 10 min to a maximum dose of 300 mg OR Nicardipine 5 mg/hr IV infusion as initial dose; titrate to desired effect by increasing 2.5 mg/hr every 5 min to max of 15 mg/hr Aim for a 10% to 15% reduction in blood pressure|
|Diastolic > 140||Nitroprusside 0.5 µg/kg per min IV infusion as initial dose with continuous blood pressure monitoring|
|Aim for a 10% to 15% reduction in blood pressure|
Candidates eligible for fibrinolytic therapy
|Systolic > 185 or diastolic > 110||Labetalol 10 to 20 mg IV for 1–2 min—may repeat 1 time or nitropaste 1–2 inches|
During or after TREATMENT
|Check blood pressure every 15 min for 2 hrs, then every 30 min for 6 hrs, and finally every hr for 16 hrs|
|Monitor blood pressure||Check blood pressure every 15 min for 2 hrs, then every 30 min for 6 hrs, and finally every hr for 16 hrs|
|Diastolic > 140||Sodium nitroprusside 0.5 µg/kg per minute IV infusion as initial dose and titrate to desired blood pressure|
|Systolic > 230 or diastolic 121 to 140||Labetalol 10 mg IV for 1–2 min—may repeat or double every 10 min to maximum dose of 300 mg or give initial labetalol dose and then start labetalol drip at 2 to 8 mg/min OR Nicardipine 5 mg/hr IV infusion as initial dose and titrate to desired effect by increasing 2.5 mg/hr every 5 min to maximum of 15 mg/hr; if blood pressure is not controlled by nicardipine, consider sodium nitroprusside|
|Systolic 180 to 230 or diastolic 105 to 120||Labetalol 10 mg IV for 1–2 min—may repeat or double every 10 to 20 min to a maximum dose of 300 mg or give initial labetalol dose, then start labetalol drip at 2 to 8 mg/min|