Stroke resident survival guide: Difference between revisions

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==Dos==
==Dos==
* Order a limited number of investigation during the initial emergency evaluation.  Only the estimation of blood glucose should precede the administration of IV rTPA.
* Cardiac monitoring for at least the first 24 hours to screen for atrial fibrillation.
* Ensure blood pressure of ≤180/110 mmHg before initiating IV rTPA, and maintain it below 180/105 mmHg for at least the first 24 hours post-IV rTPA.


==Don'ts==
==Don'ts==

Revision as of 21:23, 4 December 2013

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:

Definitions

The term 'stroke' is used to describe pathological conditions caused by brain ischemia or hemorrhage. According to the American Heart Association/American Stroke Association (July, 2013),[1] the updated definitions are:

Ischemic Stroke

This is defined as an episode of neurological dysfunction caused by focal cerebral, spinal, or retinal infarction.

CNS Infarction

CNS infarction is brain, spinal cord, or retinal cell death attributable to ischemia, based on:

1. Pathological, imaging, or other objective evidence of cerebral, spinal cord, or retinal focal ischemic injury in a defined vascular distribution; or

2. Clinical evidence of cerebral, spinal cord, or retinal focal ischemic injury based on symptoms persisting ≥24 hours or until death, and other etiologies excluded.

Hemorrhagic Stroke

This is defined as rapidly developing clinical signs of neurological dysfunction attributable to a focal collection of blood within the brain parenchyma or ventricular system that is not caused by trauma.

Time of Onset

This is defined as when the patient was last awake and symptom-free or known to be “normal".[2]

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.

  • All the causes of stroke are life-threatening.

Common Causes

Ischemic Stroke

Hemorrhagic Stroke

Management

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Evaluation
Check vitals
ABCs
Rapid Hx - time of onset, time of arrival at the ED, medications (especially anticoagulants)
Rapid physical exam - neuro exam, NIHSS
Activate stroke team
Stat fingerstick
Labs
EKG, troponin, CXR
NPO
Obtain stroke protocol
 
 
 
 
 
 
Rule out DD
Seizure, syncope, migraine, hypoglycemia
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Non-contrast enhanced CT (or MRI) to r/o hemorrhage
 
 
 
Bleed positive
 
 
Hemorrhagic stroke
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Bleed negative
 
 
 
 
 
 
 
 
Hemorrhagic stroke algorithm
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Acute ischemic stroke
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
{{{ }}}
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Time of onset
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
<3 hours
 
 
 
 
3 -4.5 hours
 
 
 
 
>4.5 hours
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Eligibility criteria for IV rTPA
 
 
 
 
Consider rTPA
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Eligible
 
 
 
 
 
 
 
 
 
Not eligible
 
 
 
 
 
 
 
 
Blood pressure control algorithm

Treat fever with IV antipyretics
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
BP≤180/110
 
 
 
 
 
BP≥180/110
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
{{{ }}}
IV rTPA 0.9 mg/kg (maximum of 90 mg) with 10% given as intravenous bolus over 1 minute and the rest as IV infusion over 1 hour
 
 
 
 
 
Commence IV antihypertensives
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Admit ICU for BP monitoring + bleeding complications
Vitals
Neurocheck hourly
Aspiration precautions
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
After 24 hours post rTPA or no rTPA
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Follow-up head CT/MRI before commencing antiplatelets
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
ASA 325 mg (if no contraindication)
Statins
DVT prophylaxis
 
 
 
PTOT evaluation
Speech and swallow evaluation
 
 
 
 
Investigate the cause
MRA/CTA/carotid duplex
Venous doppler USS
Echocardiography
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Exclusion Criteria for IV Recombinant TPA Treatment

Less than 3 hours of onset

  • Significant head trauma or prior stroke in previous 3 months
  • Symptoms suggest subarachnoid hemorrhage
  • Arterial puncture at noncompressible site in previous 7 days
  • History of previous intracranial hemorrhage
  • Intracranial neoplasm, arteriovenous malformation, or aneurysm
  • Recent intracranial or intraspinal surgery
  • Elevated blood pressure (systolic >185 mm Hg or diastolic >110 mm Hg)
  • Active internal bleeding
  • Acute bleeding diathesis, including but not limited to
  • Platelet count <100,000/mm³
  • Heparin received within 48 hours, resulting in abnormally elevated aPTT greater than the upper limit of normal
  • Current use of anticoagulant with INR >1.7 or PT >15 seconds
  • Current use of direct thrombin inhibitors or direct factor Xa inhibitors with elevated sensitive laboratory tests (such as aPTT, INR, platelet count, and

ECT; TT; or appropriate factor Xa activity assays)

  • Blood glucose concentration <50 mg/dL (2.7 mmol/L)
  • CT demonstrates multilobar infarction (hypodensity >1/3 cerebral hemisphere)

Relative exclusion criteria

  • Only minor or rapidly improving stroke symptoms (clearing spontaneously)
  • Pregnancy
  • Seizure at onset with postictal residual neurological impairments
  • Major surgery or serious trauma within previous 14 days
  • Recent gastrointestinal or urinary tract hemorrhage (within previous 21 days)
  • Recent acute myocardial infarction (within previous 3 months)

Between 3 and 4.5 hours of onset

  • Aged >80 years
  • Severe stroke (NIHSS>25)
  • Taking an oral anticoagulant regardless of INR
  • History of both diabetes and prior ischemic stroke

Dos

  • Order a limited number of investigation during the initial emergency evaluation. Only the estimation of blood glucose should precede the administration of IV rTPA.
  • Cardiac monitoring for at least the first 24 hours to screen for atrial fibrillation.
  • Ensure blood pressure of ≤180/110 mmHg before initiating IV rTPA, and maintain it below 180/105 mmHg for at least the first 24 hours post-IV rTPA.

Don'ts

References

  1. Sacco, RL.; Kasner, SE.; Broderick, JP.; Caplan, LR.; Connors, JJ.; Culebras, A.; Elkind, MS.; George, MG.; Hamdan, AD. (2013). "An updated definition of stroke for the 21st century: a statement for healthcare professionals from the American Heart Association/American Stroke Association". Stroke. 44 (7): 2064–89. doi:10.1161/STR.0b013e318296aeca. PMID 23652265. Unknown parameter |month= ignored (help)
  2. Jauch, EC.; Saver, JL.; Adams, HP.; Bruno, A.; Connors, JJ.; Demaerschalk, BM.; Khatri, P.; McMullan, PW.; Qureshi, AI. (2013). "Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association". Stroke. 44 (3): 870–947. doi:10.1161/STR.0b013e318284056a. PMID 23370205. Unknown parameter |month= ignored (help)

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