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Chapter 17 : ACLS Stroke

Stroke is one of the leading causes of deaths in the United States. Over 700,000 people suffer from acute stroke medical emergencies every year in the US and 1/6 cardiovascular deaths are stroke related. Early detection of a patient having stoke is important because they will need IV fibrinolytic treatment within 3 to 4.5 hours of the initial symptoms.

ACLS Acute Stroke Video Demonstration:

Acute Stroke

Understanding the signs of a suspected stroke and fastened response helps save patient’s life while maintaining its quality. Stroke occurs due to insufficient blood flow to the different area of the victim’s brain. There are 2 major ACLS stroke types:

  1. Ischemic stroke: It accounts for 85% of suspected stroke cases in the US and blockage of an artery in the brain is the primary reason for it happen.
  2. Hemorrhagic stroke (includes intracerebral & subarachnoid): It is less likely to often. Rupture of a blood vessel in the brain is its primary cause.
ischemic-and-hemorrhagic-stroke.img

Adequate ACLS stroke care involves reducing brain injury and increasing chance of patient’s recovery.  According to the American Heart Association (AHA) there are 8D’s of stroke care, important in diagnosis and treatment of a stroke.

Detection: Rapid recognition of stroke symptoms
Dispatch: early activation and dispatch of EMS by 911
Delivery: Rapid EMS identification, management, and transport
Door: appropriate triage to stroke center
Data: Rapid triage, evaluation, and management within ED
Decision: Stroke expertise and therapy selection
Drug: Fibrinolytic therapy, intra-arterial strategies
Disposition: Rapid admission to the stroke unit or critical care unit

Reference: American Heart Association.  Advanced Cardiac Life Support (ACLS) Student Provider Manuel.  Dallas: American Heart Association, 2011. Print

Stroke Chain of Survival
Possibility of permanent brain damage and risk of death reduces with the chain of survival. It is:

  • Quick identification and reaction to the early symptoms of acute stroke
  • Quick EMS dispatch
  • Quick transport by EMS and notification before arriving at the hospital
  • Quick diagnosis and treatment upon patient’s arrive at the hospital

The Cincinnati Prehospital Stroke Scale from strokecenter.org highlights ways in recognizing accurate symptoms of a stroke.

adult-suspected-stroke.img
stroke-chart.img

Facial Droop

  • Normal: Both sides of face move simultaneously
  • Abnormal: One side of face is not moving at all

Arm Drift

  • Normal: Both arms move equally or not even once together
  • Abnormal: One arm drifts when compared

Speech

  • Normal: Patient uses correct words with no stammering or slurring
  • Abnormal: Inappropriate words or patient becomes mute

If any 1 of these 3 signs is abnormal, the probability of a suspected stroke is 72%.  The presence of all 3 findings increases probability of a stroke to >85%

The following is an algorithm showing management of acute stroke:

Treatment of Stroke Patients Goals

  • Quick general assessment in 10 minutes
  • Quick neurological assessment in 25 minutes
  • CT scan on head in 25 minutes
  • Quick interpretation of CT scan in 45 minutes
  • Fibrinolytic therapy in 60 minutes of ED arrival
  • Fibrinoloytic therapy in 3 hours of onset
  • Admitted to a monitored bed in 3 hours of onset

CT scan Interpretation
The purpose of the CT scan is to differentiate between ischemic and hemorrhagic stroke. The most common type is a non-contrast CT scan for the acute stroke patient. Treatments for hemorrhagic and ischemic stroke are:

  • Fibrinolytic therapy may be considered for non-hemorrhagic stroke patients with no additional signs or symptoms
  • For hemorrhagic stroke patients consider a consult from neurologists or neurosurgeon as they do not quality for fibrinolytics
  • A patient who is qualified for fibrinolytic therapy will be assessed for fibrinolytic therapy
  • If no hemorrhaging on CT and does not qualify for fibrinolytic therapy, they should be given aspirin

Fibrinolytic Therapy
The NINDS protocol and criteria show tPA is the first line treatment within 3 hours of the onset of symptoms for patients who have acute ischemic stroke. The AHA guidelines recommend IV tPA administration for patients with acute ischemic stroke. To qualify a patient for fibrinolytic therapy a checklist must be applied.

Fibrinolytic Therapy Checklist:

Inclusion Criteria (all below should be YES)Exclusion Criteria (all below should be NO)Relative Contraindications/Precautions
Patient is 18 years or older?Intracranial hemorrhage on non-contrast head CT?Symptoms are not major and improve quickly and spontaneously
Dx of ischemic stroke with neurologic deficit?Presentation of patient shows subarachnoid hemorrhage even with normal CT?14 days since major surgery or trauma
Time of system onset – less than 3 hours?Multilobar Infarction on CT (hypodensity greater than 1/3 of cerebral hemisphere)?Current GI or Urinary tract hemorrhage (approx. 21 days)
All ABOVE SHOULD BE YESHistory of intracranial hemorrhage?Current acute Myocardial infarction (in approx.. 3 months)
 Hypertension: SBP > 185 mmHg or DBP > 110 mm Hg on repeated measurements?Postmyocardial infarction pericarditis
 Arteriovenous malformation, neoplasm, or aneurysm?Abnormal blood glucose level (400 mg/dl [22.2 mmmol/L])
 Witnessed seizure at stroke onset?THESE ARE ALL CONTRAINDICATIONS/PRECAUTIONS
 Active internal bleeding or acute trauma (fracture)? 
 

Acute bleeding diathesis, including

  • Platelet count less than 100,000 mm3
  • Heparin received within 48 hours with an aPTT greater than upper limit of normal
  • Current use of anticoagulant with INR >1.7 or prothrombin time PT >12 seconds?
 
 History of intracranial or intraspinal surgery, serious head trauma or previous stroke within past 3 months? 
 Arterial puncture at a noncompressible site within past 7 days? 
 ALL ABOVE SHOULD BE NO!
Inclusion Criteria (all below should be YES)Exclusion Criteria (all below should be NO)Relative Contraindications /Precautions
Patient is 18 years or older?Intracranial hemorrhage on non-contrast head CT?Symptoms are not major and improve quickly and spontaneously
Dx of ischemic stroke with neurologic deficit?Presentation of patient shows subarachnoid hemorrhage even with normal CT?14 days since major surgery or trauma
Time of system onset – less than 3 hours?Multilobar Infarction on CT (hypodensity greater than 1/3 of cerebral hemisphere)?Current GI or Urinary tract hemorrhage (approx. 21 days)
All ABOVE SHOULD BE YESHistory of intracranial hemorrhage?Current acute Myocardial infarction (in approx.. 3 months)
Hypertension: SBP > 185 mmHg or DBP > 110 mm Hg on repeated measurements?Postmyocardial infarction pericarditis
Arteriovenous malformation, neoplasm, or aneurysm?Abnormal blood glucose level (400 mg/dl [22.2 mmmol/L])
Witnessed seizure at stroke onset?THESE ARE ALL CONTRAINDICATIONS /PRECAUTIONS
Active internal bleeding or acute trauma (fracture)?
Acute bleeding diathesis, including
  • Platelet count less than 100,000 mm3
  • Heparin received within 48 hours with an aPTT greater than upper limit of normal
  • Current use of anticoagulant with INR >1.7 or prothrombin time PT >12 seconds?
History of intracranial or intraspinal surgery, serious head trauma or previous stroke within past 3 months?
Arterial puncture at a noncompressible site within past 7 days?
ALL ABOVE SHOULD BE NO!

Learning Outcomes:
You have completed Chapter XIII. Now you should be able to:

  1. Understand the 8Ds of an acute ACLS stoke care
  2. Apply Adult Stroke Algorithm accurately
  3. Recognize the early symptoms of an acute stroke
  4. Understand the above-mentioned fibrinolytic therapy checklist

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