Suspected Stroke Algorithm

When to Use This Algorithm

Use this algorithm when a patient exhibits signs and symptoms of a possible stroke, such as sudden numbness or weakness, confusion, trouble speaking, vision problems, dizziness, or severe headache. Immediate action is crucial to improve outcomes.

Steps in the Algorithm

1. Activate Emergency Response (EMS)
   • Identify signs and symptoms of possible stroke.
   • Ensure prompt activation of emergency medical services (EMS).
2. Critical EMS Assessments and Actions
   • Support ABC’s:
     • Ensure airway, breathing, and circulation. Provide oxygen if needed.
   • Prehospital Stroke Assessment:
     • Perform a quick stroke assessment (e.g., FAST scale).
   • Establish Time of Symptom Onset:
     • Determine when the patient was last seen normal.
   • Triage to Stroke Center:
     • Alert the hospital and consider direct transfer for CT scan.
   • Check Glucose if Possible:
     • Rule out hypoglycemia as a cause of symptoms.

Immediate General Assessment and Stabilization (ED Arrival within 10 Minutes)

1. Assess ABC’s, Vital Signs:
   • Continuously monitor airway, breathing, and circulation.
2. Provide Oxygen if Hypoxemic:
   • Maintain oxygen saturation >94%.
3. IV Access and Lab Assessments:
   • Establish IV access and draw blood for necessary labs.
4. Check Glucose; Treat if Indicated:
   • Correct hypoglycemia if present.
5. Neurologic Screening Assessment:
   • Perform an initial neurologic assessment.
6. Activate Stroke Team:
   • Notify the stroke team immediately.
7. Order Emergent CT Scan or MRI of Brain:
   • Obtain imaging to determine the presence of hemorrhage.
8. Obtain 12-Lead ECG:
   • Check for arrhythmias or myocardial infarction.

Immediate Neurologic Assessment by Stroke Team or Designee (ED Arrival within 25 Minutes)

1. Review Patient History:
   • Gather detailed medical history, including stroke risk factors.
2. Establish Time of Symptom Onset or Last Known Normal:
   • Confirm the exact time symptoms began.
3. Perform Neurologic Examination:
   • Use NIH Stroke Scale or Canadian Neurological Scale to assess the severity of the stroke.

CT Scan Interpretation (ED Arrival within 45 Minutes)

• Hemorrhage Shown by CT Scan?
  • No Hemorrhage (Probable Acute Ischemic Stroke):
    • Consider fibrinolytic therapy.
    • Check for fibrinolytic exclusions and repeat neurologic exam.
    • Ask: Are deficits rapidly improving to normal?
  • Hemorrhage Present:
    • Determine if the patient is a candidate for fibrinolytic therapy.
    • If yes, consult a neurologist or neurosurgeon and consider transfer if not available.
    • If no, initiate intracranial hemorrhage protocol.

Fibrinolytic Therapy Decision

1. Review Risks and Benefits with Patient and Family:
   • Discuss the potential benefits and risks of fibrinolytic therapy.
   • If acceptable, administer IV rtPA (tissue plasminogen activator).
   • Avoid anticoagulants or antiplatelet treatment for 24 hours.

Post-rtPA Stroke Pathway

1. Begin Post-rtPA Stroke Pathway:
   • Aggressively monitor blood pressure and neurologic status as per protocol.
2. Emergent Admission:
   • Admit the patient to a stroke unit or intensive care unit for close monitoring.

Key Takeaways

Effective management of acute stroke involves rapid recognition of symptoms, timely activation of EMS, and swift transport to a stroke center. Critical assessments and interventions should be performed immediately upon arrival at the emergency department. This includes supporting ABC’s, performing neurologic assessments, and obtaining imaging to determine the type of stroke. For ischemic stroke, fibrinolytic therapy can be considered, while hemorrhagic stroke requires a different treatment pathway.

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