Adult Suspected Stroke

Suspected Stroke Sequence

The stroke sequence is critical in providing rapid assessment and treatment to minimize disability:

1. Identify signs of stroke
   1. Sudden weakness of the face or one side of the body
   2. Garbled speech
   3. Sudden severe headache
   4. Sudden trouble seeing out of one or both eyes
   5. Sudden confusion
   6. Trouble walking with loss of balance or decreased coordination
2. Activate the Emergency Response system.
3. EMS Assessment and Treatments
   1. EMS should do a rapid stroke assessment
      1. Facial droop – Ask the patient to smile and note if one side of face does not move
      2. Arm drift – Ask the patient to extend arms with palms up and note if one arm does not move or drifts down
      3. Speech –Ask the patient simple questions and note if speech is slurred or incomprehensible or inappropriate words are used.
   2. Support the ABCs to keep oxygen saturation > 94%
   3. Ask family when the last time was that the patient appeared to be normal.
   4. Alert the hospital that a possible stroke victim is on the way to the hospital.
4. Transport to Emergency Department at a hospital with a stroke center if available. During transport, check the patient’s glucose.
5. Assessment and stabilization in the ED
   1. Monitor the ABCs and assess vital signs.
   2. Administer oxygen to keep oxygen saturation > 94%.
   3. Start an IV and do baseline lab exams.
   4. Treat hypoglycemia with glucose.
   5. Conduct a neurological exam.
   6. Know the facility protocols for activation of the stroke team and have them standing by.
   7. Order a stat CT scan of the brain.
   8. Obtain an ECG and monitor cardiac rhythms for at least the first 24 hours.
6. Neurological assessment by the stroke team – The stroke team will use a neurological exam such as the National Institutes of Health Stroke Scale.
7. Interpret CT scan – Do not give any anticoagulants until hemorrhagic stroke is ruled out.
   1. If the CT scan shows a hemorrhagic stroke, consult a neurosurgeon and admit to a stroke unit.
   2. If the CT scan shows an ischemic stroke, the stroke team will review the criteria for fibrinolytic therapy:
      1. Patient age must be > 18 years
      2. Diagnosis = ischemic stroke with neurological deficit
      3. Onset of symptoms should be < 3 hours in past
      4. No exclusion criteria identified:
         1. Previous stroke or head trauma in last 3 months
         2. Subarachnoid hemorrhage
         3. Blood glucose < 50 mg/dL
         4. Acute bleeding disorders or diathesis
         5. Active bleeding at time of examination
         6. Hypertension with SBP>185 mm Hg or DBP > 110 mm Hg.
      5. Risk /Benefit ratio should be evaluated if patient has seizures, a major surgery within the past 2 weeks, GI bleed within the last 3 weeks, or AMI within the last 3 months.
   3. If the patient is NOT a candidate for fibrinolytic therapy, give aspirin and admit to the stroke unit.
   4. If the patient IS a candidate for fibrinolytic therapy, the stroke team will discuss risks and benefits with the patient’s family.
8. Administer fibrinolytic therapy according to facility protocol.
9. Provide general post rtPA stroke care.
   1. Admit patient to stroke unit
   2. Support ABCs
   3. Monitor for complications of rtPA administration
   4. Monitor vital signs
   5. Monitor blood glucose and give insulin to keep blood glucose < 185 mg/dL