ACLS review: Acute Stroke Part 3

Critical EMS Assessments

·         Support ABCs: O2 for oxygen saturation <94%

·         Perform CPSS assessment

·         Establish time of onset of symptoms

·         Triage to stoke center

·         Alert hospital

·         Check glucose

Note:  If the patient wakes from sleep or is found with symptoms of a stroke, the time of onset of symptoms is defined as the last time the patient was observed to be normal.

Unless the patient is hypotensive (systolic blood pressure <90 mm Hg), prehospital intervention for blood pressure is not recommended
EMS systems should establish a stroke destination preplan to enable EMS providers to direct patients with acute stroke to appropriate facilities
Circulation. 2010; 122: S818-S828 doi: 10.1161/​CIRCULATIONAHA.110.971044

In-hospital Assessment

·         Assess ABCs

·         Provide oxygen

·         Establish IV access and draw labs

·         Check blood glucose

·         Perform neurologic exam

·         Activate stroke team

·         Order CT scan of brain

·         Obtain 12-lead ECG

Note:  A 12-lead electrocardiogram (ECG) does not take priority over the CT scan but may identify a recent acute myocardial infarction or arrhythmias (eg, atrial fibrillation) as the cause of an embolic stroke

Recommend cardiac monitoring during the first 24 hours of evaluation in patients with acute ischemic stroke to detect atrial fibrillation and potentially life-threatening arrhythmias

Neurologic Exam

·         The NIH Stroke Scale

·         Canadian Neurological Scale

Management of Hypertension

Blood pressure must be ≤185 mm Hg systolic and ≤110 mm Hg diastolic

Patients with sustained hypertension  (ie, systolic blood pressure >185 mm Hg or diastolic blood

pressure >110 mm Hg) will not be eligible for IV rtPA

Patient eligible for acute reperfusion therapy except that BP is >185/110  

Labetalol 10–20 mg IV over 1–2 minutes, may repeat ×1, or

Nicardipine IV 5 mg/hr, titrate up by 2.5 mg/hr every 5–15 minutes, maximum 15 mg/hr; when desired blood pressure reached, lower to 3 mg/hr, or

Other agents (hydralazine, enalaprilat, etc) may be considered when appropriate

During and After Reperfusion Therapy

Monitor blood pressure every 15 minutes for 2 hours from the start of rtPA therapy; then every 30 minutes for 6 hours; and then every hour for 16 hours

If systolic BP 180–230 mm Hg or diastolic BP 105–120 mm Hg
Labetalol 10 mg IV followed by continuous IV infusion 2–8 mg/min, or
Nicardipine IV 5 mg/h, titrate up to desired effect by 2.5 mg/hr every 5–15 minutes, maximum 15 mg/h
If blood pressure not controlled or diastolic BP >140 mm Hg, consider sodium nitroprusside

Patients Ineligible for Reperfusion Therapy

Consider lowering blood pressure in patients with acute ischemic stroke if systolic blood pressure >220 mm Hg or diastolic blood pressure >120 mm Hg

Consider blood pressure reduction as indicated for other concomitant organ system injury

     Acute myocardial infarction

     Congestive heart failure

     Acute aortic dissection

A reasonable target is to lower blood pressure by 15% to 25% within the first day