Introduction

The incidence of stroke in the United States is estimated to be approximately 800,000 per year. It is a leading cause of severe long-term disability and death.²⁷ Acute ischemic stroke can be treated with medications, while hemorrhagic stroke requires surgery. Both disease conditions require radiologic imaging with an emergent CT scan of the head as the most important diagnostic modality.

For acute ischemic stroke, fibrinolytic therapy with alteplase must be administered within the first hours of symptom onset. Therefore, prompt activation of the emergency response system and dispatch of EMS personnel must occur. EMS personnel must appropriately triage the patient to a stroke center if needed and inform the center before they arrive.

Quick emergency response, including fibrinolytic therapy, is critical for acute ischemic stroke.

Family and community members and BLS responders must learn to recognize the signs and symptoms of stroke and immediately activate the emergency response system.

EMS dispatchers must be adept at suspecting a possible stroke diagnosis and relay that information to the emergency responders. They must also accurately record the time of symptom onset, provide cardiopulmonary support to the caller, and notify the receiving hospital of the impending arrival of a patient with a suspected stroke. It is essential that EMS triage the patient to an institution with a dedicated stroke center if available.

ACLS responders must understand the types of stroke and that the immediate focus is to identify ischemic stroke. The most critical modality when determining the use of fibrinolytic therapy is a CT scan of the head to confirm that the acute stroke is secondary to ischemia. Fibrinolytic therapy is contraindicated if the stroke is hemorrhagic. Best practice is for the stroke team to be activated prior to patient arrival and for the patient to be taken directly to the imaging center.

Stroke Types

The ACLS team must understand the initial in-hospital management of acute stroke. For the patient triaged as having an acute stroke, the team should pursue the stroke pathway and consider admitting the patient to a stroke unit.

They should determine if a patient is eligible to receive fibrinolytic therapy with alteplase and how to administer this treatment within the recommended time frame under the supervision of a neurologic specialist. The National Institute of Neurological Disorders (NINDS) has advised that the recommended time frames are critical success factors and must be achieved in at least 80% of patients with acute stroke.

The ACLS responder must also be aware of pharmacologic therapies and other treatment options for acute stroke, such as endovascular therapy. 

An ECG to evaluate for arrhythmia (a potential cause of embolic stroke) does not take precedence over a CT scan. However, the value of the ECG is in identifying an acute myocardial infarction (AMI) or an arrhythmia such as atrial fibrillation. These two conditions can lead to an embolic stroke.

The Adult Suspected Stroke Algorithm

Short Description

This algorithm outlines the steps to efficiently assess patients and manage suspected stroke.

Related video: CPR –Stroke

Algorithm at a Glance

• The lay rescuer recognizes the signs and symptoms of a stroke and calls EMS quickly.
• EMS begins the assessment and treatment process and transports the patient as rapidly as possible.
• The patient bypasses the ED and is taken directly to the imaging suite, where the stroke team is waiting whenever possible.
• Personnel stabilize the patient and obtain an emergent head CT scan. 
• The stroke team does a more in-depth neurological assessment to determine appropriate definitive treatment.
• In the case of a hemorrhagic stroke, the clinician immediately calls for expert consultation.
• In the case of a nonhemorrhagic stroke and in the absence of contraindications, the clinician considers the administration of alteplase.
• Endovascular treatment (EVT) is considered for patients with nonhemorrhagic stroke who are not alteplase candidates and for patients who received alteplase.
• Following definitive treatment, the patient is continued on the poststroke pathway as defined by the facility.

Goals for the Management of Adult Suspected Stroke

The team must succeed in the following to successfully manage suspected stroke in adult patients:

• Quickly recognize stroke.
• Use brain imaging to rapidly differentiate between hemorrhagic and ischemic stroke.
  • Complete the scan within 20 minutes of hospital arrival.
  • Complete a review of the scan within 45 minutes of hospital arrival.
• Deliver the appropriate treatment based on the type of stroke as quickly as possible.
  • Deliver fibrinolytic therapy within 45 minutes of hospital arrival.
  • Provide EVT within 90 minutes for direct admits by EMS and 60 minutes for accepted transfer patients.
  • Admit to the appropriate stroke or neuro unit within 3 hours of hospital arrival.

The Adult Suspected Stroke Algorithm

This algorithm was created to present the steps for assessing patients presenting with stroke symptoms and determining management. All ACLS responders must be familiar with the AHA Stroke Algorithm:

Adult Suspected Stroke Algorithm ACLS Guidelines

Related Video: Stroke Algorithm

Box 1: Identifying Signs of Possible Stroke

Acute ischemic stroke is a clinical condition in which there has been no blood circulation to a part of the brain, causing a sudden loss of brain function in the dependent area(s). The signs and symptoms of stroke can be temporary or permanent, depending on how long the area has been deprived of adequate blood flow.

Box 2: Critical EMS Assessments and Actions

A trained EMS responder uses a validated out-of-hospital stroke assessment tool such as the Cincinnati Prehospital Stroke Scale (CPSS) and makes a presumptive diagnosis in < 1 minute.

The sooner EMS personnel bring the patient with suspected stroke to a suitable institution, the better the chances for appropriate treatment. That is because only a dedicated stroke care facility can provide the definitive therapy efficiently and effectively.

EMS personnel can provide supportive treatments to lessen the effects of stroke during transport to the ED. Interventions by EMS en route to the stroke center include:

• Ensuring proper management of the patient’s ABCs 
• Initiating stroke protocol
• Providing oxygen for patients with oxygen saturation < 94%, or if oxygen saturation cannot be determined 
• Checking the patient’s blood glucose levels with appropriate treatment of hypoglycemia 
• Performing a rapid neurological assessment within 1 minute using an appropriate tool 
• Attempting to establish the time when symptoms started
• Determining the nearest stroke center
• Alerting the receiving facility 
• Transporting the patient to the stroke center

Box 3: Arrival Imaging Suite or ED

Best practice is for the EMS team to bypass the ED and take the patient directly to the imaging suite where the stroke team is awaiting arrival. When the patient arrives, the in-hospital team completes their assessment and stabilizes the patient within 10 minutes.

The stroke team, consisting of qualified nurses, a neurovascular consultant, and an emergency physician, performs the patient’s neurologic assessment. These team members take a focused patient history, perform a physical examination, and determine the time of the onset of stroke symptoms.

The neurologic assessment also makes use of an evaluation tool such as the National Institutes of Health Stroke Scale (NIHSS) or the Canadian Neurological Scale exam. Neurologic assessment by the stroke team and the CT scan should be completed within 20 minutes of the patient’s arrival.

Critical to the treatment of acute ischemic stroke is determining the time of symptom onset confirmed by multiple informants, who may include the patient, family members, and other potential witnesses. The healthcare staff asks when the patient was last known to be healthy.

The general assessment and stabilization process should include:

• Assessing and managing ABCs and vital signs
• Delivering oxygen to keep the oxygen saturation > 94%
• Completing an emergent CT scan of the brain upon arrival or as soon as radiology is ready if the patient is not brought directly to the imaging suite by EMS
• Activating the stroke team if not activated prior to the patient’s arrival
• If not completed by EMS, establishing IV access and obtaining blood samples
• Assessing and treating hypoglycemia
• Performing a basic neurologic assessment using the hospital’s prescribed tool. An excellent tool is the National Institutes of Health Stroke Scale (NIHSS).
• Obtaining an ECG—this should not delay the CT scan

Box 4: CT Scan Interpretation to Determine Cause of Stroke

The most crucial factor in treating acute stroke is to ascertain whether the patient’s symptoms are due to ischemia or hemorrhage. Hence, an important imaging modality is a noncontrast CT scan of the head. The scan not only detects ischemia or hemorrhage but may also identify if other anatomic anomalies within the brain may have precipitated the stroke.

A Mobile CT Stroke Unit.

Helicopters efficiently airlift patients.

If the patient is transferred to an institution where a CT scanner is not available, the patient must first be stabilized and then transferred to a higher level of care. Anticoagulation medications must not be given to patients until a CT scan has ruled out the possibility of intracerebral hemorrhage.

A patient awaits a CT scan.