II. Protocol: Step 1 Prehospital Assessment

  1. Activate EMS system in all potential CVA patients
  2. Prehospital evaluation of patient
    1. Cincinnati Prehospital Stroke Scale
    2. Los Angeles Prehospital Stroke Screen (LAPSS)
  3. Transport to hospital with Stroke Team if possible (otherwise nearest facility)
  4. Fingerstick Glucose

III. Protocol: Step 2 Immediate General Assessment (<10 minutes)

  1. ABC Management
  2. Obtain full Vital Signs including Oxygen Saturation
  3. Deliver Oxygen by Nasal Cannula (if Oxygen Saturation <90%)
  4. Cardiovascular measures
    1. Obtain Intravenous Access
    2. Electrocardiogram
    3. Telemetry
  5. Airway management
    1. Maintain adequate airway and oxygenation throughout process (critical)
    2. Intubation is indicated in unreliable airway or Hypoxia refractory to oxygenation
    3. RSI medication selection should avoid ICP increase
      1. Avoid pretreatment Lidocaine and Fentanyl (no proven efficacy)
      2. Induction
        1. Etomidate
        2. Ketamine (if not severely hypertensive)
      3. Paralysis (either agent)
        1. Succinylcholine (may transiently increase ICP)
        2. Rocuronium (delays repeat neuromuscular exam for >40 minutes)
  6. Obtain bedside Serum Glucose (fingerstick Blood Sugar)
    1. Hypoglycemia (<63 mg/dl): Administer D50W (do not over-correct)
    2. Hyperglycemia (>300 mg/dl): Administer Insulin
  7. Labs to obtain in all patients
    1. Complete Blood Count (CBC) with Platelet Count
    2. Basic metabolic profile (e.g. Chem8)
    3. ProTime (PT)
    4. Partial Thromboplastin Time (PTT)
    5. Troponin I (or other Serum Cardiac Marker)
  8. Labs and other diagnostics to obtain in selected patients
    1. Liver Function Tests
    2. Urine toxicology screen
    3. Blood Alcohol level
    4. Pregnancy Test
    5. Arterial Blood Gas
    6. Chest XRay

IV. Protocol: Step 3 Immediate Neurologic Assessment (<25 minutes)

  1. Alert Stroke Team of possible Thrombolytic candidate
  2. History: Mnemonic ("LoST MIND")
    1. Last well or Onset
    2. Seizure
    3. Trauma (esp. Closed Head Injury)
    4. Migraine
    5. Illness (recent)
    6. Neck injury
    7. Diabetes Mellitus
  3. Determine eligibility for fibrinolytics
    1. Consider Thrombolytics (must be started within 3 hours of onset)
    2. Complete CVA Fibrinolytic Checklist
    3. CVA Blood Pressure Control
  4. Neurologic Examination
    1. Assess Level of Consciousness (Glasgow Coma Scale)
    2. Assess Stroke Severity
      1. NIH Stroke Scale (preferred in U.S.)
      2. Hunat and Hess Scale
  5. Physical Examination
    1. Identify acute comorbidities
  6. Consider most common differential diagnosis
    1. Complicated Migraine (especially younger women)
    2. Hemorrhagic Stroke (Intracerebral Hemorrhage)
    3. Hypoglycemia
    4. Hypertensive Encephalopathy
    5. Seizure (post-ictal paralysis or Todd's Paralysis)

V. Protocol: Step 4 Rule-out Hemorrhagic CVA

  1. Imaging
    1. Obtain urgent noncontrast Head CT (<25 minutes)
      1. MRI Brain is as sensitive for Hemorrhage and may be substituted if no delay
      2. However CT Head is typically the preferred study over MRI
      3. Fiebach (2004) Stroke 35(2): 502-6
    2. Head CT read by radiologist (<45 minutes)
    3. CT C-Spine Indications
      1. Altered Level of Consciousness
      2. Trauma
  2. Head CT suggests intracranial bleeding
    1. See Hemorrhagic CVA
    2. Immediate angiography (e.g. CT Angiogram, MR Angiogram) to evaluate for aneurysm
    3. Neurosurgery Consultation
    4. Reverse Anticoagulants or Bleeding Disorder
    5. Manage Hypertension appropriately
  3. Head CT negative despite high suspicion for Subarachnoid Hemorrhage
    1. Lumbar Puncture contraindicates Thrombolytics
    2. Consider Head CT Angiogram (CTA) instead
    3. Obtain Lumbar Puncture to assess for subarachnoid blood
      1. Recommended at 12 hours after onset of symptoms
      2. Send cell count (although blood cells can be seen also with traumatic LP)
      3. Send specimen for spectrophotometry for Bilirubin (only produced in vivo)
  4. Head CT negative suggesting Ischemic CVA
    1. Consider Thrombolytic Therapy below for moderate to severe CVA (NIH Stroke Scale of 5 or more)
    2. Additional imaging to consider (if no delay to Thrombolytics)
      1. Head and Neck CT Angiogram (CTA) with and without contrast
        1. May help direct specific interventions (e.g. directed Thrombolysis or clot extraction in large proximal thrombosis)
      2. Perfusion-weight CT or MRI
        1. Identifies the penumbra (ischemic brain surrounding the infarct) that may be salvageable outside the 3-4.5 hour window
      3. Transcranial doppler Ultrasound
        1. Identifies arterial vasospasm

VI. Protocol: Step 5 Thrombolytic Therapy (if indicated)

  1. Immediate Consultation with stroke team (where available)
  2. Evaluate for Thrombolytic Contraindications
    1. See CVA Fibrinolytic Checklist
  3. Blood Pressure (if SBP >185 mmHg or DBP >110 mmHg)
    1. See CVA Blood Pressure Control
    2. Failure to control Blood Pressure <185/110 mmHg with the following agents contraindicates Thrombolysis
    3. Preparations
      1. Labetalol 10-20 mg IVP for 1-2 doses or
      2. Nitropaste 1-2 inches or
      3. Enalapril 1.25 mg IVP
  4. Review risks and benefits of CVA Thrombolysis with patient and family
    1. Given 18 patients with moderate to severe stroke (NIH Stroke Scale of 5 or more)
    2. No TPA given
      1. Good CVA recovery: 6 patients (33% or one third)
      2. Poor or no CVA recovery: 12 patients (66% or two thirds)
    3. TPA given within 3 hours
      1. Major CNS bleeding: 1 patient (6%) with 45% of those patients dying and the others with typically severe Disability
      2. Good CVA recovery: 8 patients (44%) or an additional 2 patients more than if no TPA had been given
      3. Poor or no CVA recovery: 9 patients (50%)
    4. References
      1. (1995) N Engl J Med 333:1581-1587
  5. Review indications for CVA Thrombolysis
    1. Age over 18 years old
    2. Persistent neurologic deficits with NIH Stroke Scale of 5 or more
    3. CVA Symptom onset <3 hours prior
      1. May consider for <4.5 hours from onset in some patients based on ECASS3 trial
        1. See CVA Fibrinolytic Checklist for cases in which extended time limit to 4.5 hours may be appropriate
        2. CT Head with perfusion-weighted imaging to define penumbra in late presentations may be considered if no delay
      2. However no benefit and increased risk Intracranial Hemorrhage when extended to 6 hours
        1. Arora and Menchine in Herbert (2014) EM: Rap 14(1): 8
  6. Precaution
    1. Do not delay CVA Thrombolysis for lab results unless high suspicion of abnormality
  7. Management
    1. See CVA Thrombolysis

VII. Protocol: Step 6 General Measures

  1. Admit all stroke patients for 24-48 hours
    1. Cardiac monitoring (telemetry)
    2. Frequent neurologic checks (every 2-3 hours is a common interval)
      1. Speech
      2. Extremity Motor Strength
      3. Facial symmetry
    3. Consider transfer to stroke center
      1. All patients receiving CVA Thrombolysis should be transferred to stroke center (neurology ICU)
  2. Keep patient NPO acutely to lower risk of aspiration
    1. Swallowing assessment for aspiration risk
  3. Gentle intravenous fluid hydration only (avoid D5W)
    1. Normal Saline or Lactated Ringers at 50 cc/hour
  4. Maintain Body Temperature <97.5
    1. Acetaminophen (Tylenol)
    2. Cooling blankets
  5. Continue Oxygen by Nasal Cannula to keep O2 Sat >92%
  6. Consider Thiamine in Alcoholics and malnourishment

VIII. Protocol: Step 7 Observe for and treat complications

  1. Blood Sugar Monitoring
    1. Hypoglycemia (<63 mg/dl): Administer D50W (do not over-correct)
    2. Hyperglycemia (>300 mg/dl): Administer Insulin
  2. CVA Blood Pressure Control
    1. See CVA Blood Pressure Control
    2. Post-tPA Blood Pressure control is initiated at BP >180/105
    3. Non-tPA Blood Pressure control is initiated if BP >220/120 mmHg
    4. Avoid lowering Blood Pressure too low in first 24 hours
    5. Anticipate spontaneous resolution over days
  3. Seizures
    1. Evaluate with Glucose and Serum Sodium
    2. Treat with Diazepam and Phenytoin
  4. Cerebral edema (peaks on day 3-5, duration 10 days)
    1. Severe, large volume cerebral edema (malignant edema)
    2. Responsible for one third of the 25% of CVA cases that deteriorate
    3. RSI and Intubate
    4. Mannitol or hypertonic saline
    5. Neurosurgery Consultation for decompression
    6. Corticosteroids are not indicated
  5. Delirium
    1. Avoid medications that cause Altered Level of Consciousness (e.g. sedatives, Anticholinergics)
    2. Preserve normal sleep-wake cycle by avoiding disturbing night-time sleep
    3. Maintain orientation by maximizing sensory input (adequate lighting, eliminate background noise)
  6. Pressure Sores (Decubitus Ulcer)
    1. Early mobilization and frequent turning
    2. Frequent skin examination
    3. Alternating pressure mattresses
    4. Maintain adequate nutrition (see below)
  7. Malnutrition
    1. Assess albumin, Prealbumin, and Cholesterol as markers of malnutrition
  8. Fever
    1. Associated with worse outcome in Ischemic Stroke
    2. Thoroughly investigate for fever cause
    3. Lower fever with antipyretics
  9. Pneumonia
    1. Early mobilization
    2. Incentive Spirometry hourly
    3. Decrease Aspiration Pneumonia risk
      1. Avoid medications that cause Altered Level of Consciousness
      2. Assess swollowing study
  10. Urinary Tract Infections
    1. Avoid indwelling catheters as much as possible
  11. Other common complications
    1. Serum Inappropriate ADH Syndrome
    2. Pulmonary Embolism

IX. Protocol: Step 8 Adjunctive Therapy

  1. See Prevention of Ischemic Stroke
    1. Includes Anticoagulation in Ischemic Stroke
  2. Avoid Heparin
  3. Start Antiplatelet Therapy (e.g. Aspirin 325 mg daily)
    1. Do not start within the first 24 hours if Thrombolysis (e.g. tPA) is used
  4. See Dysphagia after Cerebrovascular Accident
  5. Early rehabilitation
    1. Speech Therapy
    2. Physical Therapy
    3. Occupational Therapy

X. Precautions: Neurointerventional Endovascular Procedures (e.g. Thrombectomy, Directed Thrombolysis)

  1. Neurointerventional Endovascular Procedure Indications
    1. Not recommended for acute Ischemic CVA based on current data
    2. May be considered in large vessel Occlusion (NIHSS>8) unchanged at 1 hour following tPA
    3. Consider directed Thrombolysis in CVA patients within 6 hours if standard tPA protocol contraindicated (per AHA/ASA and ACCP)
  2. Studied for severe ischemic Cerebrovascular Accident with high NIH Score and have not shown benefit compared with Thrombolysis
    1. Broderick (2013) N Engl J Med 368(10):893-903
    2. Cicone (2013) N Engl J Med 368(10): 904-13
    3. Kidwell (2013) N Engl J Med 368(1): 914-23

XI. Prognosis

  1. Indicators of poor outcome
    1. Hyperglycemia
    2. Fever
    3. Hypertension
  2. Factors with positive impact on functional recovery
    1. Family Support has significant positive impact

XII. Prevention

XIII. Resources

  1. tPA for Stroke Patient Information - Risks and Benefits
    1. http://www.aaem.org/UserFiles/file/tpaedtool-AAEM.pdf

Images: Related links to external sites (from Google)

Ontology: Cerebrovascular accident (C0038454)

Definition (NCI) A disorder characterized by a sudden loss of sensory function due to an intracranial vascular event.
Definition (NCI) A sudden loss of neurological function secondary to hemorrhage or ischemia in the brain parenchyma due to a vascular event.
Definition (MEDLINEPLUS)

A stroke is a medical emergency. Strokes happen when blood flow to your brain stops. Within minutes, brain cells begin to die. There are two kinds of stroke. The more common kind, called ischemic stroke, is caused by a blood clot that blocks or plugs a blood vessel in the brain. The other kind, called hemorrhagic stroke, is caused by a blood vessel that breaks and bleeds into the brain. "Mini-strokes" or transient ischemic attacks (TIAs), occur when the blood supply to the brain is briefly interrupted.

Symptoms of stroke are

  • Sudden numbness or weakness of the face, arm or leg (especially on one side of the body)
  • Sudden confusion, trouble speaking or understanding speech
  • Sudden trouble seeing in one or both eyes
  • Sudden trouble walking, dizziness, loss of balance or coordination
  • Sudden severe headache with no known cause

If you have any of these symptoms, you must get to a hospital quickly to begin treatment. Acute stroke therapies try to stop a stroke while it is happening by quickly dissolving the blood clot or by stopping the bleeding. Post-stroke rehabilitation helps individuals overcome disabilities that result from stroke damage. Drug therapy with blood thinners is the most common treatment for stroke.

NIH: National Institute of Neurological Disorders and Stroke

Definition (NCI) In medicine, a loss of blood flow to part of the brain, which damages brain tissue. Strokes are caused by blood clots and broken blood vessels in the brain. Symptoms include dizziness, numbness, weakness on one side of the body, and problems with talking, writing, or understanding language. The risk of stroke is increased by high blood pressure, older age, smoking, diabetes, high cholesterol, heart disease, atherosclerosis (a build-up of fatty material and plaque inside the coronary arteries), and a family history of stroke.
Definition (CSP) sudden neurologic impairment due to a cerebrovascular disorder, either an arterial occlusion or an intracranial hemorrhage.
Definition (MSH) A group of pathological conditions characterized by sudden, non-convulsive loss of neurological function due to BRAIN ISCHEMIA or INTRACRANIAL HEMORRHAGES. Stroke is classified by the type of tissue NECROSIS, such as the anatomic location, vasculature involved, etiology, age of the affected individual, and hemorrhagic vs. non-hemorrhagic nature. (From Adams et al., Principles of Neurology, 6th ed, pp777-810)
Concepts Disease or Syndrome (T047)
MSH D020521
ICD10 I64 , I63.9
SnomedCT 82797006, 195208004, 313267000, 270883006, 230690007, 155388006, 155405006, 266312006, 266315008
English Cerebrovascular accident, CVA, Stroke, cerebrovascular, Apoplexy, ACCIDENT CEREBROVASCULAR, APOPLEXY, APOPLEXY, CEREBRAL, CEREBRAL VASCULAR ACCIDENT, CEREBROVASCULAR ACCIDENT, STROKE, Apoplexy, NOS, CVA, NOS, Cerebral apoplexy, NOS, Cerebrovascular accident, NOS, Stroke, NOS, Stroke Syndrome, Stroke and cerebrovascular accident unspecified, Stroke, not specified as haemorrhage or infarction, Stroke, not specified as hemorrhage or infarction, Stroke/cerebrovasc accident, Strokes, Stroke, neurological, CEREBRAL INFARCTION, Stroke, Cerebrovascular Accident, CVA (cerebral vascular accident), cerebral vascular accident, CVA - cerebrovascular accident (& unspecified [& stroke]) (disorder), Stroke/CVA unspecified, Stroke NOS, Brain attack, Brain Attack, Accident cerebrovascular, Cerebrovascular accident NOS, CVA NOS, Brain Vascular Accident, Brain Vascular Accidents, Vascular Accident, Brain, Vascular Accidents, Brain, CVA (Cerebrovascular Accident), Apoplexy, Cerebrovascular, Cerebrovascular Apoplexy, Cerebral Stroke, Cerebral Strokes, Stroke, Cerebral, Strokes, Cerebral, Cerebrovascular Stroke, Cerebrovascular Strokes, Stroke, Cerebrovascular, Strokes, Cerebrovascular, Stroke NOS (disorder), Stroke and cerebrovascular accident unspecified (disorder), STROKE SYNDROME, SYNDROME, STROKE, CVA, CEREBROVASCULAR ACCIDENT, CEREBROVASCULAR ACCIDENT, (CVA), Stroke [Disease/Finding], cerebrovascular accidents, stroke cerebral, strokes, vascular cerebral accident, vascular brain accident, cerebral stroke, cerebrovascular stroke, stroke, CVAs (Cerebrovascular Accident), CVA - Cerebrovascular accident, Cerebrovascular accident (disorder), Stroke/cerebrovascular accident, cerebrovascular accident, apoplexy, cerebral; accident, cerebral; apoplexy, cerebrovascular; accident, accident; cerebral, accident; cerebrovascular, apoplexy; cerebral, CVA unspecified, Stroke unspecified, CVA - Cerebrovascular accident unspecified, CVA - cerebrovascular accident (& unspecified [& stroke]), Cerebral apoplexy, Cerebrovascular accident (disorder) [Ambiguous], Accident - cerebrovascular, Stroke/CVA - undefined, Cerebrovascular Accidents, Stroke (Cerebrum)
Italian Accidente cerebrovascolare, Accidente cerebrovascolare NAS, Ictus, Apoplessia cerebrale, CVA (Incidente cerebrovascolare), Apoplessia cerebrovascolare, Incidente cerebrovascolare, Incidente vascolare cerebrale, Colpo/accidente cerebrovascolare, Stroke, Apoplessia, Ictus cerebrale
Dutch accident cerebrovasculair, apoplexie, cerebrovasculair accident NAO, beroerte, Cerebrovasc accid (CVA), Cerebrovasculair accident (CVA), accident; cerebraal, accident; cerebrovasculair, apoplexie; cerebraal, cerebraal; accident, cerebraal; apoplexie, cerebrovasculair; accident, Beroerte, niet gespecificeerd als bloeding of infarct, cerebrovasculair accident, Accident, cerebrovasculair, Apoplexie, Beroerte, CVA, Cerebrale beroerte, Cerebrovasculair accident, Cerebrovasculaire apoplexie, Vasculair accident van de hersenen
French Accident, cérébrovasculaire, Apoplexie, Accident cérébro-vasculaire SAI, AVC, Ictus, ACCIDENT VASCULAIRE CEREBRAL, Accident vasculaire cerebral, Accident cérébrovasculaire, Accident vasculaire cérébral, Accident ischémique cérébral, AVC (Accident Vasculaire Cérébral), Accident cérébro-vasculaire, Apoplexie cérébrale, Attaque d'apoplexie
German CVA, Schlaganfall NNB, Apoplex (ex TIA), SCHLAGANFALL, Schlaganfall, nicht als Blutung oder Infarkt bezeichnet, apoplektischer Insult, Apoplexie, Schlaganfall, Zerebraler Schlaganfall, Vaskulärer Insult des Gehirns, Zerebrovaskuläre Apoplexie, Zerebrovaskulärer Insult
Portuguese Acidente vascular cerebral, Acidente vascular cerebral NE, Acidente Vascular Encefálico, Acidente Vascular Cerebral, Icto Cerebral, Acidente Cerebrovascular, Acidente Cerebral Vascular, ACIDENTE VASCULAR CEREBRAL, Acidente/doenca cerebrovascular, Apoplexia Cerebral, Apoplexia Cerebrovascular, Ictus Cerebral, AVE, Acidentes Cerebrovasculares, Acidentes Cerebrais Vsasculares, Acidente cerebrovascular, AVC, Acidente Vascular do Cérebro, Apoplexia, Derrame Cerebral
Spanish Accidente cerebrovascular NEOM, Accidente cerebral vascular, Cerebrovascular accident, Stroke NOS, Accident - cerebrovascular, CVA unspecified, CVA - cerebrovascular accident (& unspecified [& stroke]), Stroke and cerebrovascular accident unspecified, CVA - Cerebrovascular accident unspecified, Stroke unspecified, Stroke/CVA - undefined, Derrame Cerebral, Acc cerebrovascular/apoplejia, ICTUS, Apoplejía Cerebral, Apoplejia Cerebral, Apoplejía Cerebrovascular, Apoplejia Cerebrovascular, Accidentes Cerebrovasculares, ACV, ACV, SAI, accidente cerebrovascular (concepto no activo), accidente cerebrovascular (trastorno), accidente cerebrovascular, SAI (trastorno), accidente cerebrovascular, SAI, accidente cerebrovascular, no especificado (trastorno), accidente cerebrovascular, no especificado, accidente cerebrovascular, apoplejía cerebral, apoplejía, stroke, Accidente cerebrovascular, Apoplejia, Ataque, Ictus, Accidente Cerebral Vascular, Accidente Cerebrovascular, Accidente Vascular Cerebral, Accidente Vascular del Cerebro, Accidente Vascular Encefálico, Apoplejía, Ataque Cerebral, AVC, Ictus Cerebral, Accidente Vascular Encefalico
Japanese 脳血管発作NOS, ソッチュウ, ノウケッカンホッサNOS, ノウケッカンホッサ, ノウソッチュウ, 脳血管発作, 血管発作-脳血管, ストローク, 卒中, 卒中発作, 発作症候群, 脳クリーゼ, 脳出血発作症候群, 脳卒中, 脳卒中発作, 脳発症
Swedish Slaganfall, HJARNSLAG/CEREBROVASKULAR SKADA
Czech cévní mozková příhoda, apoplexie, mozková mrtvice, Apoplexie, Cévní mozková příhoda, Cévní mozková příhoda NOS, Mozková příhoda, ictus, iktus, CMP
Finnish Aivohalvaus, AIVOHALVAUS/ AIVOVERENKIERRON HAIRIO
Russian TSEREBROVASKULIARNAIA APOPLEKSIIA, INSUL'T TSEREBROVASKULIARNYI, GEMORRAGICHESKII INSUL'T, ИНСУЛЬТ ЦЕРЕБРОВАСКУЛЯРНЫЙ, APOPLEKSIIA MOZGA, INSUL'T GEMORRAGICHESKII, INSUL'T ISHEMICHESKII, ISHEMICHESKII INSUL'T, INSUL'T, ИНСУЛЬТ, АПОПЛЕКСИЯ МОЗГА, ГЕМОРРАГИЧЕСКИЙ ИНСУЛЬТ, ИНСУЛЬТ ГЕМОРРАГИЧЕСКИЙ, ИНСУЛЬТ ИШЕМИЧЕСКИЙ, ИШЕМИЧЕСКИЙ ИНСУЛЬТ, ЦЕРЕБРОВАСКУЛЯРНАЯ АПОПЛЕКСИЯ
Danish Apopleksi/cerebrovaskulaer katastr
Norwegian HJERNESLAG/CEREBROVASK KATASTROFE
Hungarian agyergorcs/agyverzes, Stroke, Cerebrovascularis esemény, Cerebralis insultus k.m.n., Cerebralis insultus, Apoplexia, CVA
Korean 출혈 또는 경색증으로 명시되지 않은 뇌중풍
Basque ATAKEA/EZBEHAR BASKULAR BURMUINETAKOA
Hebrew erua moxi
Polish Apopleksja, Udar mózgowy, Ostry udar mózgu, Udar mózgu, Incydent naczyniowo-mózgowy
Croatian MOŽDANA KAP, MOŽDANI UDAR, CEREBROVASKULARNI INCIDENT