Stroke resident survival guide

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief:

Definition

Time of onset is defined as either the witnessed onset of symptoms or the time last known normal if symptom onset was not witnessed.

Causes

Life Threatening Causes

Life-threatening causes include conditions which may result in death or permanent disability within 24 hours if left untreated.

Management

Evaluation Goal: Evaluation done within 60 mins of patient's arrival Check vitals ABCs Rapid Hx - time of onset, time of arrival at the ED, medications (especially anticoagulants) Rapid physical exam - neuro exam, NIHSS Activate stroke team Stat fingerstick Labs EKG, troponin, CXR NPO Obtain stroke protocol

Rule out DD Seizure, syncope, migraine, hypoglycemia

Non-contrast enhanced CT (or MRI) to r/o hemorrhage

Bleed positive

Hemorrhagic stroke

Bleed negative

Hemorrhagic stroke algorithm

Acute ischemic stroke

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Time of onset

<3 hours

3 -4.5 hours

>4.5 hours

Eligibility criteria for IV rTPA

Consider rTPA after excluding patients >80 years old, those taking anticoagulants regardless of INR, baseline NIHSS >25, those with imaging evidence of ischemic injury involving >1/3 of the MCA territory, or those with a history of both stroke and diabetes mellitus

Eligible

Not eligible

Blood pressure control algorithm Treat fever with IV antipyretics

BP≤180/110

BP≥180/110

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IV rTPA 0.9 mg/kg (maximum of 90 mg) with 10% given as intravenous bolus over 1 minute and the rest as IV infusion over 1 hour

Commence IV antihypertensives

Admit ICU for BP monitoring + bleeding complications Vitals Neurocheck hourly Aspiration precautions

After 24 hours post rTPA or no rTPA

Follow-up head CT/MRI before commencing antiplatelets

ASA 325 mg (if no contraindication) Statins DVT prophylaxis

PTOT evaluation Speech and swallow evaluation

Investigate the cause MRA/CTA/carotid duplex Venous doppler USS Echocardiography

Dos

Eligibility Criteria for IV Recombinant TPA

Below are the exclusion criteria:

• Significant head trauma or prior stroke in previous 3 months
• Symptoms suggest subarachnoid hemorrhage
• Arterial puncture at noncompressible site in previous 7 days
• History of previous intracranial hemorrhage
• Intracranial neoplasm, arteriovenous malformation, or aneurysm
• Recent intracranial or intraspinal surgery
• Elevated blood pressure (systolic >185 mm Hg or diastolic >110 mm Hg)
• Active internal bleeding
• Acute bleeding diathesis, including but not limited to
• Platelet count <100,000/mm³
• Heparin received within 48 hours, resulting in abnormally elevated aPTT greater than the upper limit of normal
• Current use of anticoagulant with INR >1.7 or PT >15 seconds
• Current use of direct thrombin inhibitors or direct factor Xa inhibitors with elevated sensitive laboratory tests (such as aPTT, INR, platelet count, and

ECT; TT; or appropriate factor Xa activity assays)

• Blood glucose concentration <50 mg/dL (2.7 mmol/L)
• CT demonstrates multilobar infarction (hypodensity >1/3 cerebral hemisphere)

Relative exclusion criteria

• Only minor or rapidly improving stroke symptoms (clearing spontaneously)
• Pregnancy
• Seizure at onset with postictal residual neurological impairments
• Major surgery or serious trauma within previous 14 days
• Recent gastrointestinal or urinary tract hemorrhage (within previous 21 days)
• Recent acute myocardial infarction (within previous 3 months)