Stroke protocol .. Dina Ashraf (ZUHP team 2012-2013 )

2. Prof. Dr / AtefRadwan
The dean of the faculty of medicine zagazigunversity
Prof. Dr / HananAbdel Azim
Professor at the Neurology department
Dr / HalaHafez
MD of neurology
Dr/ Ahmed Abdul Sabour
ALS instructor at the ERC & head of DMTC
Dr/ ShaimaaEl-Aidy
Resident doctor at the neurology department

3. Case 1 at the ER
55years old male with severe headache & slurred
speech.
What is your attitude as a house officer ?

5. Case 2
Your Grandfather 65 years old male with history of
DM & Hypertensionsuffered suddenweakness in
his right arm & leg with mouth deviation
-Will you give him Asprin?
No
-What if symptoms relieved in 10 mins?
It’s A TIA R/ Asprin75 mg 1x2
-What to do next ?
Call EMS 123

6. Chain of Survival

7. When to suspect stroke ?
1.Sudden numbness or weakness of the face, arm or
leg (especially on one side of the body)
2.Sudden confusion, trouble speaking or
understanding speech
3.Sudden trouble seeing in one or both eyes
4.Sudden trouble walking, dizziness, loss of balance
or coordination
5.Sudden severe headache with no known cause
ACLS guidelines 2012

8. Pre-hospital EMS actions
•Support ABCs ( BLS )
•Pre-hospital Stroke assessment
3 orders ( Cincinnati Pre-Hospital Stroke scale )
Ask the patient to
1.Smile +/-deviation in one / both sides
2.Close his eyes and both arms straight with palms up 10 seconds +/-Hand drift one /
both sides
3.Tell you the time or place or ( you can’t teach an old dog new tricks ) Slurred speech
•Time Zero ?
•Alert the nearest hospital with stroke team
•Check glucose ( If possible )
ACLS guidelines 2012

9. Time zero :
•Def:
It’s The time when the patient is last seen normal
•It’s important for thrombolytic therapy administration
decision
•If > 8 hsor not identified absolute contraindication
for r-TPA
ACLS guidelines 2012

11. ACLS guidelines 2012

12. Time Is brain
ACLS guidelines 2012

13. Our Timeline
ACLS guidelines 2012

14. In 10 minutes
ACLS guidelines 2012

15. In 10 minutes
ACLS guidelines 2012
Airway -Checkairway if needed( Head tilt / Chin left or Jaw thrust )
-Clearthe air way If obstructed and choosea suitable airway **

16. In 10 minutes
ACLS guidelines 2012
Breathing -Check for breathing( Look , Listen & feel and count to 10)
-Auscultateand Percussthe Chest / Tidal volume / equality
-Apply pulse oximeter.. Oxygen for O2 Saturation < 92 %
Circulation -Vital signs
-IV line

17. If No Pulse / No breath 
Start resuscitation Algorithm

18. In 10 minutes
ACLS guidelines 2012
Disabilty -Neurological scoring
-Lab
(CBC , RBS , ABG , --PT , PTT , INR --, Cardiac enzymes )
NB : Cardiac enzymes for suspected MIpatients only .
-R/ Thiamine100 mg IV
-Order CT & Call Acute stroke team / Neurologist
-ECGfor arrhythmias or acute MI ( Shouldn’t delay Urgent CT )
-General examination( pupil & signs of meningealirritation)

19. ** Pupil examination ( Light reflex )
•Pin point / sluggish reaction 
Pontine hemorrhage.. ( Do urgent CT )
•Intialdilatation + loss of light reactivity 
Trans-tentorialherniation
** Signs of meningealirritation
1.Exam: NuchalRigidity
2.Exam: Spinal Rigidity
3.Exam: Kernig'sSigns
4.Exam: Brudzinski'sSign

20. In 25 minutes
ACLS guidelines 2012
* Rapid History Taking
* Determine Time Zero
*Neurological ExaminationNIHSS
* Do the head CT

21. Don’t Give
Aspirin / Heparin / Iv thrombolytic
therapy
Unless after reading CT
ACLS guidelines 2012

22. In 45 minutes
ACLS guidelines 2012
•Read CT
•Take decision according to CT result& Time Zero

23. Decision Taking according to CT reading
Check for Hemorrhage
Yes No
Call a Neurologist RecanalisationCandidate ?
Stable Patient ? -Check exclusion criteria
-Rapid neurological reassessment
Yes No Still candidate ?
Ward admission
No Yes
R/ Asprin( 1x2 ) up to 325 mg/d
Call Acute Stroke team
ICU admission Thrombolytic therapy
ACLS guidelines 2012

24. 1 -AVPU score
2 -Glascow( Total score = ... /15 )
3 -NIHSS ( Total score = ... /42 )
-Modified NIHSS ( Total score = ... /31 )
OXFORD neurology 2011

25. National Institutes of Health Stroke Scale
Used for :-
1-Thrombolytic therapy decision making
2-Prognosis of stroke
OXFORD neurology 2011

26. Level of conciousnessLOC **
LOC questions
LOC Commands
Best Gaze
Visual field
Facial palsy **
Motor arm Rt. & lt.
Motor Leg Rt. & lt.
Limb Ataxia **
Sensory
Intinction& Extinction **
Language
Dysarthria
Total NIHSS
Total modifedNIHSS
3
2
2
2
2
3
4+4
4+4
2
2
2
3
3
42
31

28. Penumbra :-Area at risk

29. ( Start within 1 hour from arrival to ED )
General
Supportive Care
&Palliative care
Neurological
monitoring
Reversal of
coagulopathy
Complication
detection &
management

30. (A)
1-Oxygenation
2-Blood pressure
( See BP control )
3-Temperature
( See Fever control )
4-Blood glucose
( Measure 1x 4 x 3 &
control with Insulin )
5-Hydration
6-Lab
(B)
1-Cardiac monitoring
1st 24 hours
2-Swallowing assessment
(for nasogastrictube
application & oral drug
administration )
3-Drugs
* Anti-platelet
*Anticoagulant
*NSAID
*Lipid lowering drugs
*Vitamins
4-Treatment of other
co-morbidities
(C)
1-Head positioning
( Elevated at 20-30˚)
2-Body positioning
3-DVT prophylaxis
* Elastic stocking
* Raise the legs
* UFLMWH 5000 1x2
After 48 hs.
4-Bowel & bladder care
5-Skin Integrity
Inspect skin sacrum, heels,
elbows, shoulders for
pressure sores regularly
General supportive care & palliative care :

31. ( Start within 1 hour from arrival to ED )
General
Supportive Care
&Palliative care
Neurological
monitoring
Reversal of
coagulopathy
Complication
detection &
management

32. 1-Continuous scoring
2-Increased intracranial tension ??

33. 1-Glasgow Coma Scale (GCS)
-Hourly for the first 24 hours
-2-4 hourly for next 48 hours if stable
•A decrease in GCS of ≥ 2 points from baseline 
Neurological decline ( urgent medical assessment is required )
*GCS ≤ 8 is predictive of impending cardiorespiratoryarrest
OR NIHSS … score from 42
Score :-
>4 points increase in the score deterioration
OR Modified NIHSS … score from 31
Score :-
< 12 Good prognosis ≥12 Poor prognosis

34. 2-Increased intracranial pressure
* Signs:-
-Reduced consciousness
-Headache , nausea , projectile vomiting
-Visual disturbance
-Seizures
-Sudden increase in blood pressure
* Treatment :-
-Exclude ICH byCT
-R/ Mannitol(0.25-1 gm/kg)
-Lumber puncture for decompression
-Hemi-Craniotomy

35. ( Start within 1 hour from arrival to ED )
General
Supportive Care
&Palliative care
Neurological
monitoring
Reversal of
coagulopathy
Complication
detection &
management

36. 1-Correct coagulopathy ( guided by PT , PTT , INR )
Treatment :-Platelets & Cryoprecipitate
2-Recanalisation therapy

39. ( Start within 1 hour from arrival to ED )
General
Supportive Care
&Palliative care
Neurological
monitoring
Reversal of
coagulopathy
Complication
detection &
management

40. 1-Seizures
2-Increased intracranial pressure
3-Complication of r-TPA & management :
Intracranial hemorrhage
Angiodema
4-Venous thrombo-embolism ( ttt: IVC filter )

41. 1.Ophthalmoscope
2.Thrombolytic therapy
3.Stroke suspecting culture ( 3 orders )
4.NIHSS quick application in 25 minsfrom arrival
5.Lab Facility in 10 mins

42. -ACLS 2012 guidelines
-www.emedicine.com
-Oxford press ( Neurology emergencies ) text book
-http://www.fpnotebook.com/neuro/exam
-www.pubmed.com
-Egyptian ministry of health protocols 2012