ACLS CVA

What is a stroke?

20% 80%

Signs and Symptoms The “Suddens” Sudden: numbness or weakness of face, arm, or leg confusion, trouble speaking or understanding speech trouble seeing in one eye or both trouble walking, dizziness, loss of balance or coordination severe headache with no known cause

Signs and Symptoms Speech Disturbance Aphasia: Inability to speak Dysphasia: Difficulty speaking Dysarthria: Impairment of the tongue muscles essential to speech

Conditions that may mimic stroke Altered mental status Electrolyte imbalances (esp. Sodium) Epidual or subdural hematoma Brain abscess or tumor Post-seizure Migraine Hypoglycemia

Timeline: Time is Brain MD at bedside within 5 min of patient notification (in ED or inpatient) IV: 18 guage Labs (see orderset) CT within 25 min Neurology and Neuroradiology paged immediately if patient is a t-PA candidate Note: Patients are eligible for t=PA up to 4.5 hours from first s/s

MANAGEMENT FOR PATIENTS PRESENTING WITH NEW ONSET STROKE SYMPTOMS: Determine exact time of onset of symptoms and document in medical record. Activate the Acute Stroke Protocol. Order STAT non-contrast head CT. CT Scan will be read by a neurologist or radiologist. Obtain blood samples for STAT CBC, Platelets, BMP, PT, PTT, fingerstick BS at bedside, bHCG (when applicable). CALL ext 5154 to notify the lab of a potential stroke patient eligible for t-PA. Obtain ECG Insert one or two 18G or 20G peripheral IVs (2 IVs are preferred)

Door to Needle The benefit of intravenous thrombolytic therapy in acute brain ischemia is strongly time dependent Therapeutic yield is maximal in the first minutes after symptom onset and declines steadily during the first 3 hours 1.9 million neurons lost per minute Every 10 minute delay in delivery of TPA, 1 fewer patient has improved outcome BAC/AHA/NIH recommendation: door to needle (DTN) time < 60 minutes 9

tPA and Ischemic Stroke Management tPA is recommended for treatment of ischemic stroke in selected patients However, tPA is only administered to less than 3% of ischemic stroke patients Delay in presentation contributes significantly to underutilization of tPA for stroke Extending time window for tPA administration beyond the current recommended 3 hrs might be beneficial. The European Cooperative Acute Stroke Study (ECASS III), investigated tPA (alteplase) treatment in the 3.0 - 4.5 hour window 1. Adams HP, Jr., del Zoppo G, Alberts MJ, Bhatt DL, Brass L, Furlan A, Grubb RL, Higashida RT, Jauch EC, Kidwell C, Lyden PD, Morgenstern LB, Qureshi AI, Rosenwasser RH, Scott PA, Wijdicks EF. Guidelines for the early management of adults with ischemic stroke: a guideline from the American Heart Association/American Stroke Association Stroke Council, Clinical Cardiology Council, Cardiovascular Radiology and Intervention Council, and the Atherosclerotic Peripheral Vascular Disease and Quality of Care Outcomes in Research Interdisciplinary Working Groups: the American Academy of Neurology affirms the value of this guideline as an educational tool for neurologists. Stroke. 2007;38(5):1655-1711. 4/21/2018© 2009, American Heart Association. All rights reserved. Information from the Expansion of the Time Window for Treatment of Acute Ischemic Stroke with IV TPA – Science Advisory 10

Recommendations tPA should be administered to eligible pts within 3.0-4.5 hours after stroke (Class I Recommendation, LOE B) Eligibility criteria in this time period are similar to those for persons treated at earlier time periods with the following additional exclusion criteria: Age > 80 years; Oral anticoagulant use with INR ≤ 1.7*; baseline NIH Stroke Scale score > 25; a history of stroke and diabetes (*For the 3.0 – 4.5 hr window all pts receiving oral anticoagulant are excluded whatever their INR). The efficacy of IV rt-PA within 3.0 – 4.5 hours after stroke in pts with these exclusion criteria is not well-established & requires further study. (Class IIb Recommendation, LOE C) 4/21/2018© 2009, American Heart Association. All rights reserved. Information from the Expansion of the Time Window for Treatment of Acute Ischemic Stroke with IV TPA – Science Advisory

AHA Recommendations: IV and IA Thrombolysis Intravenous Intravenous rtPA is recommended for selected patients who may be treated within 3 hours of onset of ischemic stroke. (Class I, LOE A) rt-PA should be administered to eligible pts within 3.0-4.5 hours after stroke (Class I Recommendation, LOE B) (Adams, Stroke 2007)

AHA Recommendations: IV and IA Thrombolysis Intra-Arterial Option for treatment of selected patients who have major stroke of <6 hours’ duration due to occlusions of the MCA and who are not otherwise candidates for IV rtPA (Class I, LOE B) Reasonable in patients who have contraindications to use of IV tPA, such as recent surgery (Class IIa, LOE C) Should generally not preclude IV tPA in otherwise eligible patients (Class III, LOE C) (Adams, Stroke 2007)

All patients who are treated with TPA should receive that treatment within 1 hour of arrival to the hospital/emergency department.

T-PA Exclusions Evidence of intracranial hemorrhage on CT scan Clinical presentation suggestive of subarachnoid hemorrhage Multilobar infarction History of intracranial hemorrhage Uncontrolled HTN (SBP >185) Known arteriovenous malformation Witnessed seizure at stroke onset Active internal bleeding Acute bleeding diathesis Within 3 months of intracranial or intraspinal surgery, head trauma, or stroke

Relative Exclusions Within 14 days of major surgery or serious trauma Resent GI or urinary tract hemorrhage (within previous 21 days) Recent MI (within 3 months) Postmyocardial infarction pericarditis Abnormal blood glucose level

Imaging at MAH CT (with and without contrast) CTA MRI MRA perfusion studies MRI MRA Carotid imaging

Interventions and Treatment MAH Neuro-radiology Imaging Order-sets Ischemic stroke t-PA orderset Medications t-PA Prothrombin Complex Concentrate