1. Adult Stroke 2010 AHA Guidelines for CPR and ECC
Circulation. 2010;122:S818-S828
summarized & animated by sun yaicheng

2. The “D's of Stroke Care” Rapid recognition of stroke symptoms
Detection
Rapid recognition of stroke symptoms
Dispatch
Early activation and dispatch of EMSS by calling 911
Delivery
Rapid EMS identification, management & transport
Door
Appropriate triage to stroke center
Data
Rapid triage, evaluation & management within the ED
Decision
Stroke expertise and therapy selection
Drug
Fibrinolytic therapy, intra-arterial strategies
Disposition
Rapid admission to stroke unit, ICU

3. Management Goals Time is Brain
Minimize acute brain injury and maximize patient recovery
Stroke Chain of Survival

4. EMS Stroke Recognition
Cincinnati Prehospital Stroke Scale (CPSS)
Sensitivity: 59%
Specificity: 89%
Los Angeles Prehospital Stroke Screen (LAPSS)
Sensitivity: 93%
Specificity: 97%

7. In-Hospital Care
Protocols should be used in the ED to minimize delay to definitive diagnosis and therapy.
ED personnel should assess the patient with suspected stroke within 10 minutes of arrival in the ED.
The EP should perform a neurologic screening assessment, order emergent CT, and activate the stroke team.

9. Approach To Arterial Hypertension In Acute Ischemic Stroke

10. For Patients Potentially Eligible for Acute Reperfusion Therapy
Patient eligible for acute reperfusion therapy except that BP >185/110 mmHg
Labetalol 10 to 20 mg IV over 1 to 2 minutes, may repeat ×1; or
Nicardipine infusion, 5 mg/h, titrate up by 2.5 mg/h every 5–15 minute, maximum 15 mg/h; when desired BP reached, lower to 3 mg/h
If BP does not below 185/110 mmHg,
do not administer rtPA

11. Management of BP During and After rtPA or Other Acute Reperfusion Therapy
Monitor BP every 15 minutes for 2 hours from the start of rtPA therapy; then every 30 minutes for 6 hours; and then every hour for 16 hours
If SBP180–230 mmHg or DBP 105–120 mmHg
Labetalol 10 mg IV followed by continuous IV infusion 2–8 mg/min, or
Nicardipine IV 5 mg/h, titrate up to desired effect by 2.5 mg/hr every 5–15 minutes, maximum 15 mg/h
If BP not controlled or diastolic BP >140 mmHg, consider sodium nitroprusside

12. For Patients Not Potential Candidates for Acute Reperfusion Therapy
Consider lowering BP in acute ischemic stroke if BP >220/120 mmHg
Consider BP reduction as indicated for other concomitant organ system injury
AMI
CHF
Acute aortic dissection
A reasonable target is to lower BP by 15% to 25% within the first day

13. Imaging
CT should be completed within 25 minutes and should be interpreted within 45 minutes of the patient's arrival in the ED.
Centers may perform more advanced neurologic imaging (MRI, CT perfusion, and CTA), but obtaining these studies should not delay initiation of IV rtPA in eligible patients.

14. Inclusion and Exclusion Characteristics of Patients with Ischemic Stroke Who Could Be Treated with rtPA within 3 Hours from Symptom Onset

15. Inclusion Criteria
Diagnosis of ischemic stroke causing measurable neurologic deficit
Onset of symptoms <3 hours before beginning treatment
Age >18 years

16. Exclusion Criteria Head trauma or prior stroke in previous 3 months
Symptoms suggest SAH
Arterial puncture at non-compressible site in previous 7 days
History of previous ICH
Elevated BP (systolic >185 mmHg or diastolic >110 mmHg)
Evidence of active bleeding on examination
Acute bleeding diathesis, including but not limited to
Platelet count <100,000/mm3
Heparin received within 48 hours, resulting in aPTT >upper limit of normal
Current use of anticoagulant with INR >1.7 or PT >15 seconds
Blood glucose <50 mg/dL
CT demonstrates multilobar infarction (hypodensity >1/3 cerebral hemisphere)

17. Relative Exclusion Criteria
Only minor or rapidly improving stroke symptoms (clearing spontaneously)
Seizure at onset with postictal residual neurologic impairments
Major surgery or serious trauma within previous 14 days
Recent GI or urinary tract hemorrhage (within previous 21 days)
Recent AMI (within previous 3 months)

18. Additional Inclusion and Exclusion Characteristics of Patients with Ischemic Stroke Who Could Be Treated with rtPA from 3 to 4.5 Hours from Symptom Onset

19. Inclusion Criteria
Diagnosis of ischemic stroke causing measurable neurologic deficit
Onset of symptoms 3 to 4.5 hours before beginning treatment

20. Exclusion Criteria Age >80 years Severe stroke (NIHSS >25)
Taking an oral anticoagulant regardless of INR
History of both DM and prior ischemic stroke
At present, use of IV rtPA within 3 to 4.5 hour has not yet been FDA approved, although it is recommended by current AHA/ASA science advisory

21. General Stroke Care Blood Pressure Management Glycemic Control
hyperglycemia should be treated with insulin when glucose >185 mg/dL
Temperature Control
treat fever >37.5°C
Dysphagia Screening
Observe for signs of IICP
severe stroke
posterior circulation stroke
younger patient

22. Treatment of Acute Ischemic Stroke: IV rtPA
Infuse 0.9 mg/kg (maximum dose 90 mg) over 60 minutes with 10% of the dose given as a bolus over 1 minute.
Admit the patient to an ICU or stroke unit for monitoring.
Perform neurological assessments every 15 minutes during the infusion and every 30 minutes for the next 6 hours, then hourly until 24 hours after treatment.
If the patient develops severe headache, acute hypertension, nausea, or vomiting, discontinue the infusion and obtain emergency CT.
Measure BP every 15 minutes for the first 2 hours and subsequently every 30 minutes for the next 6 hours, then hourly until 24 hours after treatment.
Increase the frequency of BP measurements if a SBP >180 mm Hg or if a DBP >105 mm Hg. Administer antihypertensive medications to maintain BP at or below these level.

23. Identify signs of possible stroke
Activate EMS
Critical EMS assessment and actions
Support ABCs; give O2 if needed
Perform prehospital stroke assessment
Establish time of symptoms onset (last normal)
Triage to stroke center
Alert hospital
Check glucose if possible
MINS TIME GOLES
Immediate general assessment and stabilization
Assess ABCs, vital signs
Provide O2 if hypoxemic (SpO2 < 94%)
Obtain IV access and perform lab assessments
Check glucose; treat if indicated
Perform neurologic screening assessment
Activate stroke team
Oder emergent CT scan of brain
Obtain 12-lead ECG
ED Arrival
10 min
ED Arrival
Immediate neurologic neurologic assessment by stroke team or designee
Review patient history
Establish symptom onset
Perform neurologic examination (NIHSS)
25 min

24. Does CT scan show any hemorrhage
ED Arrival
Does CT scan show any hemorrhage
45 min
No hemorrhage
Hemorrhage
Probable acute ischemic stroke; consider fibrinolytic therapy
Check for fibrinolytic exclusions
Repeat neurologic exam: are deficits rapidly improving to normal?
Consult neurologist or neurosurgon; consider transfer if not available
Not a Candidate
Patient remains candidate for fibrinolytic therapy?
Administer aspirin
Candidate
ED Arrival
60 min
Review risks/benefits with patient and family
if accptable:
Give tPA
No anticoagulants or antiplatelet tx for 24 hrs
Begin stroke pathway
Admit to stroke unit or ICU
Stroke Admission
Begin post-rtPA stroke pathway
Aggressively monitor:
BP per protocol
For neurologic deterioration
Emergent admission to stroke unit or ICU
3 hrs

25. What
Has
Change ?

26. Administrate rtPA to treat acute ischemic stroke within 4.5 hrs
Time is Brain !

27. Exclusions Older than 80 years Oral anticoagulants NIHSS > 25
Both stroke & DM hx

28. Benefit vs. Risk
Neurologic Outcome
Symptomatic ICH

29. Thanks for
Your Attention