4/5/2018 ACLS Suspected Stroke Algorithm
ACLS Suspected Stroke Algorithm
Apr 3, 2018
Version control: This document is current with respect to 2015 American Heart Association Guidelines for CPR
and ECC. These guidelines are current until they are replaced on October 2020. If you are reading this page
after October 2020, please contact ACLS Training Center at support@acls.net for an updated document.
Using the Suspected Stroke Algorithm for
Managing Acute Ischemic Stroke PDF Version
The ACLS Suspected Stroke Algorithm emphasizes critical actions for out-of-
hospital and in-hospital care and treatment.
National Institute of
Neurological Disorders and
Stroke Critical Time Goals
Included in the algorithm are critical time goals set by
the National Institute of Neurological Disorders (NINDS) Algorithm
for in-hospital assessment and management. These
time goals are based on findings from large studies of
stroke victims: Order the full set of
Immediate general assessment by a stoke team, printed crash cart cards
emergency physician, or other expert within 10
minutes of arrival, including the order for an urgent CT
scan Order now $40
Neurologic assessment by stroke team and CT scan
performed within 25 minutes of arrival
Interpretation of CT scan within 45 minutes of ED
arrival
Initiation of fibrinolytic therapy, if appropriate, within
1 hour of hospital arrival and 3 hours from onset of
symptoms. rTpa can be administered in “well
screened” patients who are at low risk for bleeding for
up to 4.5 hours.
Door-to-admission time of 3 hours in all patients
Algorithm Steps
Step 1
Identify signs of a possible stroke.
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Facial droop (have patient show teeth or smile)
Arm drift (patient closes eyes and extends both arms straight out, with palms up for 10 seconds)
Abnormal speech (have the patient say “you can’t teach an old dog new tricks”)
If any 1 of these 3 signs is abnormal, the probability of a stroke is 72%
Step 2
Call 911 immediately (activate EMS system). This is an important step because EMS responders can transport the
patient to a hospital that provides acute stroke care and notify the hospital that the patient is coming. The hospital staff
can then prepare for efficient evaluation and management of the patient. Currently, half of all stroke victims are driven
to the ED by family members or friends.
Step 3
Complete the following assessments and actions.
Assessment Actions
Define and Support the ABC's (airway, breathing, and circulation).
recognize the
signs of stroke.
Assess the Give oxygen as needed.
patient using the
CPSS or the
LAPSS.
Establish last Last known well time: set the time when the patient was last
known well time known to be neurologically normal. If the patient was sleeping and
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wakes up with symptoms, time last known well (LKW)is the last
time the patient was seen to be normal.
Consider triage Transport the patient quickly.
to a stroke
center, if
possible.
Assess Bring a family member or witness to confirm last known well time.
neurological Alert the receiving hospital. Check glucose levels.
status while the
patient is being
transported.
General Assessment in the ED
NINDS time goal: 10 min
Step 4
Within 10 minutes of the patient's arrival in the ED, take the following actions:
Actions
Assess circulation, airway, breathing and evaluate vital signs.
Give oxygen if patient is hypoxemic (less than 94% saturation). Consider oxygen if
patient is not hypoxemic.
Make sure that an IV has been established.
Take blood samples for blood count, coagulation studies, and blood glucose. Check
the patient's blood glucose and treat if indicated. Give dextrose if the patient is
hypoglycemic. Give insulin if the patient's serum glucose is more than 300. Give
thiamine if the patient is an alcoholic or malnourished.
Assess the patient using a neurological screening assessment, such as the NIH Stroke
Scale (NIHSS).
Order a CT brain scan without contrast and have it read quickly by a qualified
specialist.
Obtain a 12-lead ECG and assess for arrhythmias.
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Do not delay the CT scan to obtain the ECG. The ECG is taken to identify a recent or
ongoing acute MI or arrhythmia (such as atrial fibrillation) as a cause of embolic stroke.
Life-threatening arrhythmias can happen with or follow a stroke.
Immediate Neurological Assessment by Stroke Team
NINDS time goal: 25 min
Step 5
Within 25 minutes of the patient's arrival, take the following actions:
Actions
Review the patient's history, including past medical history.
Perform a physical exam.
Establish last known well time if not already done.
Perform a neurological exam to assess patient's status using the NIHSS or the
Canadian Neurological Scale.
The CT scan should be completed within 25 minutes from the patient's arrival in the
ED and should be read within 45 minutes.
Treatment Decisions by Specialist
NINDS time goal: 45 min
Step 6
Within 45 minutes of the patient's arrival, the specialist must decide, based on the CT scan or MRI, if a hemorrhage is
present.
Take these actions if a Take these actions if a hemorrhage is NOT
hemorrhage is present present
Note that the patient is not a Decide if the patient is a candidate for fibrinolytic
candidate for fibrinolytics. therapy.
Arrange for a consultation with a Review criteria for IV fibrinolytic therapy by using
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neurologist or neurosurgeon. the fibrinolytic checklist (see Figure 1).
Consider transfer, if available. Repeat the neurological exam (NIHSS or
Canadian Neurological Scale).
If the patient is rapidly improving and moving to normal, fibrinolytics may not be necessary.
Treatment
NINDS time goal: 60 min
If the patient is a candidate for fibrinolytic therapy, review the risks and benefits of therapy with the patient and family
(the main complication of IV tPA is intracranial hemorrhage) and give tissue plasminogen activator (tPA).
Do not give anticoagulants or antiplatelet treatment for 24 hours after tPA until a follow-up CT scan at 24 hrs does not
show intracranial hemorrhage.
If the patient is NOT a candidate for fibrinolytic therapy, give the patient aspirin.
For both groups (those treated with tPA and those given aspirin), give the following basic stroke care:
Begin stroke pathway.
Support patient's airway, breathing, and circulation.
Check blood glucose.
Watch for complications of stroke and fibrinolytic therapy.
Transfer patient to intensive care if indicated.
Patients with acute ischemic stroke who are hypoglycemic tend to have worse clinical outcomes, but there is no direct
evidence that active glucose control improves outcomes. Consider giving IV or subcutaneous insulin to patients
whose serum glucose levels are greater than 10 mmol/L (about 200 mg/dL).
Inclusion Exclusion criteria Exclusion criteria
criteria
Age: 18 yrs or Evidence of intracranial hemorrhage Active internal bleeding
older from CT scan or acute trauma, such as
a fracture
Diagnosis of Clinical presentation suggestive of a Acute bleeding diathesis,
an ischemic subarachnoid hemorrhage, even with including the following
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stroke with normal CT but may include other
neurologic manifestations
deficit
Time from Evidence of multilobar infarction in more Intraspinal surgery,
onset of than one-third of the cerebral serious head trauma, or
symptoms is hemisphere on CT previous stroke within the
within 3 hours past 3 months
History of intracranial hemorrhage Arterial puncture at a
non-compressible site
within the past 7 days
Uncontrolled hypertension based on
repeated measurements of > 185 mm
Hg systolic pressure or > 110 mm Hg
diastolic pressure
Known AV malformation, neoplasm, or
aneurysm
Witnessed seizure at stroke onset
Relative contraindications/precautions
Relative contraindications/precautions
Minor or rapidly improving stroke symptoms
Major surgery or serious trauma within the past 14 days
Recent gastrointestinal or urinary tract hemorrhage within the past 3 weeks
Post-myocardial infarction pericarditis
Recent acute myocardial infarction within the past 3 months
Abnormal blood sugar level < 50 mg/dl or > 400 mg/dl
Platelet count < 100,000/mm3
Heparin received within 48 hours prior to onset of stroke, with elevated activated partial thromboplastin time (aPTT)
Current use of anticoagulant (e.g., warfarin) with an elevated international normalized ratio (INR) > 1.7
Complications. The major complication of IV tPA is intracranial hemorrhage. Other bleeding complications, ranging
from minor to severe, may also happen. Angioedema and transient hypotension also can occur.
Research. Several studies have shown that good to excellent outcomes are more likely when tPA is given to adults
with acute ischemic stroke within 3 hrs of onset of symptoms. However, these results happened when tPA was given
in hospitals with a stroke protocol that adheres closely to the therapeutic regimen and eligibility requirements of the
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NINDS protocol. Evidence from prospective randomized studies in adults documented a greater likelihood of benefit
the earlier treatment begins.
Managing Hypertension in tPA Candidates
For patients who are candidates for fibrinolytic therapy, you need to control their blood pressure to lower their risk of
intracerebral hemorrhage following administration of tPA. See the general guidelines in Figure 2.
Figure 2. Management guidelines for elevated blood pressure in patients with acute ischemic stroke
Candidates NOT eligible for fibrinolytic therapy
Blood Treatment
pressure
level,
mm Hg
Systolic Observe patient unless there is other end-organ involvement. Treat the
≤220 or patient's other symptoms of stroke (headache, pain, nausea, etc). Treat
diastolic other acute complications of stroke, including hypoxia, increased
≤120 intracranial pressure, seizures, or hypoglycemia.
Systolic Labetalol 10 to 20 mg IV for 1–2 min—may repeat or double every 10 min
> 220 or to a maximum dose of 300 mg OR Nicardipine 5 mg/hr IV infusion as
diastolic initial dose; titrate to desired effect by increasing 2.5 mg/hr every 5 min to
121 to max of 15 mg/hr Aim for a 10% to 15% reduction in blood pressure
140
Diastolic Nitroprusside 0.5 µg/kg per min IV infusion as initial dose with continuous
> 140 blood pressure monitoring.
Aim for a 10% to 15% reduction in blood pressure.
Stroke patients eligible for a fibrinolytic
PRETREATMENT
Systolic > 185 or Labetalol 10 to 20 mg IV for 1–2 min—may repeat 1 time or
diastolic > 110 nitropaste 1–2 inches
During or after
TREATMENT
Monitor blood Check blood pressure every 15 min for 2 hrs, then every 30 min
pressure for 6 hrs, and finally every hr for 16 hrs
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Diastolic > 140 Sodium nitroprusside 0.5 µg/kg per minute IV infusion as initial
dose and titrate to desired blood pressure
Systolic > 230 or Labetalol 10 mg IV for 1–2 min—may repeat or double every 10
diastolic 121 to min to maximum dose of 300 mg or give initial labetalol dose and
140 then start labetalol drip at 2 to 8 mg/min OR nicardipine 5 mg/hr
IV infusion as initial dose and titrate to desired effect by
increasing 2.5 mg/hr every 5 min to maximum of 15 mg/hr; if
blood pressure is not controlled by nicardipine, consider sodium
nitroprusside
Systolic 180 to Labetalol 10 mg IV for 1–2 min—may repeat or double every 10
230 or diastolic to 20 min to a maximum dose of 300 mg or give initial labetalol
105 to 120 dose, then start labetalol drip at 2 to 8 mg/min
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