• Eligibility criteria for IVT (table and algorithm)
• Rapid overview of ICH
• NIHSS score calculator
• Stroke subtypes
📝ED #order for suspected acute stroke
❗️Critical measures:
🔺Stabilize vital signs, "A.B.C"
🔺Urgent studies
• CT w/o contrast to exclude hemorrhage,
• Finger stick blood glucose,
• Oxygen saturation.
Imp: suspected acute stroke(all patients)
Cond: emergeny
Diet: NPO/ swallowing assessment
Act: CBR, bed-sides up
▪️two large-bore (18-gauge) peripheral IV lines
▪️CM and POM
▪️C.V.S stat then q15 min
▪️head in neutral alignment with the body and elevating the head of the bed to 30 degrees, if there is risk of elevated ICP, aspiration and Cardiopulmonary decompensation.
▪️Obtain patient weight
▪️ECG stat, but do not delay the head CT.
🔺as patients with ischemic stroke frequently harbor coronary artery disease but may not be able to report chest pain.
🔺Cardiac monitoring for at least the first 24 hours after the onset of ischemic stroke to look for atrial fibrillation (AF) or atrial flutter.
▪️Fingerstick Blood Glucose stat
▪️CBC with diff, BUN, Cr, Na, K, Mg, Ca, PT, PTT, INR, Trop, VBG, beta hcg, urine toxic, u/a, BS, blood group/rh,
▪️Brain CT w/o contrast stat, to rule-out the hemorrhage.
🔺It is important to assess and stabilize vital physiologic functions before sending the patient for an imaging study.
▪️CXR, urinalysis and blood cultures are indicated if fever is present.
▪️Supplemental oxygen if needed, it should not routinely be given to nonhypoxic patients with acute ischemic stroke(maintain sat>94).
▪️Consider intubation if needed.
🔺Failure to Protect Airway(GCS<8), Respiratory Failure, Impending Herniation(Clinical signs of rapidly increasing intracranial pressure (ICP), such as Cushing's triad (hypertension, bradycardia, irregular respirations), unilateral or bilateral blown pupils, or decerebrate/decorticate posturing.
🔺single dose of ceftriaxone 2 g intravenous (IV) who require endotracheal intubation to decrease the risk of ventilator-associated pneumonia (VAP).
▪️IV fluid therapy with isotonic saline without dextrose like 0.9% N.S for repletion and maintenance to Maintain euvolemia.
🔺avoid excess free water (eg, as in ½ isotonic saline, D5W) because hypotonic fluids may exacerbate cerebral edema.
▪️Hypoglycemia or Hyperglycemia, (goal: 140 to 180 mg/dL).
▫️if BS<60, rapidly correct at the first opportunity.
• Administer 25 grams of 50% Dextrose in Water (D50W) IV push over 1-3 minutes. Recheck blood glucose in 15 minutes.
▫️if BS> 180, do insulin protocol.
• insulin regular 0.05-0.1u/kg s.c q6h as needed.
▪️Amp Acetaminophen 650 mg to 1000 mg IV every 6 hours as needed if temperature > 38.0°C.
▪️ PPIs or H2 antagonists prophylaxis is effective for reducing overt GI bleeding but may increase the risk of nosocomial pneumonia.
🔺Therefore, stress ulcer prophylaxis is not used routinely for patients with acute stroke but is reserved for select patients as follow:
• sepsis, hereditary or acquired coagulopathy, including therapeutic anticoagulation, a history of GI ulceration or bleeding within the past year, occult gastrointestinal bleeding lasting ≥ 6 days, or treatment with high-dose glucocorticoids.
▪️ICU admission
▪️Neurosurgery and Neurology consultant