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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 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 5/6/2017© 2009, American Heart Association. All rights reserved. Window for Treatment of Acute Advisory Information from the Expansion of the Time Ischemic Stroke with IV TPA – Science 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) 5/6/2017© 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 – 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