65 year old female with a history of DM and HTN
develops acute onset left face droop, left arm and
leg weakness. 118 is called and arrives within 15
minutes. Patient has a BP 200/110.
• What interventions should be provided in the field?
• Where should the patient be transported?
• Closest hospital?
Field Management in Stroke
• Cardiac monitor, O2
• Blood sugar
• Reassurance / no pharmacologic intervention for
• Time of onset documented; medications; physical
exam focusing on speech, facial droop, drift
• Rapid transport with notification of receiving
Patient arrives in the ED with unchanged blood
pressure, unchanged neurologic exam.
• What are the key components of history?
• What are the key components of the physical
• What laboratory tests should be ordered?
• Pharmacologic interventions?
Key Components of the History
• Time of onset
• Head trauma, previous stroke
• Known AVM or aneurysm
• Major surgery within 14 days
• Medications: use of anticoagulants
• Symptoms suggestive of MI / pericarditis
• Symptoms suggestive of hemorrhage
• Severe headache
• Neck stiffness / Pain
• Nausea / vomiting
Key Components to the Physical
• Vital signs (BP both arms; presence of fever)
• LOC (when depressed, consider other diagnoses)
• Trauma exam
• Neck exam
• Cardiopulmonary exam
Key Components of the Neuro Exam
• Glasgow coma scaleGlasgow coma scale
• NIHSS: 15 Item measure: 42 PointsNIHSS: 15 Item measure: 42 Points
• < 4 Not a candidate for thrombolytics
• > 22 Increased risk for hemorrhage
NIH Stroke Scale
• Level of
• Orientation (month
• Follow commands
• Best gaze
• Visual fields
• Facial palsy
• Motor arm
• Motor leg
• Limb ataxia
• Best language
• Extinction and
What Laboratory Tests Should be
What Laboratory Tests Should be
• CBC and platelets
• PT, PTT
• Noncontrast head CT
Blood Pressure Management in
• Systolic 185 - 220, Diastolic 105 - 120; Do not treat
for the first hour (consider benzodiazepines); if
persists, IV Labetolol, 10 mg.
• Systolic > 220 mm Hg or diastolic 121 - 140; 2
readings 20 min apart: Start Labatolol 10 MG IV.
Patients requiring more than 2 doses are not
candidates for t-PA
• Diastolic > 140 mm Hg; 2 readings 5 minutes apart:
Start Nitroprusside. Patient is not a candidate for t-
• Patient has a NIHSS score of 8
• ECG is normal sinus
• Glucose 140; Platelets 200 K
• PT / PTT are normal
• Head CT is read as “normal”
• What are the indications for t-PA?
Indications for t-PA
• Symptoms less than 3 hours from onset
• Symptoms not improving
• No evidence of hemorrhage on CT
• No recent head trauma, surgery, GI bleeding
• No use of anti-coagulants
• No known aneurysm, neoplasm
• Blood pressure controlled
A decision is made to give t-PA.
• How is t-PA administered
• How is suspected intracranial
• .9 mg/kg in a 1:1 dilution
• Maximum dose 90 mg
• 10% initial bolus over 1-2 minutes; the
rest infused over 60 minutes
• Monitor blood pressure
• Do not give heparin or aspirin!
The patient received t-PA and within one hour her
strength was markedly improved.
She was admitted to the stroke unit where she was
monitored and began early rehabilitation
She was discharged home one week later with
minimal left sided weakness.
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