This document provides guidance for evaluating and treating two cases presenting with potential stroke symptoms. For a 55-year-old male with headache and slurred speech, the guidance is to perform a neurological exam and assess using the NIH stroke scale within 25 minutes. For a 65-year-old male with sudden weakness, do not give aspirin and suspect a transient ischemic attack if symptoms resolve within 10 minutes. The document outlines the chain of survival and pre-hospital actions for stroke, guidelines for in-hospital evaluation and decision making within time windows, and supportive care and complication management.
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Stroke protocol .. Dina Ashraf (ZUHP team 2012-2013 )
1.
2. Prof. Dr / Atef Radwan
The dean of the faculty of medicine zagazig unversity
Prof. Dr / Hanan Abdel Azim
Professor at the Neurology department
Dr / Hala Hafez
MD of neurology
Dr/ Ahmed Abdul Sabour
ALS instructor at the ERC & head of DMTC
Dr/ Shaimaa El-Aidy
Resident doctor at the neurology department
3. Case 1 at the ER
55 years old male with severe headache & slurred
speech .
What is your attitude as a house officer ?
4.
5. Case 2
Your Grandfather 65 years old male with history of
DM & Hypertension suffered sudden weakness in
his right arm & leg with mouth deviation
-Will you give him Asprin ?
No
-What if symptoms relieved in 10 mins ?
It’s A TIA R/ Asprin 75 mg 1x2
-What to do next ?
Call EMS 123
7. When to suspect stroke ?
1. Sudden numbness or weakness of the face, arm or
leg (especially on one side of the body)
2. Sudden confusion, trouble speaking or
understanding speech
3. Sudden trouble seeing in one or both eyes
4. Sudden trouble walking, dizziness, loss of balance
or coordination
5. Sudden severe headache with no known cause
ACLS guidelines 2012
8. Pre-hospital EMS actions
•Support ABCs ( BLS )
•Pre-hospital Stroke assessment
3 orders ( Cincinnati Pre- Hospital Stroke scale )
Ask the patient to
1. Smile +/- deviation in one / both sides
2. Close his eyes and both arms straight with palms up 10 seconds +/- Hand drift one /
both sides
3. Tell you the time or place or ( you can’t teach an old dog new tricks ) Slurred speech
•Time Zero ?
•Alert the nearest hospital with stroke team
ACLS guidelines 2012
•Check glucose ( If possible )
9. Time zero :
• Def:
It’s The time when the patient is last seen normal
• It’s important for thrombolytic therapy administration
decision
• If > 8 hs or not identified absolute contraindication
for r-TPA
ACLS guidelines 2012
15. In 10 minutes
Airway - Check airway if needed ( Head tilt / Chin left or Jaw thrust )
- Clear the air way If obstructed and choose a suitable airway **
ACLS guidelines 2012
16. In 10 minutes
Breathing - Check for breathing ( Look , Listen & feel and count to 10)
- Auscultate and Percuss the Chest / Tidal volume / equality
- Apply pulse oximeter .. Oxygen for O2 Saturation < 92 %
Circulation - Vital signs
- IV line
ACLS guidelines 2012
17. If No Pulse / No breath
Start resuscitation Algorithm
18. In 10 minutes
Disabilty - Neurological scoring
- Lab
(CBC , RBS , ABG , -- PT , PTT , INR -- , Cardiac enzymes )
NB : Cardiac enzymes for suspected MI patients only .
- R/ Thiamine 100 mg IV
- Order CT & Call Acute stroke team / Neurologist
- ECG for arrhythmias or acute MI ( Shouldn’t delay Urgent CT )
- General examination ( pupil & signs of meningeal irritation)
ACLS guidelines 2012
25. National Institutes of Health Stroke Scale
Used for :-
1- Thrombolytic therapy decision making
2- Prognosis of stroke
OXFORD neurology 2011
26. Level of conciousness LOC ** 3
LOC questions 2
LOC Commands 2
Best Gaze 2
Visual field 2
Facial palsy ** 3
Motor arm Rt. & lt. 4+4
Motor Leg Rt. & lt. 4+4
Limb Ataxia ** 2
Sensory 2
Intinction & Extinction ** 2
Language 3
Dysarthria 3
Total NIHSS 42
Total modifed NIHSS 31
29. ( Start within 1 hour from arrival to ED )
General Complication
Supportive Care Neurological Reversal of
detection &
monitoring coagulopathy
&Palliative care management
30. General supportive care & palliative care :
(A) (B) (C)
1-Oxygenation 1- Cardiac monitoring 1- Head positioning
2- Blood pressure 1st 24 hours ( Elevated at 20-30 ˚)
( See BP control ) 2- Swallowing assessment 2- Body positioning
3-Temperature (for nasogastric tube 3- DVT prophylaxis
( See Fever control ) application & oral drug * Elastic stocking
4-Blood glucose administration ) * Raise the legs
( Measure 1x 4 x 3 & 3-Drugs * UFLMWH 5000 1x2
control with Insulin ) * Anti-platelet After 48 hs.
5- Hydration *Anticoagulant 4-Bowel & bladder care
*NSAID 5-Skin Integrity
6- Lab *Lipid lowering drugs Inspect skin sacrum, heels,
*Vitamins elbows, shoulders for
4- Treatment of other pressure sores regularly
co-morbidities
31. ( Start within 1 hour from arrival to ED )
General Complication
Supportive Care Neurological Reversal of
detection &
monitoring coagulopathy
&Palliative care management
33. 1- Glasgow Coma Scale (GCS)
- Hourly for the first 24 hours
- 2-4 hourly for next 48 hours if stable
•A decrease in GCS of ≥ 2 points from baseline
Neurological decline ( urgent medical assessment is required )
* GCS ≤ 8 is predictive of impending cardiorespiratory arrest
OR NIHSS … score from 42
Score :-
>4 points increase in the score deterioration
OR Modified NIHSS … score from 31
Score :-
< 12 Good prognosis ≥12 Poor prognosis
35. ( Start within 1 hour from arrival to ED )
General Complication
Supportive Care Neurological Reversal of
detection &
monitoring coagulopathy
&Palliative care management
39. ( Start within 1 hour from arrival to ED )
General Complication
Supportive Care Neurological Reversal of
detection &
monitoring coagulopathy
&Palliative care management