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.

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 ?

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

6. Chain of Survival

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

11. ACLS guidelines 2012

12. Time Is brain
ACLS guidelines 2012

13. Our Timeline
ACLS guidelines 2012

14. In 10 minutes
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

19. ** Pupil examination ( Light reflex )
•Pin point / sluggish reaction 
Pontine hemorrhage .. ( Do urgent CT )
•Intial dilatation + loss of light reactivity 
Trans-tentorial herniation
** Signs of meningeal irritation
1. Exam: Nuchal Rigidity
2. Exam: Spinal Rigidity
3. Exam: Kernig's Signs
4. Exam: Brudzinski's Sign

20. In 25 minutes
* Rapid History Taking
* Determine Time Zero
* Neurological Examination NIHSS
* Do the head CT
ACLS guidelines 2012

21. Don’t Give
Aspirin / Heparin / Iv thrombolytic
therapy
Unless after reading CT
ACLS guidelines 2012

22. In 45 minutes
•Read CT
•Take decision according to  CT result & Time Zero
ACLS guidelines 2012

23. Decision Taking according to CT reading
Check for Hemorrhage
Yes No
Call a Neurologist Recanalisation Candidate ?
Stable Patient ? - Check exclusion criteria
- Rapid neurological reassessment
Yes No Still candidate ?
No Yes
R/ Asprin ( 1x2 ) up to 325 mg/d
Ward admission
Call Acute Stroke team
ACLS guidelines 2012
ICU admission Thrombolytic therapy

24. 1 - AVPU score
2 - Glascow ( Total score = ... /15 )
3 - NIHSS ( Total score = ... /42 )
- Modified NIHSS ( Total score = ... /31 )
OXFORD neurology 2011

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

28. Penumbra :- Area at risk

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

32. 1- Continuous scoring
2- Increased intracranial tension ??

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

34. 2- Increased intracranial pressure
* Signs:-
- Reduced consciousness
- Headache , nausea , projectile vomiting
- Visual disturbance
- Seizures
-Sudden increase in blood pressure
* Treatment :-
- Exclude ICH by CT
- R/ Mannitol (0.25-1 gm/kg)
- Lumber puncture for decompression
- Hemi-Craniotomy

35. ( Start within 1 hour from arrival to ED )
General Complication
Supportive Care Neurological Reversal of
detection &
monitoring coagulopathy
&Palliative care management

36. 1- Correct coagulopathy ( guided by PT , PTT , INR )
Treatment :- Platelets & Cryo precipitate
2- Recanalisation therapy

39. ( Start within 1 hour from arrival to ED )
General Complication
Supportive Care Neurological Reversal of
detection &
monitoring coagulopathy
&Palliative care management

40. 1- Seizures
2- Increased intracranial pressure
3- Complication of r-TPA & management :
Intracranial hemorrhage
Angiodema
4- Venous thrombo-embolism ( ttt : IVC filter )

41. 1. Ophthalmoscope
2. Thrombolytic therapy
3. Stroke suspecting culture ( 3 orders )
4. NIHSS quick application in 25 mins from arrival
5. Lab Facility in 10 mins

42. - ACLS 2012 guidelines
- www.emedicine.com
- Oxford press ( Neurology emergencies ) text book
- http://www.fpnotebook.com/neuro/exam
- www.pubmed.com
- Egyptian ministry of health protocols 2012