Treatment Guidelines & Recommendations

NIH National Symposium Recommendations

Door-to-MD: < 10 minutes
Door-to-Neurologic Expertise: < 15 minutes
Door-to-CT scan: < 25 minutes
Door-to-CT Interpretation: < 45 minutes
Door-to-Drug: (80% compliance) < 60 minutes
Door-to-Admission: < 3 hours

Notes:

At this National Symposium, experts developed in-hospital time intervals to allow the stroke patient to be treated and evaluated in a expedient manner.  These recommendations include:

1. Emergency department arrival to initial physician evaluation:  10 minutes
2. Emergency department arrival to Stroke Team Notification:  15 minutes
3. Emergency department arrival to CT Scan initiation:  25 minutes
4. And they recommended that 80% of eligible stroke patients presenting to the emergency department should be treated with tPA within 60 minutes.

Stroke Chain of Survival & Recovery

Dispatch & Delivery: Transport & Management

• ABC’s
• Stroke recognition
• Establish time of onset / his
• Perform neurological evaluation
• Check glucose
• Early hospital notification
• Rapid transport

Cincinnati Pre-Hospital Stroke Scale

Facial Droop

• Normal: Both sides of face move equally
• Abnormal: One side of face does not move at all

Arm Drift

• Normal: Both arms move equally or not at all
• Abnormal: One arm drifts compared to the other

Speech

• Normal: Patient uses correct words without slurring
• Abnormal: Slurred or inappropriate words or mute

Neurologic Examination - NIH Stroke Scale

Preparation

Know your stroke team before you need them

• Check glucose
• Two large IV lines
• Oxygen as needed
• Cardiac monitor
• Continuous pulse-ox
• Stat non-contrast CT scan
• ECG
• CXR
• Get rt-PA
  > Prepare to mix
  > Have pharmacy alerted
• Discuss options with patient and family
• Contact  primary care provider

American Heart Association Recommendations

Oxygen

• Use to correct hypoxia
• Suggestion that supernormal levels may hurt
  > one year survival 69% 3L NC vs 73% control

Glucose

• Maintain euglycemia
• Treat glucose > 300 mg/dl with insulin

 Source: Rønning, Stroke 1999

True Time of Onset

How normal were they?

• What are they like at baseline?
• Who saw them last?
• Clearly no symptoms?

Times of reference

• Television
• The time the basketball game started

Stroke Risk Factors

Modifiable risk factors	Non-modifiable risk factors
High blood pressure Cigarette smoking Transient ischemic attacks Heart disease Diabetes mellitus Hypercoagulopathy Carotid stenosis Other	Age Gender Race Prior stroke Heredity

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This presentation was written by Dr. Edward C. Jauch of the Greater Cincinnati / Northern Kentucky Stroke Team at the University of Cincinnati College of Medicine.

Last Revised: February 26, 2008