Stroke?

Call EMS

EMT
Table 1 : Intial Evaluation on Evaluation
ABCs and O2
Arrival to ER
FAST
For all Patients
· History Stroke Center Emergency Ward
· Noncontrast brain CT or MRI
· Blood glucose ER Evaluation
· Serum eletrolytes/renal function ABCs, O2, BP
tests NIHSS score
· ECG See Table 1
· Markest of cardiac ischemia
· Full blood count, including
CT Scan
platelet count
Evidence Treatment of
· PT/INR aPTT Yes Hemorrhagic
of
· Oxygen saturation stroke
Hemorage
?
For selecte patient
· Hepatic funtion tests No
· Toxicology screen
· Blood alcohol level
· Pregnancy test
· Arterial blood gas tests (hypoxia Time since
suspected)
Symptom
· Chest radiography (lung disease
suspected)
onset
· Lumbar puncture (CT negative but
SAH suspected)
· EEG (seizures suspected) < 4.5 h 4.5 – 6 h >6h
From AHA Guidelines (Alberts, 2007)
Table 2 : Elegibility criteria for IV
rtPA
· Neurological deficit (moderate to
severe and non-isolated) without
spontaneous resolution. Eligible for Consider
Consider IA
· Symptoms not suggestive of IV rtPA ? No Mechanical
rtPA thrombectomy
subarachnoid hemorrahage. See Table 2
· No head rauma, prior stroke or
myocardial infarction in previous
3 month.
· No gastrointestinal or urinary tract Yes
hemorrhage in previous 14 days or
arterial puncture at
noncompressible site in previous 7
days (consider IA rtPA otherwise). IV rtPA
· No previous history of intracranial 0,9 mg/kg IA rtPA
hemorrhage.
· Normotrnssive (systolic <185
mmHg and diastolic <110 Thrombolysis
mmHg).
· No evidence of active bleeding or Discontinue infusion if patient develops severe
acute trauma (fracture) on headache, acute hypertension, nausea, vomiting and
examination. abtain emergency CT Scan.
· Not taking an oral anticoagulant Measure blood pressure and assess neurological
(if on anticoagulant INR >1.7 or if integrity every 15 minutes for first 2 hours than
on heparin in range). Platelet every 30 minutes for next 6 hours, then hourly until
count >100,000/Ul. 24 hours after treatment.
· No seizure with postictal rsidual
neurological impairments.
24 h since rtPA
· No evidence of multilobar
or
infarction (hypodensity > 1/3 of Not treated with
cerebral hemisphere) on CT. rtPA?
· Informed concent (patient or
family)
From AHA Guidelines (alberts, 2007)
Aspirin 325 mg
Or
Clopidogrel 300 mg
Continue long-term lower dose.

ECG, Ecocardiogram, Carotid Doppier, Blood Tests

Atherothrombotic
Cardioembolic ? Atheroembolic ? ?

Anticoagulation : Consider carotid

Manage HTN
Warfarin to INR Endarterectomy
2.0 – 3.0 Statins
And/or DM

Hospital Discharge

Risk Factor Reduction, Rehabilitiation and Follow-up