2 Critical Assessments and Actions

4 Immediate Assessmentby Stroke Team

5 Does CT ScanReveal

Hemorrhage?

6 Possible ischemic stroke

No Yes

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Adult Suspected Stroke

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ACLS

Immediate Patient Assessmentand Stabilization

3

1 Patient presents with signs and symptoms of possible stroke/CVAInitiate emergency response/EMS system

Assess and support ABCs, supply oxygen if neededInitiate pre-hospital stroke assessmentEstablish last normal (time of symptom onset)Alert and transport patient to appropriate stroke centerObtain blood glucose reading

Assess ABCs, vital signsInitiate appropriate oxygen therapy if hypoxicEstablish vascular access, send blood for appropriate lab testingAssess for and treat hypoglycemiaPerform stroke screening assessmentActivate stroke teamOrder stat CT scan or MRI of brainPerform 12-Lead ECG

Obtain/review patient historyEstablish last normal (time of symptom onset)Perform NIH Stroke Scale or Canadian Neurological Scale exam

Consider fibrinolytic therapyPerform fibrinolytic exclusions screeningRepeat neuro exam (are symptoms improving to normal?)

7 Consult neurosurgeon or neurologistImmediate transfer to appropriatefacility if neuroservices unavailable

8 Patient candidatefor

fibrinolytic therapy?No

Administer Aspirin

Review risk/benefits of fibrinolytic therapy with patient/familyIf acceptable, give rtPAWithhold anticoagulants or antiplatelet treatment for 24 hrs

Yes 9Admit to neuro unit or appropriate ICUIf neurological condition worsens, order stat repeat CT scan

11

10

12 Initiate post-rtPA stroke pathwayContinuous monitoring of BP per protocol and for any neurological changes/deteriorationEmergent admission to stroke/neuro unit or appropriate ICU

NINDS Time Goals(From ED Arrival)

10 min

25 min

45 min45 min

60 min

60 min

3 hrs

NINDS Time Goal(From Stroke Admission)

10 min

25 min

3 hrs