Adult Suspected Stroke Algorithm

Step 1:
Identify signs and symptoms of possible stroke
Activate Emergency Response

Step 2:
Critical EMS assessments and actions
    • Support ABCs; give oxygen if needed
    • Perform prehospital stroke assessment (Table 1)
    • Establish time of symptom onset (last normal)
    • Triage to stroke center
    • Alert hospital
    • Check glucose if possible

Step 3:
Immediate general assessment and stabilization
    • Assess ABCs, vital signs
    • Provide oxygen if hypoxemic
    • Obtain IV access and perform laboratory assessments
    • Check glucose; treat if indicated
    • Perform neurologic screening assessment
    • Activate stroke team
    • Order emergent CT scan or MRI of brain
    • Obtain 12-lead ECG

Step 4:
Immediate neurologic assessment by stroke team or designee
    • Review patient history
    • Establish time of symptom onset or last known normal
    • Perform neurologic examination (NIH Stroke Scale or Canadian Neurological Scale)

Step 5:
Does CT scan show hemorrhage?

                No Hemorrhage        Hemorrhage


Step 6:
Probable acute ischemic stroke; consider fibrinolytic therapy
    • Check for fibrinolytic exclusions (Tables 4 and 5)
    • Repeat neurologic exam: are deficits rapidly improving to normal?

Step 7:
Consult neurologist or neurosurgeon; consider transfer if not available

Step 8:
Patient remains candidate for fibrinolytic therapy?

                    Not a Candidate        Candidate

Step 9:
Administer aspirin

Step 10:
Review risks/benefits with patient and family. If acceptable:
    • Give rtPA
    • No anticoagulants or antiplatelet treatment for 24 hours

Step 11:
    • Begin stroke or hemorrhage pathway
    • Admit to stroke unit or intensive care unit

Step 12:
    • Begin post-rtPA stroke pathway
    • Aggressively monitor:
        o BP per protocol (Tables 2 and 3)
        o For neurologic deterioration
    • Emergent admission to stroke unit or intensive care unit

NINDS TIME GOALS

ED Arrival
10 min
ED Arrival
25 min
ED Arrival
45 min
ED Arrival
60 min
Stroke Admission
3 hours

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