Harbor:Code stroke

Overview

• Activate for all focal neuro deficits with onset <8 hours
  • Pager 501-0771
• Order:
  • Accucheck, non-contrast CT brain

if no contraindication to contrast, CTA brain and neck with CTP brain

• • CBC, Chem 14, Troponin, INR, CXR, ECG
• Re-page if neuro resident not present in 15 minutes; stroke attending on amion
  • neuro resident to assist with tPA if patient is a candidate; should consent acceptance or declination of tPA
  • Interventional neuro for IA tPA or thrombectomy (501-5423)
  • Neuroradiology for reads: x2808 (days); 501-5814 (nights)
• From TRIAGE: Router RN concern for possible stroke --> direct to physician in Team Triage --> MSE provider places code stroke orders from "ED Initial Acute Stroke" order set and works with Charge RN to get patient to non-con CT, and ready a bed for patient as BBN. MSE provider gives signout to new team physician at CT

Phone Numbers

• Code Stroke Neurology Spectralink 23369
• Code Stroke Pager -0921

Timeline Goals

• 10 minutes from arrival: ED MD evaluation
• 15 minutes from arrival: Neurology evaluation
• 20 minutes from arrival: CT head noncontrast obtained
• 45 minutes from arrival: CT head read by radiologist
• 60 minutes from arrival: TPA given for appropriate candidates
• 20 minutes from Neuro IR discussion: If have IR capacity at Harbor
• 120 minutes from arrival: LVO with no IR capacity at Harbor --> transfer to Comprehensive Stroke Center
• 45 minutes from Neuro IR activation: LVO with IR capacity at Harbor

CODE STROKE Procedure

• INCLUSION: age 18 years or older, new focal neurological deficit for <24 hours
• Rooming:
  • From Triage: BBN and call charge RN to place in AED room immediately
  • By Ambulance: room immediately
  • **If no room available: RN to start IVs, obtain POC and labs; Initial ED MD evaluation then proceed directly to CT
• EVALUATION:
  • Initial ED MD evaluation within 10 minutes
  • Stabilize ABCs
  • Last known well time (LKWT), patient’s age, and deficit (consider deferring complete NIHSS until after activated)
• ACTIVATE CODE STROKE: notify ED clerk to page with information above: “code stroke, name/MRN if available, location, age, M/F, deficits/NIHSS, LKWT”
  • p0921: Batch page to Neurology (chief and attending, resident on call), lab, CT tech, radiology/IR, ED pharmacist, patient flow coordinator
  • Neurology to bedside to evaluate patient w/in 15min
• Prior to CT, in AED room
  • Complete ED MD evaluation/orders: Perform full NIHSS exam, and use order set “ED Initial Acute Stroke”
  • Automatic Imaging: CT head, CTA head and neck, CT cerebral perfusion study (can cancel later if a bleed on non-contrast CT)
  • Labs/Studies
    • Automatic: CBC, BMP, PT/PTT, POC glucose, POC chemistry for Cr
    • Consider: EKG, troponin, T&S, CXR, Upreg, U/A, Utox (NOT in order set)
    • RN: obtain POC glucose and chemistry (including Cr), place 2 large bore IVs, send blood work to lab
• Go to CT
  • Always CT head non-contrast
  • Complete NIHSS if not already done so
  • IF high risk of Large Vessel Occlusion with NIHSS ≥ 6 obtain CT Perfusion and CTA Head and Neck at the same time [regardless of if Cr on POC testing]
• Back to AED room from CT
  • RN to obtain weight from scale on bed, EKG/CXR and other studies as needed
  • Further history as needed (including TPA contraindications https://www.wikem.org/wiki/Thrombolysis_in_Acute_Ischemic_Stroke_(tPA), await CT results
• CT Head result – Radiology calls Neurology Spectralink 23369 with read (back up ED clerk transferred to resident Spectralink)
  • Intracranial hemorrhage
    • Neurosurgery consult, if subarachnoid hemorrhage consider IR intervention; admit neurosurgery ICU
  • No intracranial hemorrhage
    • <4.5 hours from LKWT, 18+ years old = possible TPA Candidate
      • TPA Candidate (no ICH, symptoms <4.5 hours). Use “ED Ischemic Stroke/TIA” order set
        • Manage BP to goal SBP <180, DBP <105
          • IV labetalol, Nicardipine drip (in order set); if still uncontrolled, no TPA
        • If not IR candidate as below and no contraindications to TPA Neurology consents patient, discuss with neurology ED team; Neurology orders TPA (alteplase), ED as backup if Neurology unable
          • TPA protocol per neurology/ED pharmacist (in order set): 0.9 mg/kg IV (max 90mg) total with 10% as bolus and remainder over 60 min
        • Admit to neuro ICU
          • Q15 minutes neuro checks for first 2 hours
          • No anticoagulation/antiplatelets for 24 hours
          • No foley catheter or NG tube placement after TPA
          • Consider ordering MRI brain with DWI (non-contrast), MRA head and neck with and without contrast
    • <6 24 hours from LKWT, NIHSS ≥ 6, CTA findings of large vessel obstruction = possible IR thrombectomy candidate
      • IR Thrombectomy candidate (<6 hours with LVO on CTA, up to 24 hours in some cases – DAWN trial); Neurology will activate stroke IR batch page
        • Yes IR Capacity --> obtain CT cerebral perfusion --> IR thrombectomy; admit to neurology ICU
        • No IR Capacity --> give TPA if candidate as above; Neurology coordinates transfer to Comprehensive Stroke Center (Long Beach 562-480-3487 or Little Co of Mary, Torrance 310-4-STROKE. Do not use MAC, the accepting comprehensive stroke center arranged their own transport)
    • 4.5-24 hours from LKWT without suspicion for LVO = Not TPA or IR Candidate
      • Not TPA Candidate, no evidence of LVO
        • Give aspirin, permissive HTN (only treat for SBP >220, DBP >120), glucose control (60-180), early swallow evaluation by RN
        • Admit to neurology on telemetry for further workup/management

See Also

• Harbor:Main