Iowa Healthcare Collaborative

100 East Grand, Suite 360
Des Moines, IA 50309
(515) 283-9330

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Stroke is a leading cause of disability and death in the United States.  It is the fourth leading cause of death for Iowans.  Rapid evaluation and treatment by healthcare providers improve outcomes for stroke survivors.  EMS and hospitals with protocols for stroke are better equipped to respond to someone with stroke symptoms.  This toolkit provides guidance and resources for implementing or revising stroke protocols.

Interventions upon arrival to ER
– Ischemic or Hemorrhagic Stroke

  1. Recognize stroke signs/symptoms

            •    Sudden onset of numbness or weakness on one side of body
            •    Sudden onset of confusion, trouble speaking or understanding
            •    Sudden onset of vision changes
            •    Sudden onset of trouble walking, dizziness, loss of balance or coordination
            •    Sudden onset of severe headache with no known cause

  1. Immediately triage and contact physician or stroke team
  2. Stabilize patient—airway, vital signs, continuous EKG monitor, pulse oximetry
  3. NIH stroke scale
  4. Bed rest
  5. Frequent re-assessments
  6. NPO, until patient passes swallow screen or speech therapy evaluation

*The following tests should be completed and the results reviewed within 45 minutes of patient arrival to the ER:

  1. Non-contrast head CT
  2. 12-lead EKG
  3. Labs:  glucose (may done as finger stick upon arrival), CBC, coagulation studies (PT, PTT, INR), Na, K, Cl, CO2, BUN, creatinine, troponin

Guidelines for the Early Management of Adult with Ischemic Stroke

The American Stroke Association (ASA)
This website provides links to evidence-based stroke guidelines and patient education resources.  These guidelines are evidence-based articles that support and drive protocol development for stroke care.  The information in this toolkit highlights the primary principles of stroke care from these articles.

Eligible for Alteplase:

  1. At least 18 years old
  2. Ischemic Stroke (no hemorrhage seen on CT scan)
  3. No Contraindication (refer to the Guidelines for Ischemic Stroke on the ASA website)

Alteplase treatment:

  1. Dosage: 0.9 mg/kg, maximum dose is 90 mg
  2. 10% of total dose is given IV push over one minute as a bolus dose, and remaining 90% is infused over one hour
  3. Vital signs and neuro checks q15 minutes x 2 hours, q 30 minutes x 6 hours, then q 60 minutes x 16 hours
  4. Place 2 peripheral IV lines before giving Alteplase (however don’t delay treatment placing second IV)
  5. Maintain BP less than 180/105
  6. No nasogastric tube placement for 24 hours after the infusion
  7. No indwelling urinary catheter for 30 minutes after the infusion
  8. Consider immediate transfer to a stroke center for other therapies if no improvement

Not eligible for Alteplase:

  1. Consider transport to stroke center for other therapies
  2. Monitor vital signs and neuro checks
  3. Higher BP may be indicated
  4. Admit patient for complete stroke workup (address risk factors)

Hemorrhagic Stroke

Guidelines for the Management of Intracerebral Hemorrhage (ICH) and Guidelines for the Management of Aneurysmal Subarachnoid Hemorrhage (SAH)
•    ICH or SAH on CT scan
•    Immediate neurology/neurosurgery consult
•    Consider transfer after patient is stabilized
•    Monitor blood pressure and treat based on neurology/neurosurgery consult

Standardized Stroke Performance Measures
American Stroke Association
This website contains information on how to spot a stroke including provider toolkits and printable resources.

Centers for Disease Control and Prevention - Paul Coverdell National Acute Stroke Registry
The CDC provides information on the Paul Coverdell National Acute Stroke Registry on this website. For more information on the Iowa Coverdell Stroke Project click this link.

Professional Stroke Resources for Health Professionals

Forecasting the Future of Stroke in the United States: A Policy Statement
The American Heart Association and American Stroke Association created this policy statement to inform healthcare providers and healthcare facilities about the future of stroke in the United States.

Get With The Guidelines: Stroke
The American Stroke Association created this website to assist quality improvement programs for acute stroke treatment and ischemic stroke prevention.

Improving the Management of TIA to Prevent Stroke
This is an archived audio webcast from the National Stroke Association that reviews stroke risk reduction of TIA.

JCAHO Primary Stroke Center Certification Program
The American Stroke Association and Joint Commission on Accreditation of Healthcare Organization created this website to provide information on advanced certification for primary stroke centers.

Journal of Stroke and Cerebrovascular Diseases
This is a multidisciplinary, bi-monthly clinical journal devoted to all aspects of stroke from the National Stroke Association.

Post Stroke Checklist (PSC)

This is a checklist from the National Stroke Association.  This two-page checklist reviews information about activities of daily living, mobility, and other factors in life after stroke.

NIH Stroke Scale Training Online
The National Institutes of Health provides this free online stroke scale for continuing education credit.  The program can be accessed from mobile devices and computers.

Stroke Connection Magazine
The stroke connection magazine is a bi-monthly publication for in-depth information on conditions such as aphasia, central pain, high blood pressure and depression, to tips for daily living from healthcare professionals and other stroke survivors.

Stroke Council
The mission of the Stroke Council is to foster excellence in stroke research and education and to achieve the objectives of the American Stroke Association in stroke research, treatment and prevention.

Stroke Rapid Response

This National Stroke Association website describes a train-the-trainer program to be used by EMS educators to train EMS professionals to accurately identify and expedite delivery of stroke patients.

Stroke Smart Magazine
This is a bi-monthly publication from the National Stroke Association for stroke survivors and their families, caregivers and stroke care professionals.

Scientific Statements

American Heart Association
(2005) Scientific Statement: Recommendations for the Establishment of Stroke Systems of Care. Dallas, TX.

Atlas of Stroke Mortality: Racial, Ethnic, and Geographic Disparities in the United States
Casper, M.L., Barnett, E., Williams, G.I., Halverson, J.A., Braham, V.A. & Greenlund, K.J.  Atlas of Stroke Mortality: Racial, Ethnic & Geographic Disparities in the United States. Atlanta, GA: Department of Health and Human Services, Centers for Disease Control and Prevention; January 2003. 

Centers for Disease Control and Prevention
Heart-healthy and Stroke-free States: A Communication Guide for Policy and Environmental Change. Atlanta, GA: U.S Department of Health and Human Services, Centers for Disease Control and Prevention.

Website Resources

  1. American Heart Association
  2. American Stroke Association
  3. Brain Attack Coalition
  4. Educational Resource on Stroke and TIA
  5. Healthy People 2020
  6. Heart Disease and Stroke Statistics
  7. H.K. Goddess Fund
  8. Internet Stroke Center
  9. Mayo Clinic
  10. Medline Plus
  11. National Heart, Lung & Blood Institute
  12. National Institute of Neurological Disorders and Stroke
  13. National Stroke Association
  14. Stanford Hospital & Clinics
  15. Stroke Center at The University Hospital
  16. University of Virginia Health System

Healthcare Professional Organizations

  1. American Academy of Neurology
  2. American Academy of Physical Medicine and Rehabilitation
  3. American Academy of Physician Assistants
  4. American Association of Neurological Surgeons
  5. American Society of Neuroimaging
  6. The Society for Vascular Surgery
  7. The Joint Commission
  8. Society of NeuroInterventional Surgery


Consumer Resources

  1. A Stroke In Time, Frances Nemtin
  2. After a Stroke: A Support Book for Patients, Caregivers, Families and Friends, Carol Burton, Geoffery A. Donnan
  3. After a Stroke: Enhancing the Quality of Life, Wallace Pife
  4. After the Stroke: Coping with America’s Third Leading Cause of Death, Evelyn P.
  5. Body Awareness As Healing Therapy: The Case of Nora, Moshe Feldenkrais
  6. Cracking Up: Nice Day for Brain Hemorrhage, Peter Swet, Florence Weiner, Matthew H.M. Lee & Harriet Bell
  7. Brain Attack: Danger, Chaos, Opportunity EmpPerez, P. Johnson,How to Conquer the World with One Hand...and an Attitude, Stephanie Minsch, Paul E. Berger
  8. Living With Stroke: A Guide for Families Help and New Hope for All Those Touched by Stroke, Richard C. Senelick, MD; Peter W. Rossi, MD & Karla Doughtery
  9. Living With Stroke: A Guide for Families, Richard C. Senelick, Peter W. Rossi & Karla Doughtery
  10. Look Up for Yes, Julia Tavalaro, Richard Tayson,
  11. My Stroke Insight: A Brain Scientist’s Personal Journey, Jill Bolte Taylor
  12. My Year Off: Recovering Life After a Stroke, Robert McCrum
  13. Oh My Gosh! I Had a Stroke! Booklet for Stroke Survivors, JackQue McKinney Day
  14. Oh My Gosh! I Had a Stroke! Booklet for the Families, Friends and Caregivers of Stroke Survivors, JackQue McKinney Day
  15. One-Handed in a Two-Handed World, Tommye K. Mayer
  16. Recovering At Home After a Stroke, a Practical Guide for You & Your Family, Florence Weiner, Matthew H.M. Lee & Harriet Bell
  17. Return to Ithaca, Barbara Newborn
  18. Slow Dance: Story of Stroke, Love, and Disability, Bonnie Sherr Klein, Persimmon Blackbridge
  19. Speechless: My Recovery from Stroke, Jennifer Gordon
  20. The Best of Stroke Connection Magazine: A collection of personal stories by stroke survivors and care givers, complied by American Stroke Association
  21. The Diving Bell and the Butterfly, Jean Dominique Bauby
  22. The Enabling Garden: A Guide to Lifelong Gardening, Gener Rothert, Laurie Noffs (Illustrator)
  23. The Family Guide to Surviving Stroke and Communication Disorders, Dennis Tanner
  24. The Shattered Mind: The Prism After Brain Damage, Howard Gardner
  25. The Stroke Recovery Book, Kip Burkman
  26. When Someone You Loves Has a Stroke, Marilynn Larkin, Lynn Sonberg Gonzalez, R.G., Hirsch, J.A. Koroshetz, W.J. & Schaefer, L.P.
  27. Stein, J. Stroke and New Family: A New Guide. Cambridge, Massachucetts; London, England.
  28. Wall, B. The Long Gray Tunnel: A True Story of Crisis, Spirit and Recovery. Austin, Texas

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Created: November 11, 2009
Updated: May 19, 2014