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.

Toolkit Quick Links:

  1.    Interventions Upon Arrival to ER
  2.    Acute Ischemic Stroke
         2.1.    Guidelines for the Early Management of Adult with Ischemic Stroke
  3.    Hemorrhagic Stroke
         3.1.    Standardized Stroke Performance Measures
  4.    Resources
         4.1.    Professional Stroke Resources for Health Professionals
         4.2.    Scientific Statements
         4.3.    Provider References
  5.    Websites
  6.    Healthcare Professional Organizations
  7.    Consumer Resources


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
  2.    Immediately triage and contact physician or stroke team
  3.    Stabilize patient—airway, vital signs, continuous EKG monitor, pulse oximetry
  4.    NIH stroke scale
  5.    Bed rest
  6.    Frequent re-assessments
  7.    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

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Acute 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.

Guidelines for the Early Management of Adult with Ischemic Stroke

•    Eligible for Alteplase:
     1.    At least 18 yrs. old
     2.    Ischemic Stroke (no hemorrhage seen on CT scan)
     3.    No Contraindication (refer to the Guidelines for Ishemic 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 than180/105
     6.    No nasogastric tube placement for 24 hrs. 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)

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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
     •    “Spot a stroke: FAST”

•    Centers for Disease Control and Prevention
     •    “CDC State Heart Disease and Stroke Prevention Programs: Paul Coverdell National Acute Stroke Registry”

•    The Joint Commission

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Professional Stroke Resources for Health Professionals
     •    American Stroke Association - Stroke Journal - "Forecasting the future of stroke in the United States: A policy
          statement from the American Heart Association and American Stroke Association (Ovbiagele et al., 2013)."

     •    Get With The Guidelines: Stroke - quality improvement program for acute stroke treatment and ischemic stroke
          prevention (American Stroke Association)

     •    Improving the Management of TIA to Prevent Stroke - Archived Audio Webcast (National Stroke Association)

     •    JCAHO Primary Stroke Center Certification Program - first nationwide stroke center certification program for
          hospitals (American Stroke Association and Joint Commission on Accreditation of Healthcare Organization)

     •    Journal of Stroke and Cerebrovascular Diseases -multidisciplinary, bi-monthly clinical journal devoted to all
          aspects of stroke (National Stroke Association)

     •    National Stroke Association - Post Stroke checklist (PSC): Improving life after stroke

     •    NIH Stroke Scale Training Online - National Institutes of Health free online stroke scale for continuing education
          credit (American Stroke Association)

     •    Stroke: Clinical Updates - bi-monthly newsletter for stroke clinicians and is a benefit of National Stroke
          Association's professional membership program (National Stroke Association)

     •    Stroke Connection Magazine - 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 (American Stroke Association)

     •    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 (American Stroke Association)

     •    Stroke Rapid Response - train-the-trainer program to be used by EMS educators to train EMS professionals to
          accurately identify and expedite delivery of stroke patients (National Stroke Association)

     •    Stroke Smart Magazine - bi-monthly publication for stroke survivors and their families, caregivers and stroke
          care professionals (National Stroke Association)

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Scientific Statements

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

Provider References
     •    "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, 2004.

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Website Resources

•    American Heart Association
•    Heart Disease and Stroke Statistics – 2012 Update
•    American Stroke Association
•    Brain Attack Coalition
•    Healthy People 2020
•    H.K. Goddess Fund - Stroke Research in Women
•    Internet Stroke Center - Washington University
•    Mayo Clinic - Stroke
•    Medline Plus - Stroke
•    National Heart, Lung & Blood Institute
•    National Institute of Neurological Disorders and Stroke
•    National Stroke Association
•    Stanford Hospital & Clinics - Stanford University Medical Center
•    Stroke Center at The University Hospital
•    University of Virginia Health System
•    Educational Resource on Stroke and TIA
•    Centers for Disease Control and Prevention

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Healthcare Professional Organizations

•    American Academy of Neurology
•    American Academy of Physical Medicine and Rehabilitation
•    American Academy of Physician Assistants
•    American Association of Neurological Surgeons
•    American Society of Neuroimaging
•    The Society for Vascular Surgery
•    The Joint Commission
•    Society of NeuroInterventional Surgery

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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: August 23, 2013