Harbor:Code stroke

Code Stroke

• 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)

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

1. Timeline Goals
   1. 10 minutes from arrival: ED MD evaluation
   2. 15 minutes from arrival: Neurology evaluation
   3. 20 minutes from arrival: CT head noncontrast obtained
   4. 45 minutes from arrival: CT head read by radiologist
   5. 60 minutes from arrival: TPA given for appropriate candidates
   6. 20 minutes from Neuro IR discussion: If have IR capacity at Harbor
   7. 120 minutes from arrival: LVO with no IR capacity at Harbor --> transfer to Comprehensive Stroke Center
   8. 45 minutes from Neuro IR activation: LVO with IR capacity at Harbor

1. CODE STROKE Procedure
   1. INCLUSION: age 18 years or older, new focal neurological deficit for <24 hours
   2. Rooming:
      1. From Triage: BBN and call charge RN to place in AED room immediately
      2. By Ambulance: room immediately
      3. **If no room available: RN to start IVs, obtain POC and labs; Initial ED MD evaluation then proceed directly to CT
   3. EVALUATION:
      1. Initial ED MD evaluation within 10 minutes
      2. Stabilize ABCs
      3. Last known well time (LKWT), patient’s age, and deficit (consider deferring complete NIHSS until after activated)
   4. ACTIVATE CODE STROKE: notify ED clerk to page with information above: “code stroke, name/MRN if available, location, age, M/F, deficits/NIHSS, LKWT”
      1. p0921: Batch page to Neurology (chief and attending, resident on call), lab, CT tech, radiology/IR, ED pharmacist, patient flow coordinator
      2. Neurology to bedside to evaluate patient w/in 15min
   5. Prior to CT, in AED room
      1. Complete ED MD evaluation/orders: Perform full NIHSS exam, and use order set “ED Suspected Stroke TPA Intervention Candidate Initial Orders”
      2. Automatic Imaging: CT head, CTA head and neck, CT cerebral perfusion study (can cancel later if a bleed on non-contrast CT)
      3. Labs/Studies
         1. Automatic: CBC, BMP, PT/PTT, POC glucose, POC chemistry for Cr
         2. Consider: EKG, troponin, T&S, CXR, Upreg, U/A, Utox (NOT in order set)
         3. RN: obtain POC glucose and chemistry (including Cr), place 2 large bore IVs, send blood work to lab
   6. Go to CT
      1. Always CT head non-contrast
      2. Complete NIHSS if not already done so
      3. 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]
   7. Back to AED room from CT
      1. RN to obtain weight from scale on bed, EKG/CXR and other studies as needed
      2. Further history as needed (including TPA contraindications https://www.wikem.org/wiki/Thrombolysis_in_Acute_Ischemic_Stroke_(tPA), await CT results
   8. CT Head result – Radiology calls Neurology Spectralink 23369 with read (back up ED clerk transferred to resident Spectralink)
      1. Intracranial hemorrhage
         1. Neurosurgery consult, if subarachnoid hemorrhage consider IR intervention; admit neurosurgery ICU
      2. No intracranial hemorrhage
         1. <4.5 hours from LKWT, 18+ years old = possible TPA Candidate
            1. TPA Candidate (no ICH, symptoms <4.5 hours). Use “ED Ischemic Stroke/TIA” order set
               1. Manage BP to goal SBP <180, DBP <105
                  1. IV labetalol, Nicardipine drip (in order set); if still uncontrolled, no TPA
               2. 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
                  1. 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
               3. Admit to neuro ICU
                  1. Q15 minutes neuro checks for first 2 hours
                  2. No anticoagulation/antiplatelets for 24 hours
                  3. No foley catheter or NG tube placement after TPA
                  4. Consider ordering MRI brain with DWI (non-contrast), MRA head and neck with and without contrast
         2. <6 24 hours from LKWT, NIHSS ≥ 6, CTA findings of large vessel obstruction = possible IR thrombectomy candidate
            1. 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
               1. Yes IR Capacity --> obtain CT cerebral perfusion --> IR thrombectomy; admit to neurology ICU
               2. 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)
         3. 4.5-24 hours from LKWT without suspicion for LVO = Not TPA or IR Candidate
            1. Not TPA Candidate, no evidence of LVO
               1. Give aspirin, permissive HTN (only treat for SBP >220, DBP >120), glucose control (60-180), early swallow evaluation by RN
               2. Admit to neurology on telemetry for further workup/management

See Also

• Harbor:Main