Harbor:Code stroke

Overview

File:ED Acute Stroke Flowchart 2.7.19.pdf

  • Activate for all focal neuro deficits with onset <24 hours
    • Charge RN/Clerk will batch page to Lead Pager 501-0921 with whatever clinical info is available and location of patient and overhead page.
  • From TRIAGE: Router RN concern for possible stroke --> direct to provider 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
  • Orders via "ED Initial Acute Stroke" Orderset:
    • POC gluc, chem (for Cr), and INR, non-contrast CT brain. If no contraindication to contrast, CTA head and neck with CTP brain
    • CBC, Chem 14, Troponin, INR, CXR, ECG
  • GET PATIENT TO CT NONCONTRAST ASAP! Labs, IV, NIHSS can be completed in CT if not already done.
  • Call Neuro resident Spectralink 23369 if not present in 15 minutes; stroke attending on amion - ED provider gives report to Neuro resident
    • Radiology calls Neuro resident for CT reads. To reach Neurorads: x2808 (days); US Radiology for night/weekends/holidays 1-866-448-7762.
    • Neuro resident takes lead on consent and ordering tPA if patient is a candidate. If tPA being given, should be communicated to ED team.
    • Neuro will contact Interventional Neuro for IA tPA or thrombectomy (p501-5423). If our IR does not have capacity, then Neuro resident will initiate transfer to Comprehensive Stroke Center.
      • Long Beach 562-480-3487
      • Little Co of Mary, Torrance 310-4-STROKE

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, MSE provider places orders, get patient to CT ASAP. Call charge RN to ready AED room immediately
    • By Ambulance: room immediately
    • **If no room available: Initial ED MD evaluation then proceed directly to CT
    • RN to start IVs, obtain POC and labs; can be done in CT scanner
  • 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 if available: “code stroke, name/MRN if available, location, age, M/F, symptoms/deficits, 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: 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], discuss desired imaging with Neurology.
  • Back to AED room from CT
  • 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

References