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Stroke is an emergency. Every minute counts.

  • Neurologic damage is more likely to occur the longer a stroke goes untreated1
  • Rapid response and intervention is crucial to the treatment of stroke2
  • Rapid response begins with the early recognition of signs and symptoms and rapid transport to a stroke-capable facility, and it continues in the emergency room with proper assessment and coordination3

Prehospital

Guidelines for EMS management of patients with suspected stroke4

On sceneIn transit
Manage ABCs: airway, breathing, circulation — give oxygen, if needed Rapid transport to closest facility capable of treating stroke* Check and record blood glucose to assess for hypoglycemia
Perform prehospital stroke assessment Bring witness, family member, or caregiver, if possible Check and record blood pressure
Establish and record exact time when patient last seen normal Alert receiving emergency department Establish cardiac monitoring and IV access, if possible
  • *
  • EMS bypass of hospital without stroke resources supported by guidelines if a stroke center is within reasonable transport range.3

ACT F.A.S.T.!

Prehospital stroke screening tools5

  • These screening tools are designed to help EMS personel quickly assess and identify stroke patients
F.A.S.T. prehospital stroke screening tool

EMS fact sheetLos Angeles Prehospital Stroke Screen (LAPSS)6

DOWNLOAD OR ORDER EMS FACTSHEET


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In-hospital

The "Golden Hour" for evaluating and treating acute stroke7

NIH-recommneded emergency department response times7

door-to-needle less than or equal to 60 min

The National Institutes of Health (NIH) recommends time intervals that enable eligible stroke patients presenting to the emergency department to receive Activase (t-PA) within 60 minutes.

American Heart Association/American Stroke Association (AHA/ASA) guidelines for the diagnosis of stroke3

AHA/ASA 2007 guidelines: immediate diagnostic tests for all patients with suspected ischemic stroke

  • Noncontrast brain CT or brain MRI
  • Blood glucose
  • Serum electrolytes/renal function tests
  • Electrocardiogram (ECG)
  • Markers of cardiac ischemia
  • Complete blood count (CBC), including platelet count†
  • Prothrombin time (PT)/international normalized ratio (INR)†
  • Activated partial thromboplastin time (aPTT) †
  • Oxygen saturation
  • †
  • Although it is desirable to know the results of these tests before giving t-PA, thrombolytic therapy should not be delayed while awaiting results unless: (1) there is clinical suspicion of a bleeding abnormality or thrombocytopenia; (2) the patient has received heparin or warfarin; or (3) use of anticoagulants is unknown.

AHA/ASA 2007 guidelines: immediate diagnostic tests for selected patients with suspected ischemic stroke

  • Liver function tests (LFTs)
  • Toxicology screen
  • Blood alcohol level
  • Pregnancy test
  • Arterial blood gas tests (if hypoxia suspected)
  • Chest X-ray (if lung disease suspected)
  • Lumbar puncture (if subarachnoid hemorrhage suspected and CT scan negative for blood)
  • Electroencephalogram (if seizures suspected)
DOWNLOAD AHA/ASA GUIDELINES

Activase (t-PA): contraindications

  • Evidence of intracranial hemorrhage on pretreatment evaluation
  • Suspicion of subarachnoid hemorrhage on pretreatment evaluation
  • Intracranial or intraspinal surgery, serious head trauma, or stroke within the previous 3 months
  • History of intracranial hemorrhage
  • Uncontrolled hypertension at time of treatment (eg, >185 mm Hg systolic or >110 mm Hg diastolic)
  • Seizure at the onset of stroke
  • Active internal bleeding
  • Intracranial neoplasm, arteriovenous malformation, or aneurysm
  • Known bleeding diathesis including but not limited to:
    • – Current use of oral anticoagulants (eg, warfarin sodium) or with an international normalized ratio (INR) >1.7 or a prothrombin time (PT) > 15 seconds
    • – Administration of heparin within 48 hours preceding the onset of stroke and an elevated activated partial thromboplastin time (aPTT) at presentation
    • – Platelet count <100,000/mm3

Assessments

Indication
Activase (Alteplase) is indicated for the management of acute ischemic stroke in adults for improving neurological recovery and reducing the incidence of disability. Treatment should only be initiated within 3 hours after the onset of stroke symptoms, and after exclusion of intracranial hemorrhage by a cranial computerized tomography (CT) scan or other diagnostic imaging method sensitive for the presence of hemorrhage (see CONTRAINDICATIONS).

Safety Information
Activase therapy in patients with AIS is contraindicated in certain situations (eg, suspicion of subarachnoid hemorrhage on pretreatment evaluation, recent (within 3 months) intracranial or intraspinal surgery, history of intracranial hemorrhage, uncontrolled hypertension at time of treatment, active internal bleeding, known bleeding diathesis (eg, current use of oral anticoagulants, administration of heparin within 48 hours of onset of stroke, platelet count <100,000) (see CONTRAINDICATIONS for full list).

The most common complication during Activase therapy is bleeding. Should serious bleeding in a critical location (intracranial, gastrointestinal, retroperitoneal, pericardial) occur, Activase therapy should be discontinued immediately. Death and permanent disability are not uncommonly reported in patients who have experienced stroke (including intracranial bleeding) and other serious bleeding episodes.

The risks of Activase therapy may be increased and should be weighed against the anticipated benefits in certain conditions. [See WARNINGS in full prescribing information].

  • Patients with severe neurological deficit (eg, NIHSS >22) at presentation. There is an increased risk of intracranial hemorrhage in these patients.
  • Patients with major early infarct signs on a computerized cranial tomography (CT) scan (eg, substantial edema, mass effect, or midline shift).

Treatment of patients with minor neurological deficit or with rapidly improving symptoms is not recommended.

Orolingual angioedema has been observed in postmarketing experience in patients treated with Activase for AIS. Patients should be monitored during and for several hours after infusion for signs of orolingual angioedema.

Please click here for full prescribing information.
References:
1.
Saver JL. Time is brain — quantified. Stroke. 2006;37:263-266.
2.
National Institute of Neurological Disorders and Stroke (NINDS). Know stroke. Know the signs. Act in time. NINDS Web site. http://www.ninds.nih.gov/disorders/stroke/knowstroke.htm. Updated March 6, 2009. Accessed March 20, 2009.
3.
Adams HP Jr, Del Zoppo G, Alberts MJ, et al. Guidelines for the early management of adults with ischemic stroke. Stroke. 2007;38:1655-1711.
4.
American Heart Association. 2005 American Heart Association guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Part 9: adult stroke. Circulation. 2005;112:IV-111-IV-120.
5.
Kothari RU, Pancioli A, Liu T, Brott T, Broderick J. Cincinnati Prehospital Stroke Scale: reproducibility and validity. Ann Emerg Med. 1999;33:373-378.
6.
Kidwell CS, Starkman S, Eckstein M, Weems K, Saver JL. Identifying stroke in the field: prospective validation of the Los Angeles Prehospital Stroke Screen (LAPSS). Stroke. 2000;31:71-76.
7.
Jauch EC. The "golden hour" of acute ischemic stroke: treatment guidelines & recommendations. The Internet Stroke Center Web site. http://www.strokecenter.org/education/jauch/02.htm. Updated February 26, 2008. Accessed March 25, 2009.