Stroke Management Protocol

Comprehensive stroke assessment and treatment guidelines

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Stroke Management & FAST Assessment

Time is Brain!

Every minute of untreated stroke destroys 1.9 million neurons

Goal: Door-to-needle time < 60 minutes for thrombolytics

FAST Assessment

F - Face

Ask patient to smile

  • Look for facial droop
  • One side of face doesn't move
  • Asymmetric smile

A - Arms

Ask patient to raise both arms

  • One arm drifts downward
  • Unable to hold arms up
  • Weakness on one side

S - Speech

Ask patient to repeat a phrase

  • Slurred speech
  • Difficulty finding words
  • Incomprehensible speech

T - Time

Time is critical

  • Note time of onset
  • Call emergency services
  • Transport to stroke center

NIH Stroke Scale (NIHSS)

Standardized assessment tool for stroke severity (0-42 points)

1. Level of Consciousness (0-3)

0 = Alert, 1 = Drowsy, 2 = Obtunded, 3 = Coma

2. Best Gaze (0-2)

0 = Normal, 1 = Partial gaze palsy, 2 = Forced deviation

3. Visual Fields (0-3)

0 = No visual loss, 1 = Partial hemianopia, 2 = Complete hemianopia, 3 = Bilateral hemianopia

4. Facial Palsy (0-3)

0 = Normal, 1 = Minor paralysis, 2 = Partial paralysis, 3 = Complete paralysis

5. Motor Arm (0-4 each arm)

0 = No drift, 1 = Drift, 2 = Some effort, 3 = No effort, 4 = No movement

6. Motor Leg (0-4 each leg)

0 = No drift, 1 = Drift, 2 = Some effort, 3 = No effort, 4 = No movement

7. Limb Ataxia (0-2)

0 = Absent, 1 = Present in one limb, 2 = Present in two limbs

8. Sensory (0-2)

0 = Normal, 1 = Mild to moderate, 2 = Severe to total

9. Best Language (0-3)

0 = No aphasia, 1 = Mild to moderate, 2 = Severe, 3 = Mute

10. Dysarthria (0-2)

0 = Normal, 1 = Mild to moderate, 2 = Severe

11. Extinction/Inattention (0-2)

0 = Normal, 1 = Mild, 2 = Severe

NIHSS Interpretation

  • 0-4: Minor stroke
  • 5-15: Moderate stroke
  • 16-20: Moderate to severe stroke
  • 21-42: Severe stroke

Treatment Algorithm

1

Immediate Assessment

FAST assessment, vital signs, NIHSS scoring

2

Time Window Determination

Establish last known well time (LKW)

3

Imaging

Non-contrast CT head to rule out hemorrhage

4

Thrombolytic Decision

tPA if within 4.5 hours and no contraindications

5

Endovascular Therapy

Consider thrombectomy if large vessel occlusion

tPA Contraindications

Absolute Contraindications

  • Intracranial hemorrhage on CT
  • Subarachnoid hemorrhage
  • Active internal bleeding
  • Recent surgery or trauma
  • Uncontrolled hypertension (>185/110)
  • Platelet count < 100,000
  • INR > 1.7 or PT > 15 seconds
  • Blood glucose < 50 mg/dL

Relative Contraindications

  • Minor stroke symptoms
  • Rapidly improving symptoms
  • Seizure at onset
  • Pregnancy
  • Recent myocardial infarction
  • Major surgery in last 14 days
  • Gastrointestinal bleeding in last 21 days
  • Arterial puncture in last 7 days

Post-Treatment Care

Monitoring

  • Vital signs every 15 minutes for 2 hours
  • Neurological assessment every hour
  • Blood pressure control
  • Watch for signs of hemorrhage

Secondary Prevention

  • Antiplatelet therapy (ASA + clopidogrel)
  • Statin therapy
  • Blood pressure management
  • Diabetes control
  • Smoking cessation

Key Points

  • Time is critical - every minute counts
  • FAST assessment for rapid recognition
  • NIHSS for standardized severity assessment
  • tPA within 4.5 hours if no contraindications
  • Consider thrombectomy for large vessel occlusion
  • Aggressive secondary prevention is essential