What is the CDC protocol for acute stroke management?

CDC Stroke Protocol: A Comprehensive Guide to Acute Stroke Management

The CDC protocol for acute stroke management emphasizes rapid identification, assessment, and treatment of stroke patients through a coordinated system of care that prioritizes minimizing time to treatment and optimizing patient outcomes.

Prehospital Phase

Stroke Recognition and EMS Response

• Use validated stroke assessment tools that include FAST (Face, Arm, Speech, Time) components for initial screening 1
• Perform a second screening using a validated stroke severity assessment tool to identify potential endovascular thrombectomy (EVT) candidates 1
• Designate suspected stroke cases as high priority for evaluation, response, and transport 1
• Keep on-scene time as short as possible, with a target median time of 20 minutes or less 1

Initial EMS Assessment

• Assess and manage ABCs (airway, breathing, circulation) 1
• Initiate cardiac monitoring 1
• Provide supplemental oxygen to maintain O₂ saturation >94% 1, 2
• Establish IV access per local protocol 1
• Measure blood glucose and treat accordingly 1
• Document exact time of symptom onset or "last known well" time 1, 2
• Obtain family contact information, preferably a cell phone number 1

EMS Transport

• Transport patients rapidly to the closest appropriate stroke-capable hospital 1
• Provide prehospital notification to the receiving hospital about the incoming stroke patient to mobilize hospital resources 1
• Consider direct transport to comprehensive stroke centers for patients with suspected large vessel occlusion 1
• For rural areas, consider air medical transport when ground transport to the nearest stroke-capable hospital exceeds 1 hour 1

Emergency Department Phase

Initial ED Assessment

• Triage suspected stroke patients as Canadian Triage Acuity Scale (CTAS) Level 2 in most cases, or Level 1 for patients with compromised airway, breathing, or cardiovascular function 1
• Implement an organized protocol for emergency evaluation of suspected stroke patients 1
• Designate an acute stroke team including physicians, nurses, and laboratory/radiology personnel 1
• Perform standardized neurological assessment using validated tools (preferably NIHSS) 2

Diagnostic Evaluation

• Complete initial evaluation within 30 minutes of hospital arrival 2
• Obtain non-contrast CT head immediately to differentiate between ischemic and hemorrhagic stroke 1, 2
• Consider CT angiography of head and neck for patients with suspected large vessel occlusion 2
• Perform essential laboratory tests: complete blood count, electrolytes, glucose, coagulation studies, and renal function 2
• Obtain 12-lead ECG to evaluate for atrial fibrillation or acute MI 2

Acute Treatment

For Ischemic Stroke

• Administer intravenous alteplase (tPA) to eligible patients as soon as possible after hospital arrival, with a target door-to-needle time of less than 60 minutes in 90% of treated patients, and a median door-to-needle time of 30 minutes 1
• Dose: 0.9 mg/kg (maximum 90 mg), with 10% given as bolus over 1 minute and remaining 90% as infusion over 60 minutes 1
• Consider endovascular thrombectomy for patients with large vessel occlusion within appropriate time windows (up to 24 hours in selected patients) 1, 2

For Hemorrhagic Stroke

• Implement protocols for management of intracerebral hemorrhage, including blood pressure control 1
• Consider neurosurgical consultation for cerebellar hemorrhage or hydrocephalus 2

Inpatient Stroke Care

Acute Monitoring and Management

• Admit patients to a specialized stroke unit whenever possible 1
• Monitor vital signs, neurological status, and oxygen saturation regularly 1
• Implement dysphagia screening before oral intake 1
• Provide DVT prophylaxis with intermittent pneumatic compression devices 2
• Monitor temperature every 4 hours for the first 48 hours and treat fever >37.5°C 2
• Begin early mobilization within 24 hours if no contraindications exist 2

Comprehensive Assessment

• Complete standardized assessments of stroke-related impairments and functional status 1
• Assess for dysphagia, mood and cognition, mobility, temperature, nutrition, bowel and bladder function, and skin breakdown 1
• Conduct formal assessment for rehabilitation needs within 72 hours post-stroke 1

Common Pitfalls and How to Avoid Them

1. Delayed Recognition: Ensure public education about FAST and importance of calling 9-1-1 immediately 1
2. Prolonged On-Scene Time: Implement protocols to minimize on-scene assessment and expedite transport 1
3. Failure to Notify Receiving Hospital: Establish clear communication protocols between EMS and hospitals 1
4. Missing the Treatment Window: Establish systems to track door-to-needle times and implement quality improvement initiatives 1
5. Overlooking Stroke Mimics: Consider conditions such as seizures, migraines, or hypoglycemia that can present with focal deficits 2
6. Delaying Treatment for Laboratory Results: Only essential labs should be obtained before thrombolysis decision 2

Quality Improvement

• Establish door-to-needle time goals (primary goal: ≤60 minutes in ≥50% of patients; secondary goal: ≤45 minutes in ≥50% of patients) 1
• Implement multicomponent quality improvement initiatives, including ED education and multidisciplinary teams 1
• Monitor adherence to stroke protocols as part of ongoing quality improvement 1
• Document call times, response times, patient diagnoses, treatments, and outcomes 1

By following this comprehensive protocol, healthcare systems can optimize the care of acute stroke patients, minimize treatment delays, and improve patient outcomes in terms of mortality, morbidity, and quality of life.