What should I do in a code stroke (cerebrovascular accident)?

From the Guidelines

In a code stroke, you should immediately activate the stroke team and assess the patient's airway, breathing, and circulation, followed by a rapid neurological examination using the NIH Stroke Scale, as recommended by the most recent guidelines 1. The initial steps in managing a code stroke involve quick activation of the stroke team and assessment of the patient's vital functions. This is crucial for ensuring that the patient receives timely and appropriate care.

• The patient's airway, breathing, and circulation (ABCs) should be evaluated and managed as necessary.
• A rapid neurological examination should be performed using a validated stroke assessment tool such as the NIH Stroke Scale.
• The time of symptom onset should be determined, as this is critical for deciding on the appropriateness of thrombolytic therapy.
• The patient should have IV access established, and stat laboratory tests, including complete blood count, coagulation studies, and blood glucose, should be ordered.
• An immediate non-contrast CT scan of the brain should be arranged to differentiate between ischemic and hemorrhagic stroke, as recommended by recent guidelines 1.
• If the patient has an ischemic stroke and is within the appropriate time window (typically 4.5 hours from symptom onset), intravenous thrombolysis with alteplase at 0.9 mg/kg (maximum 90 mg) should be administered, with 10% given as a bolus and the remainder over 60 minutes, as supported by the highest quality evidence 1.
• For patients with large vessel occlusion, preparation for possible endovascular thrombectomy should be made.
• Throughout this process, vital signs should be monitored closely, blood pressure should be maintained below 185/110 mmHg for thrombolysis candidates, the patient should be kept NPO, and all findings and interventions should be documented. The importance of rapid assessment and treatment in acute ischemic stroke cannot be overstated, as approximately 1.9 million neurons die each minute, making "time is brain" a critical concept in stroke care 1.

From the Research

Code Stroke Protocol

In the event of a code stroke, the following steps should be taken:

• Activate the code stroke protocol to ensure timely administration of intravenous tissue plasminogen activator (IV tPA) 2, 3
• Evaluate the patient for administration of IV tPA, and consider alternative treatment options such as intra-arterial recombinant tissue plasminogen activator, mechanical thrombectomy, or clot retrieval 4, 5, 6
• Administer intravenous hydration with normal saline, correct hypoxia with supplemental oxygen, and treat hyperglycemia and fever aggressively 4

Time-Sensitive Interventions

Time-sensitive interventions are critical in code stroke management:

• Door-to-needle time (DNT) should be less than 60 minutes, with a goal of achieving DNT within 20,30,45, or 60 minutes 2, 3
• Implementation of a code stroke protocol can significantly decrease DNT and increase the number of patients treated with IV tPA within the recommended time frame 2, 3

Additional Considerations

Additional considerations in code stroke management include:

• Blood pressure management should be individualized based on stroke pathophysiology and specific treatment plan 4
• Evaluation of stroke etiology should be undertaken to guide secondary stroke prevention efforts 4
• Identification of large vessel occlusions (LVOs) and referral to facilities capable of delivering urgent thrombectomy is crucial in acute stroke care 6