What is the recommended stroke protocol?

Stroke Protocol: A Comprehensive Approach to Acute Stroke Management

The recommended stroke protocol involves rapid identification of stroke symptoms using validated tools like FAST (Face, Arm, Speech, Time), immediate activation of emergency medical services, transport to a stroke-capable center, and time-sensitive evaluation and treatment to minimize brain damage and improve outcomes. 1

Public Recognition and EMS Response

• Public education programs should emphasize recognition of stroke signs and symptoms using the FAST method (Face drooping, Arm weakness, Speech difficulties, Time to call emergency services) 2
• Additional stroke warning signs include sudden confusion, vision problems, trouble walking, dizziness, and severe headache with no known cause 2
• Patients showing any FAST signs should undergo a second screening using a validated stroke severity assessment tool to identify potential endovascular treatment candidates 1
• Emergency medical services should be contacted immediately when stroke is suspected, as prompt treatment is critical for reducing mortality and morbidity 2
• EMS personnel should obtain information about symptom onset time, comorbidities, current medications, and advance directives 1
• On-scene time should be minimized to a median of 20 minutes or less for patients within the treatment window 1

Pre-Hospital Management

• EMS personnel should use validated stroke assessment tools that include FAST components 1
• Initial assessment should include capillary blood glucose measurement 1
• Direct transport protocols must facilitate transfer of potential stroke patients to appropriate acute care hospitals capable of providing stroke diagnosis and treatment 1
• Pre-notification of the receiving hospital while en route is essential to prepare appropriate hospital resources 1
• Patients with suspected stroke should be triaged as Canadian Triage Acuity Scale (CTAS) Level 2 in most cases, or Level 1 for those with compromised airway, breathing, or cardiovascular function 1

Emergency Department Management

• Upon arrival, patients should undergo immediate assessment using a validated stroke screening tool 1
• All patients with suspected acute stroke should undergo brain imaging (CT or MRI) without delay before receiving specific treatment 1
• A stroke severity rating scale (e.g., NIHSS) should be used in the emergency department 1
• Laboratory tests should include complete blood count, electrolytes, renal function, coagulation studies, and blood glucose, but should not delay reperfusion therapy 1
• Hospitals should establish protocols for emergency stroke evaluation and treatment with a target door-to-needle time of 30 minutes (median) or 60 minutes (90th percentile) 1

Acute Treatment

• Eligible patients should receive intravenous thrombolysis as soon as possible within the appropriate time window 1
• For patients with large vessel occlusion, endovascular treatment should be considered when appropriate 1
• Supplemental oxygen should be provided only to maintain oxygen saturation ≥94% 1
• Hypotension and hypovolemia should be corrected to maintain systemic perfusion 1
• Hypoglycemia (glucose below 60 mg/dL or 3.3 mmol/L) should be treated with IV dextrose 1
• Emergency treatment of hypertension is indicated only for specific conditions like concomitant acute myocardial ischemia, aortic dissection, or preeclampsia/eclampsia 1

Inpatient Stroke Unit Care

• Patients should be treated on a specialized, geographically defined stroke unit with coordinated care by an interdisciplinary team 1
• The stroke team should include physicians, nurses, physiotherapists, occupational therapists, speech-language therapists, social workers, and dieticians with expertise in stroke care 1
• Initial assessment by rehabilitation professionals should occur as soon as possible after admission 1
• Mobilization should begin within 48 hours of stroke onset unless contraindicated, but intensive out-of-bed activities should not start within 24 hours 1
• Person-centered, collaborative goal setting with patients and families should be implemented, clearly communicated, and regularly reviewed 1

Management of Complications

• Regular skin assessments with objective risk scales (e.g., Braden scale) should be performed 1
• Regular turning, good skin hygiene, and specialized support surfaces should be used to prevent skin breakdown 1
• Patients should be screened for dysphagia before receiving food, fluids, or oral medications 3
• For patients with swallowing difficulties, behavioral approaches such as swallowing exercises, environmental modifications, and appropriate dietary modifications should be implemented 1
• Blood glucose should be monitored at least 4 times daily for 3 days, with elevated glucose >180 mg/dL treated with insulin 3
• Body temperature should be monitored at least 4 times daily for 3 days, with treatment of temperature >37.5°C (99.5°F) with acetaminophen 3

Rehabilitation and Secondary Prevention

• Individually tailored aerobic training should be incorporated into comprehensive stroke rehabilitation 1
• Rehabilitation should include as much scheduled task-specific therapy as possible to meet optimal recovery 1
• Aspirin 160-300 mg/day should be started within 48 hours of acute ischemic stroke onset 3
• All modifiable risk factors should be addressed as part of secondary prevention 3
• Patient and family education should be provided formally and informally 1

Common Pitfalls and Considerations

• Failure to accurately determine symptom onset time can limit treatment options; note the exact time when symptoms began 2
• Delaying swallowing assessment increases risk of aspiration pneumonia; screening should be completed within 24 hours 3
• Inadequate blood pressure management can lead to complications; follow specific parameters based on whether the patient received thrombolysis 3
• Overlooking urinary retention, which occurs in 21-47% of patients in the first 72 hours after stroke 3
• Neglecting early mobilization and rehabilitation can lead to preventable complications like deep vein thrombosis and contractures 3