From the Guidelines
The management of acute ischemic stroke should follow the 2018 AHA guidelines, which emphasize rapid assessment and treatment to minimize brain damage.
SOAP Outline for Acute Ischemic Stroke Management
Subjective:
- Document time of symptom onset, as it is crucial for treatment decisions 1
- Presenting symptoms: facial droop, arm weakness, speech difficulties, vision changes, severe headache, balance issues
- Relevant medical history: prior stroke/TIA, hypertension, diabetes, atrial fibrillation, coronary artery disease
- Current medications: especially anticoagulants/antiplatelets
- Allergies
Objective:
- Record vital signs, with blood pressure being critical
- Neurological exam findings using NIH Stroke Scale
- Blood glucose level
- CT or MRI brain imaging results
- CT angiography/perfusion if available
- ECG findings
- Laboratory values: CBC, coagulation studies, electrolytes
Assessment:
- Confirm acute ischemic stroke diagnosis
- Determine time window for intervention
- Identify stroke territory/vessel involved
- Assess eligibility for thrombolysis or thrombectomy
- Evaluate for stroke mimics
Plan:
- For eligible patients within 4.5 hours of symptom onset, administer IV alteplase 0.9 mg/kg (maximum 90 mg) with 10% as bolus and remainder over 60 minutes 1
- For patients with large vessel occlusion within 24 hours and favorable imaging, consider mechanical thrombectomy
- Initiate antiplatelet therapy (aspirin 325 mg initially, then 81 mg daily) within 24-48 hours after thrombolysis or immediately if thrombolysis is contraindicated
- Control blood pressure (target <185/110 mmHg before thrombolysis, <180/105 mmHg after)
- Manage glucose (target 140-180 mg/dL)
- Maintain normothermia
- Provide supportive care
- Begin early rehabilitation, dysphagia screening before oral intake, DVT prophylaxis, and secondary prevention strategies including statin therapy, antihypertensives, and lifestyle modifications, as emphasized in the 2018 AHA guidelines 1
From the Research
SOAP Outline for Stroke Based on 2018 AHA Acute Ischemic Stroke Guideline
Subjective
- Patient's symptoms and medical history, including time of onset of stroke symptoms 2
- Patient's or family member's report of any changes in condition or concerns
Objective
- Physical examination, including neurological assessment using the National Institutes of Health Stroke Scale (NIHSS) 3
- Review of laboratory results, including complete blood count, blood chemistry, and coagulation studies
- Imaging studies, such as computed tomography (CT) or magnetic resonance imaging (MRI) of the brain 4
Assessment
- Diagnosis of acute ischemic stroke, based on clinical presentation and imaging studies 2
- Assessment of patient's eligibility for intravenous tissue plasminogen activator (t-PA) therapy, including time of onset of symptoms and presence of any contraindications 3, 5
- Evaluation of patient's ambulatory status and potential for improvement with t-PA therapy 5
Plan
- Administration of t-PA therapy, if indicated, within 3-4.5 hours of onset of stroke symptoms 3, 6
- Monitoring of patient's condition, including frequent neurological assessments and laboratory studies
- Implementation of secondary prevention measures, including antiplatelet therapy and management of modifiable risk factors 2
- Consideration of transfer to a stroke center or rehabilitation facility, if necessary, for further care and rehabilitation 4