ACLS- Acute Stroke Case 2025-2026 latest updated version with expert solutions

Drugs used during stroke

Approved fibrinolytic agent (rtPA)

Glucose

Labetalol

Nicardipine

Enalaprilat

Aspirin

Nitrprusside

When should IV fibrinolytic therapy be started for a stroke?

As early as possible

-Generally within 3 hours of onset of symptoms (4.5 hours for selected patients)

8 D's of stroke care

Highlight the major steps in diagnosis and treatment of stroke

-Detection

-Dispatch (911)

-Delivery (Rapid EMS, management, and transport)

-Door (triage to stroke center)

-Data (triage, evaluation, and management within ED)

-Decision (Stroke expertise and therapy selection)

-Drug/device (Fibrinolytic or endovascular therapy)

-Disposition (Rapid admission to the stroke unit or critical care unit)

In-hospital time goals for stroke

1. Immediate general assessment by the stroke team/ other expert within 10 minutes of arrival; order urgent noncontrast CT

2. Neurologic assessment and CT scan performed within 25 minutes of hospital arrival

3. Interpretation of the CT scan within 45 minutes of ED arrival

4. Initiation of fibrinolytic therapy therapy in appropriate patients within 1 hour of hospital arrival and 3 hours from symptom onset

5. Door-to-admission time of 3 hours

Critical time periods for stroke

Immediate general assessment: 10 minutes

Immediate neurologic assessment: 25 minutes

Acquisition of CT of the head: 25 minutes

Interpretation of the CT scan: 45 minutes

Administration of fibrinolytic therapy, timed from ED arrival: 60 minutes

Administration of fibrinolytic therapy, timed from onset of symptoms: 3 hours, or 4.5 hours in selected patients

Administration of endovascular therapy, timed from onset of symptoms: 6 hours in selected patients

Admission to a monitored bed: 3 hours

Adult Suspected Stroke Algorithm

Identification of s/s of possible stroke and activation of emergency response (step 1)

Critical EMS assessments and actions (step 2)

Immediate general assessment and stabilization (step 3)

Immediate neurologic assessment by the stroke team or designee (step 4)

CT scan: hemorrhage or no hemorrhage (step 5)

Fibrinolytic therapy risk stratification if candidate (steps 6, 8, and 10)

General stroke care (steps 11 and 12)

Warning s/s of stroke

Sudden weakness or numbness of the face, arm, or leg, especially on one side of the body

Sudden confusion

Trouble speaking or understanding

Sudden trouble seeing in one or both eyes

sudden trouble walking

Dizziness or loss of balance or coordination

Sudden severe headache with no known cause

Cincinnati Prehospital Stroke Scale (CPSS)

To provide the best outcome for the patient with potential stroke, do the following:

Support ABCs- supplementary oxygen to hypoxemic stroke

Perform stroke assessment- (CPSS)

Establish time- Determine last known well (time zero); if patient wakes from sleep with symptoms, time zero is when the patient was last seen normal

Triage to stroke center

Alert hospital

Check glucose (hypoglycemia mimics stroke symptoms)

Fibrinolytic therapy

Higher likelihood of good to excellent functional outcome when rtPA is given to adults with acute ischemic stroke within 3 hours of onset of symptoms

Evaluating for fibrinolytic therapy

If CT scan is negative for hemorrhage, perform further eligibility and risk stratification

Inclusion criteria:

-Diagnosis of ischemic stroke causing measurable neurologic deficit

-Onset of symptoms <3 hours before beginning treatment

-Age ≥18 years

Exclusion criteria for fibrinolytic therapy

Significant head trauma or prior stroke in previous 3 months

Symptoms suggesting subarachnoid hemorrhage

Arterial puncture at noncompressible site in previous 7 days

Hx of previous intracranial hemorrhage

--Intracranial neoplasm, arteriovenous malformation, or aneurysm

--Recent intracranial or intraspinal surgery

Elevated blood pressure (sys>185 or diastolic>110)

Active internal bleeding

Acute bleeding diathesis, including but not limited to:

--Platelets <100,000

--Heparin received within 48 hours, resulting in aPTT >upper limit of normal

--Current use of anticoagulant with INR>1.7 or PT>15 seconds

--Current use of direct thrombin inhibitors or direct factor Xa inhibitors with elevated sensitive laboratory tests (ie, aPTT, INR, platelet count, and ECT; TT; or appropriate factor Xa activity assays)

Blood glucose concentration <50 (2.7 mmol/L)

CT demonstrates multilobar infarction (hypodensity > 1/3 cerebral hemisphere)

Potential adverse effects of fibrinolytic therapy

Major complication= intracranial hemorrhage

Other bleeding complications

Angioedema

Transient hypotension

Intra-arterial rtPA

For patients with acute ischemic stroke who are not candidates for standard IV fibrinolysis

Provide it within first 6 hours after onset of symptoms

Mechanical clot disruption/ stent retrievers

Criteria:

-Prestroke mRS score 0-1

-Acute ischemic stroke receiving intravenous rtPA within 4.5 hours of onset

-Causative occlusion of the internal carotid artery or proximal MCA (M1)

-Age 18 or older

-NIHSS score 6+

-ASPECTS of 6+

-Treatment can be initiated (groin puncture) within 6 hours of symptom onset

General care of all patients with stroke

Begin stroke pathway

Support airway, breathing, circulation

Monitor blood glucose

Monitor BP

Monitor temperature

Perform dysphagia screening

Monitor for complications of stroke and fibrinolytic therapy

Transfer to general intensive care if indicated