Using the Suspected Stroke Algorithm for

Managing Acute Ischemic Stroke

The ACLS Suspected Stroke Algorithm emphasizes
critical actions for out-of-hospital and in-hospital care
and treatment.

National Institute of Neurological Disorders

and Stroke Critical Time Goals
Included in the algorithm are critical time goals set by the National Institute of
Neurological Disorders (NINDS) for in-hospital assessment and management.
These time goals are based on findings from large studies of stroke victims:
• Immediate general assessment by a stroke team, emergency physician, or
other expert within 10 minutes of arrival, including the order for an urgent
CT scan

• Neurologic assessment by stroke team and CT scan performed within 25

minutes of arrival

• Interpretation of CT scan within 45 minutes of ED arrival

• Initiation of fibrinolytic therapy, if appropriate, within 1 hour of hospital

arrival and 3 hours from onset of symptoms. rTpa can be administered in
“well screened” patients who are at low risk for bleeding for up to 4.5
hours.

• Door-to-admission time of 3 hours in all patients

Algorithm Steps
Step 1

Identify signs of a possible stroke.

• Facial Droop (have patient show teeth or smile)
• Arm Drift (patient closes eyes and extends both arms straight out, with
palms up for 10 seconds)
• Abnormal Speech (have the patient say “you can’t teach an old dog new
 tricks”)

If any 1 of these 3 signs is abnormal, the probability of a stroke is 72%

Step 2

Call 911 immediately (activate EMS system). This is an important step because
EMS responders can transport the patient to a hospital that provides acute
stroke care and notify the hospital that the patient is coming. The hospital staff
can then prepare for efficient evaluation and management of the patient.
Currently, half of all stroke victims are driven to the ED by family members or
friends.

Step 3

Complete the following assessments and actions.

Assessment Actions

Define and recognize the signs of Support the ABC's (airway, breathing,
stroke. and circulation).

Assess the patient using the CPSS or Give oxygen as needed.

the LAPSS.
Establish last known well time Last Known Well Time: set the time
when the patient was last known to be
neurologically normal. If the patient
was sleeping and wakes up with
symptoms, time last know well
(LKW)is the last time the patient was
seen to be normal.

Consider triage to a stroke center, if Transport the patient quickly.

possible.

Assess neurological status while the Bring a family member or witness to

patient is being transported. confirm last known well

Alert the receiving hospital.

Check glucose levels.

General Assessment in the ED

NINDS time goal: 10 min

Step 4

Within 10 minutes of the patient's arrival in the ED, take the following actions:

Actions

Assess circulation, airway, breathing and evaluate vital signs.

Give oxygen if patient is hypoxemic (less than 94% saturation). Consider oxygen is
patient is not hypoxemic.

Make sure that an IV has been established.

Take blood samples for blood count, coagulation studies, and blood glucose. Check the
patient's blood glucose and treat if indicated. Give dextrose if the patient is
hypoglycemic. Give insulin if the patient's serum glucose is more than 300. Give
thiamine if the patient is an alcoholic or malnourished.

Assess the patient using a neurological screening assessment, such as the NIH Stroke
Scale (NIHSS).

Order a CT brain scan without contrast and have it read quickly by a qualified specialist.

Obtain a 12-lead ECG and assess for arrhythmias.

Do not delay the CT scan to obtain the ECG. The ECG is taken to identify a recent or
ongoing acute MI or arrhythmia (such as atrial fibrillation) as a cause of embolic stroke.
Life-threatening arrhythmias can happen with or follow a stroke.

Immediate Neurological Assessment by

Stroke Team
NINDS time goal: 25 min

Step 5

Within 25 minutes of the patient's arrival, take the following actions:

Actions

Review the patient's history, including past medical history.

Perform a physical exam.

Establish last known well if not already done.

Perform a neurological exam to assess patient's status using the NIHSS or the
Canadian Neurological Scale.

The CT scan should be completed within 25 minutes from the patient's arrival in the ED
and should be read within 45 minutes.

Treatment Decisions by Specialist

NINDS time goal: 45 min

Step 6

Within 45 minutes of the patient's arrival, the specialist must decide, based on
the CT scan or MRI, if a hemorrhage is present.

Take these actions if a hemorrhage is Take these actions if a hemorrhage is

present NOT present

Note that the patient is not a candidate Decide if the patient is a candidate for
for fibrinolytics. fibrinolytic therapy.

Arrange for a consultation with a Review criteria for IV fibrinolytic

neurologist or neurosurgeon. therapy by using the fibrinolytic
checklist (see Figure 1).

Consider transfer, if available. Repeat the neurological exam (NIHSS

or Canadian Neurological Scale).

If the patient is rapidly improving and moving to normal, fibrinolytics may not be
necessary.

Treatment
NINDS time goal: 60 min

If the patient is a candidate for fibrinolytic therapy, review the risks and benefits
of therapy with the patient and family (the main complication of IV tPA is
intracranial hemorrhage) and give tissue plasminogen activator (tPA).
Do not give anticoagulants or antiplatelet treatment for 24 hours after tPA until a
follow-up CT scan at 24 hrs does not show intracranial hemorrhage.

If the patient is NOT a candidate for fibrinolytic therapy, give the patient aspirin.

For both groups (those treated with tPA and those given aspirin), give the
following basic stroke care:

Begin stroke pathway.

Support patient's airway, breathing, and circulation.

Check blood glucose.

Watch for complications of stroke and fibrinolytic therapy.

Transfer patient to intensive care if indicated.

Patients with acute ischemic stroke who are hypoglycemic tend to have worse
clinical outcomes, but there is no direct evidence that active glucose control
improves outcomes. Consider giving IV or subcutaneous insulin to patients
whose serum glucose levels are greater than 10 mmol/L (about 200 mg/dL).

Inclusion criteria Exclusion criteria Exclusion criteria

Age: 18 yrs or older Evidence of intracranial Active internal bleeding

hemorrhage from CT or acute trauma, such as
scan a fracture

Diagnosis of an ischemic Clinical presentation Acute bleeding diathesis,

stroke with neurologic suggestive of a including the following
deficit subarachnoid but may include other
hemorrhage, even with manifestations:
normal CT

Time from onset of Evidence of multilobar Intraspinal surgery,

symptoms is within 3 infarction in more than serious head trauma, or
hours one-third of the cerebral previous stroke within
hemisphere on CT the past 3 months

History of intracranial Arterial puncture at a

hemorrhage non-compressible site
within the past 7 days

Uncontrolled
hypertension based on
repeated measurements
of > 185 mm Hg systolic
pressure or > 110 mm Hg
diastolic pressure

Known AV malformation,
 neoplasm, or aneurysm
Witnessed seizure at
stroke onset

Relative Contraindications/Precautions
• Relative Contraindications/Precautions

• Minor or rapidly improving stroke symptoms

• Major surgery or serious trauma within the past 14 days

• Recent gastrointestinal or urinary tract hemorrhage within the past 3

weeks

• Post-myocardial infarction pericarditis

• Recent acute myocardial infarction within the past 3 months

• Abnormal blood sugar level < 50 mg/dl or > 400 mg/dl

• Platelet count < 100,000/mm3

• Heparin received within 48 hours prior to onset of stroke, with elevated

activated partial thromboplastin time (aPTT)

• Current use of anticoagulant (e.g., warfarin) with an elevated international

normalized ratio (INR) > 1.7

Complications. The major complication of IV tPA is intracranial hemorrhage.

Other bleeding complications, ranging from minor to severe, may also happen.
Angioedema and transient hypotension also can occur.

Research. Several studies have shown that good to excellent outcomes are more
likely when tPA is given to adults with acute ischemic stroke within 3 hrs of onset
of symptoms. However, these results happened when tPA was given in hospitals
with a stroke protocol that adheres closely to the therapeutic regimen and
eligibility requirements of the NINDS protocol. Evidence from prospective
randomized studies in adults documented a greater likelihood of benefit the
earlier treatment begins.

Managing Hypertension in tPA Candidates

For patients who are candidates for fibrinolytic therapy, you need to control their
blood pressure to lower their risk of intracerebral hemorrhage following
administration of tPA. See the general guidelines in Figure 2.

Figure 2. Management guidelines for elevated blood pressure in patients with

acute ischemic stroke

Candidates NOT eligible for fibrinolytic therapy

Blood Treatment
pressure level,
mm Hg

Systolic ≤220 Observe patient unless there is other end-organ involvement. Treat the
or diastolic patient's other symptoms of stroke (headache, pain, nausea, etc).
≤120 Treat other acute complications of stroke, including hypoxia,
increased intracranial pressure, seizures, or hypoglycemia.

Systolic > 220 Labetalol 10 to 20 mg IV for 1–2 min—may repeat or double every 10
or diastolic min to a maximum dose of 300 mg OR Nicardipine 5 mg/hr IV infusion
121 to 140 as initial dose; titrate to desired effect by increasing 2.5 mg/hr every 5
min to max of 15 mg/hr Aim for a 10% to 15% reduction in blood
pressure

Diastolic > 140 Nitroprusside 0.5 µg/kg per min IV infusion as initial dose with
continuous blood pressure monitoring

Aim for a 10% to 15% reduction in blood pressure

Stroke patients eligible for a fibrinolytic

PRETREATMENT

Systolic > 185 or Labetalol 10 to 20 mg IV for 1–2 min—may repeat 1 time or

diastolic > 110 nitropaste 1–2 inches

During or after
TREATMENT

Monitor blood Check blood pressure every 15 min for 2 hrs, then every 30
pressure min for 6 hrs, and finally every hr for 16 hrs

Diastolic > 140 Sodium nitroprusside 0.5 µg/kg per minute IV infusion as
initial dose and titrate to desired blood pressure

Systolic > 230 or Labetalol 10 mg IV for 1–2 min—may repeat or double every
diastolic 121 to 140 10 min to maximum dose of 300 mg or give initial labetalol
dose and then start labetalol drip at 2 to 8 mg/min OR
Nicardipine 5 mg/hr IV infusion as initial dose and titrate to
desired effect by increasing 2.5 mg/hr every 5 min to
maximum of 15 mg/hr; if blood pressure is not controlled
by nicardipine, consider sodium nitroprusside

Systolic 180 to 230 or Labetalol 10 mg IV for 1–2 min—may repeat or double every
diastolic 105 to 120 10 to 20 min to a maximum dose of 300 mg or give initial
labetalol dose, then start labetalol drip at 2 to 8 mg/min