ACLS FOR STROKE

Stroke is a time-sensitive medical emergency that occurs when blood flow to the brain is disrupted, leading to brain tissue damage. It can be caused by a blockage (ischemic stroke) or bleeding (hemorrhagic stroke). Rapid recognition and treatment are critical to minimizing neurological damage and improving survival outcomes.

Why It’s Important:
Stroke is the second leading cause of death worldwide.
Time-sensitive treatment (e.g., thrombolysis, mechanical thrombectomy) improves outcomes.
ACLS providers play a key role in early recognition, assessment, and stabilization.

RECOGNIZING STROKE (FAST) – EARLY DETECTION SAVES LIVES

Use the FAST acronym to recognize stroke symptoms quickly:

FAST Mnemonic	What to Check For
F – Face	Ask the patient to smile – does one side droop?
A – Arms	Ask the patient to raise both arms – does one drift downward?
S – Speech	Ask the patient to repeat a sentence – is their speech slurred or confused?
T – Time	If ANY symptoms are present, act FAST – call 911 immediately!

Key Takeaway: Stroke recognition and rapid emergency activation are crucial!

INITIAL ASSESSMENT & STABILIZATION (ACLS RESPONSE)

Time is Brain – Immediate Action is Critical!
The goal is to identify stroke type and initiate treatment ASAP.

Step 1: Assess Airway, Breathing, and Circulation (ABCs)

Ensure airway patency and adequate oxygenation.
Provide supplemental oxygen if SpO₂ <94%.
Monitor circulation (BP, HR, perfusion).

Step 2: Perform a Rapid Neurological Assessment

NIH Stroke Scale (NIHSS) is used in hospitals.
Prehospital: Use Cincinnati Stroke Scale or LAPSS (Los Angeles Prehospital Stroke Screen).

Step 3: Establish Time of Symptom Onset

Determine the exact time the patient was last seen normal.
This determines eligibility for thrombolytic therapy (tPA).

Step 4: Activate the Stroke Team Immediately

Early notification of the stroke team improves hospital response time.

Step 5: Obtain IV Access & Monitor Vital Signs

Establish IV access for medications and fluids.
Monitor BP, HR, SpO₂, and glucose levels.

Key Takeaway: Identifying symptom onset time is critical for determining thrombolysis eligibility!

DIFFERENTIATING STROKE TYPES: ISCHEMIC VS. HEMORRHAGIC

Stroke Type	Cause	Key Features	Treatment
Ischemic Stroke (87%)	Blood clot blocks an artery	Focal neurological deficits, FAST signs	Thrombolytics (tPA) or mechanical thrombectomy
Hemorrhagic Stroke (13%)	Blood vessel rupture	Sudden severe headache, vomiting, altered LOC	BP control, reversal of anticoagulants, neurosurgical intervention

Key Takeaway: Urgent CT scan is needed to differentiate ischemic vs. hemorrhagic stroke!

KEY CONSIDERATIONS IN ISCHEMIC STROKE

GOAL: Restore Blood Flow ASAP (Reperfusion Therapy).

Thrombolytic Therapy (tPA – Alteplase)

If ischemic stroke is confirmed and patient is within 3-4.5 hours of symptom onset, administer:
- Alteplase (tPA) 0.9 mg/kg IV (max 90 mg).
- Give 10% as a bolus, then infuse over 60 minutes.
Time to tPA: Within 60 minutes of hospital arrival!

Contraindications for tPA:
Active bleeding (e.g., GI or recent surgery).
Recent major trauma, stroke, or MI (<3 months).
BP >185/110 mmHg (must lower BP before tPA).
INR >1.7 (if on anticoagulants).

Mechanical Thrombectomy (if large vessel occlusion)

If within 6-24 hours of symptom onset, mechanical clot retrieval may be performed.
Preferred for large artery occlusions (e.g., MCA stroke).

Blood Pressure Management

If BP >185/110 mmHg, lower BP before giving tPA.
Labetalol, Nicardipine, or Clevidipine IV can be used for BP control.

Key Takeaway: Thrombolysis must be given within 3-4.5 hours for best outcomes—act fast!

KEY CONSIDERATIONS IN HEMORRHAGIC STROKE

GOAL: Prevent further bleeding and manage BP.

Strict Blood Pressure Control

Target BP: SBP <140 mmHg.
IV Labetalol or Nicardipine for BP reduction.

Reversal of Anticoagulation (If on Blood Thinners)

Warfarin reversal: Administer Vitamin K & Prothrombin Complex Concentrate (PCC).
Heparin reversal: Administer Protamine Sulfate.
DOACs (e.g., Apixaban, Rivaroxaban): Administer Andexanet Alfa.

Consider Neurosurgical Intervention

Hematoma evacuation, aneurysm clipping, or coiling may be required.

Key Takeaway: Hemorrhagic stroke requires BP control and possible neurosurgical intervention.

TRANSPORT TO A STROKE CENTER

Time to Stroke Center = Better Outcomes!

If possible, transport to a Comprehensive Stroke Center (CSC) for thrombectomy capability.
Perform a CT scan within 20 minutes of hospital arrival.
Monitor for worsening neurological deficits or stroke progression.

Key Takeaway: Rapid stroke center transport improves access to life-saving interventions.

COMMON STROKE MANAGEMENT MISTAKES & HOW TO AVOID THEM

Mistake	Impact	Prevention
Delaying stroke recognition & EMS activation	Misses critical treatment window	Use FAST & call 911 immediately!
Not obtaining symptom onset time	Ineligibility for tPA	Always determine “Last Known Normal.”
Delaying CT scan (>20 minutes)	Delays critical interventions	Rapid neuroimaging is a priority!
Not checking BP before tPA	Increased risk of bleeding	Lower BP if >185/110 before tPA.
Giving aspirin in hemorrhagic stroke	Worsens bleeding	Always confirm stroke type with CT scan first!

Key Takeaway: Stroke management is time-sensitive—early recognition and rapid intervention are essential!

STROKE MANAGEMENT SUMMARY (ACLS PROTOCOL)

If Stroke is Suspected (FAST Symptoms Present):

Activate EMS & Stroke Team immediately.
Perform ABC assessment & rapid neurological exam.
Establish “Last Known Normal” time.
Obtain a Non-Contrast CT scan within 20 minutes.

Ischemic Stroke (Confirmed by CT):

tPA within 3-4.5 hours (if eligible).
Mechanical thrombectomy (if large vessel occlusion).
BP control (<185/110 before tPA).

Hemorrhagic Stroke (Confirmed by CT):

Strict BP control (SBP <140 mmHg).
Reverse anticoagulation (if needed).
Consider neurosurgical intervention.

Takeaway: Stroke care is all about speed—faster treatment leads to better recovery!