Out-of-Hospital Setting
Once the stroke victim is identified, transport and triage are important decisions that require the participation of hospitals and community notification. Each receiving hospital should define its capabilities for treating patients with acute stroke and should communicate this information to the emergency medical services (EMS) system and the community.
Oxygen
Administration of supplementary oxygen to hypoxemic stroke patients by out-of-hospital and in-hospital medical personnel is recommended. Because there is conflicting evidence regarding the benefits of supplementary oxygen administration to normoxemic stroke patients, healthcare professionals may consider giving oxygen to these stroke patients on an individual basis.
Out-of-Hospital Stroke Assessment Tools
EMS systems must provide education and training to minimize delays in prehospital dispatch, assessment, and transport. With training in the use of relatively simple stroke assessment tools, prehospital providers can identify potential victims of stroke with high sensitivity and specificity.
Paramedics should be trained in the recognition of stroke with a validated, abbreviated out-of-hospital neurologic evaluation tool such as the Cincinnati Prehospital Stroke Scale or the Los Angeles Prehospital Stroke Screen.
Prehospital Triage
Initial low-level evidence indicates a favorable benefit from triage of stroke patients to designated stroke centers, but this concept should be explored using more rigorous levels of evidence.
Fibrinolytic Therapy
Intravenous (IV) Fibrinolytics
In the setting of a clearly defined protocol, a knowledgeable stroke team, and institutional commitment, IV administration of tissue plasminogen activator (tPA) to patients with acute ischemic stroke who meet the National Institute of Neurological Disorders and Stroke (NINDS) eligibility criteria is recommended. There is strong evidence to avoid all delays and treat patients as soon as possible.
Although not every hospital is capable of organizing the necessary resources to safely administer fibrinolytic therapy, every hospital with an emergency department should have a written plan describing how patients with acute stroke are to be managed in that institution. The plan should detail the roles of healthcare professionals in the care of patients with acute stroke and define which patients will be treated with fibrinolytic therapy at that facility and when transfer to another hospital with a dedicated stroke unit is appropriate. Emergent computerized tomography (CT) or magnetic resonance imaging (MRI) scans of patients with suspected acute stroke should be reviewed quickly by a physician who is expert in the interpretation of those studies.
Intra-Arterial Fibrinolytics
For patients with acute ischemic stroke who are not candidates for standard IV fibrinolysis, administration of intraarterial fibrinolysis in centers that have the resources available may be considered within the first 6 hours after the onset of symptoms.
In-Patient Care
Stroke Units
Hospitalized stroke patients experience improved outcomes when cared for by a multidisciplinary team experienced in managing stroke. Thus, when it is available, stroke patients who require hospitalization should be admitted to a stroke unit.
Glucose Control
For consistency with the American Stroke Association (Adams et al., 2005; Adams et al., 2003) and the European Stroke Initiative Guidelines (Klijn & Hankey, 2003), administration of IV or subcutaneous insulin may be considered for patients with acute ischemic stroke in the in-hospital setting to lower blood glucose when the serum glucose level is >10 mmol/L (about 200 mg/dL).
Therapeutic Hypothermia
There is insufficient scientific evidence to recommend for or against the routine use of hypothermia in the treatment of acute ischemic stroke (Class Indeterminate).
