Elsevier

Neurologic Clinics

Volume 26, Issue 4, November 2008, Pages 923-942
Neurologic Clinics

Emergency Department Evaluation and Management of Stroke: Acute Assessment, Stroke Teams and Care Pathways

https://doi.org/10.1016/j.ncl.2008.05.008Get rights and content

The emergency department (ED) is the entry point into the health care system for many stroke victims. Rapid evaluation, diagnosis and treatment of stroke in the prehospital setting as well as the ED are integral to preventing morbidity and mortality. In some centers, emergency medicine physicians are the health care professionals most often able to provide thrombolytic therapy to stroke patients during the brief three-hour window for this therapy. An organized ED approach including implementing stroke care pathways and collaborating with specialized stroke teams in the ED enhance the ability to identify and manage stroke patients effectively. This approach has the potential to improve outcomes on a large scale.

Section snippets

Prehospital care

Similar to acute myocardial infarction and trauma (“golden hour” concept), stroke must be treated in a timely manner. In acute stroke management the adage is “time is brain” as delays in diagnosis and treatment may render the patient neurologically impaired and disabled. Promptly implementing the “Stroke Chain of Survival” (seven Ds) (Box 1) [7], [8], [9] heightens the likelihood of early presentation and acute treatment of the ischemic or hemorrhagic stroke patient. An American Heart

Emergency department triage of the acute stroke patient and treatment goals

Advanced notification of an incoming acute stroke patient including onset time by EMS and rapid transport to the closest appropriate facility is essential to expeditious stroke care. An acute stroke victim should be transferred to the nearest center with access to stroke expertise, capable of performing a rapid brain imaging study, and able to render IV rt-PA if indicated. Published recommendations for primary stroke centers are listed in Box 2[19]. Primary stroke center certification may be

Emergency department management of the acute stroke patient

Once a patient arrives at the ED, expeditious triage, nursing, and physician assessments are paramount. This process may be facilitated by an ED stroke care map or plan. Prompt evaluation for reperfusion therapy in the case of ischemic stroke patients is vital as brain tissue becomes increasingly less salvageable as time progresses [21]. Additionally, identifying hemorrhagic stroke patients for whom early neurosurgical intervention may be beneficial is important. Ideally, every hospital should

Stabilization

Supplemental oxygen should be administered to those who have hypoxia [30]. Patients at risk for ventilatory compromise secondary to hypoventilation, aspiration, or inability to protect their airway should be immediately considered for endotracheal (ET) intubation with rapid sequence intubation. In the case that ET intubation becomes necessary, sedatives that do not elevate intracranial pressure such as propofol, thiopental, midazolam, or etomidate should be used [12]. Stroke patients who

Summary

The ED and EMS serve as a front line for care of acute stroke patients. The ED physician plays an important role in evaluating stroke patients, communicating with neurology and radiology consultants, as well as mobilizing resources. Organized and comprehensive approaches to acute stroke care including standardized protocols to effectively transport, diagnose, and treat such patients need to be in place to assure successful treatment and prevention of stroke. The 3-hour window for administration

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    • Cited by (0)

    Emergency Neurologic Education Resource: Foundation for Education and Research in Neurologic Emergencies (FERNE). FERNE is a Web-based system with targeted programs and resources for education of emergency department faculty and staff in neurologic emergencies. FERNE may be accessed at www.ferne.org.

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