SPREAD V Ed.

Acute stroke:
pre-hospital management
and emergency phase

 
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Collaborations
Authors
Introduction
Methodology
Epidemiology
Diagnostic work-up
Risk factors
Primary prevention
Acute stroke: pre-hospital
Acute stroke: diagnosis
Acute stroke: treatment
Acute stroke: steady-state
Secondary prevention
Surgical treatment
Organising rehabilitation
Rehabilitation
Post-stroke sequels
Juvenile-uncommon causes

Acute stroke:
pre-hospital management and emergency phase

R 8.1
Grade D		 Public education initiatives - with the use of mass-media, meetings with subjects at risk or elderly groups, education of young people also through schools - are recommended to increase the awareness of stroke in the general population, especially in subjects at higher risk.
R 8.2
Grade C		 If there is a clinical suspicion of stroke, an urgent transportation to the nearest emergency room is recommended, regardless of the severity of the event.
R 8.3
 ®GPP		 The EMS (Emergency Medical Services) central personnel should be trained to identify at the telephone triage a suspected stroke and, if thrombolysis is clinically indicated, to manage it as a medical emergency (red code).
R 8.4
Grade D		 The EMS ambulance personnel are recommended to gather from the patient and/or the relatives all the information useful to determine the exact time of stroke onset and the possible risk factors.
R 8.5
Grade D 		 A specific training on early evaluation and appropriate management of suspected stroke victims is recommended for the EMS ambulance personnel.
R 8.6
Grade D		 The EMS ambulance personnel are recommended to investigate for trauma or life-threatening conditions, and, for the first diagnostic assessment, to perform the following evaluations:
1. ABC (airway, breathing, circulation);
2. vital functions (breathing, heart rate, blood pressure, arterial oxygen saturation);
3. Glasgow Coma Scale (GCS);
4. Cincinnati Prehospital Stroke Scale (CPSS).
R 8.7
Grade D		 For patients in severe conditions, the emergency management during ambulance transportation should consist of:
1. establishing free airway,
2. administering oxygen and crystalloids, if necessary,
3. protecting paretic limbs from possible accidental traumas
R 8.8
 ®GPP		 The EMS ambulance personnel are recommended to inform the emergency room about the oncoming arrival of a suspected stroke victim.
R 8.9
 ®GPP		 The local health system is recommended to provide specific instructions for EMS ambulance personnel to transport suspected stroke victims to a properly equipped hospital, considering also the opinion of the caregivers.
R 8.10
Grade D		 For the home management of a suspected stroke victim, while waiting for the emergent transportation to a hospital, no therapeutic interventions are recommended except - when needed - those directed to establish free airway and normal respiration.
R 8.11 The following therapeutic interventions are not recommended:
8.11 a
Grade D		  administration of hypotensive agents, especially fast-acting drugs;
8.11 b
Grade D		  administration of glucose solutions, unless hypoglycaemia is present;
8.11 c
 ®GPP		  administration of sedative agents, unless it is strictly necessary;
8.11 d
®GPP		  administration of excessive fluids.
S 8-1

The ABCD˛ score is a validated score able to predict the early stroke risk in patients with TIA. It is the sum of 5 clinical indicators, independently associated with the stroke risk:
bulletage ≥60 years: 1 point
bulletblood pressure, systolic ≥140 mm Hg or diastolic ≥90 mm Hg: 1 point
bulletclinical features: unilateral weakness 2 points
                          speech impairment without weakness 1 point
bulletduration: ≥60 min 2 points
               10-59 min 1 point
bulletdiabetes: 1 point

Among patients with TIA, the ABCD˛ score classifies the risk of stroke at 2 days as:
bulletlow:           score <4;
bulletmoderate: score 4-5;
bullethigh:          score >5
R 8.12a
Grade D		 A timely hospital referral of a recent transient ischaemic attack (TIA)  is recommended.
R 8.12b
®GPP		 Hospital admission   is recommended for patients with a transient ischaemic attack (TIA) with moderate-high risk of stroke (ABCD2 score ≥4).
R 8.13
Grade D		 In case patients with a recent TIA are not hospitalised, it is anyway recommended that they undergo prompt (24-48h) investigations to determine the mechanism of ischemia and subsequent preventive therapy.
S 8-2 A suspected stroke victim may not be referred to a hospital for the following reasons:
1. patient refusal (or parental refusal, if the patient is unable to communicate);
2. stroke with a short-term poor prognosis;
3. severe comorbidity with a very short life expectancy;
4. probable negative impact of the hospitalisation on the patient.
R 8.14
Grade D		 The following interventions are anyway recommended in suspected stroke patients who are not hospitalised:
bulletmonitoring of body temperature and treatment of fever;
bulletmonitoring of serum glucose and treatment of hyperglycaemia;
bulletmonitoring of diuresis, and use of indwelling urinary catheter only if strictly necessary;
bulletmonitoring the possible occurrence of infections;
bulletmaintenance of an adequate nutritional status;
bulletprevention of bedsores;
bulletprophylaxis of venous thromboembolism;
bulletbest possible secondary prevention of stroke;
bulletpsychological support to patient and caregivers.
S 8-3 Acute stroke is a medical emergency that deserves immediate hospitalisation, as stated in the Helsingborg Declaration and in several guidelines. All patients suffering cerebral vascular events should be admitted to a hospital to undergo a quick and accurate diagnostic work-up, and to monitor and treat possible complications.
R 8.15
Grade A		 The patients with an acute stroke are recommended to be referred to a dedicated structure (stroke unit).
S 8-4 When access to a stroke unit is impossible, the hospital care as indicated in these guidelines should anyway be guaranteed.
S 8-5 A stroke unit consists of a hospital unit or part of a hospital unit with 4-16 beds, in which a multidisciplinary team of nurses, physiotherapists, occupational therapists, speech and language therapists and physicians, expert in cerebrovascular diseases, is dedicated to stroke care.
The aspects qualifying the stroke unit are: the multidisciplinarity of the team, the integrated medical and rehabilitative approach, the continuing medical education of the team and the education of patients and relatives.
S 8-6  There are three possible categories of stroke care organisation: 
1. the stroke unit admitting only acute cases with very short hospitalisation periods and rapid transfers;
2. the stroke unit combining assistance during the acute phase with rehabilitation, in which discharge occurs with a rehabilitation and secondary prevention programme;
3. the purely rehabilitative stroke unit, which only receives clinically stabilised patients with stroke sequels.
The evidences of efficacy are available only for the structures of the second and third categories. For those of the first category the available data are insufficient. Also in such units early rehabilitation and expert nursing techniques should be assured.
S 8-7  When structures with the characteristics indicated in S 8-5 are not available, a reasonable alternative, although less effective, is represented by the stroke team, including a physician, nurses, and rehabilitations personnel specifically dedicated to the treatment of stroke.
S 8-8 The hospital receiving patients with acute stroke should ensure:
bulletcomputed tomography 24/24 hours;
bulletlaboratory for blood chemistry, including coagulation tests, 24/24 hours;
bulletimmediate cardiological and neurological evaluation.

Ultrasonographic examination of intra- ed extracranial vessels and echocardiography should be possible. Anyway the minimum level of stroke care should consist of, besides CT to be performed as soon as possible, immediate evaluation by a physician with expertise in stroke care and rehabilitative evaluation within 24-48 hours
S 8-9 A second-level hospital should perform the neuroimaging study (CT and/or MRI) within 60 minutes from admission of a stroke patient. It is also advisable that intravenous or the intra-arterial thrombolysis within 3 hours from stroke onset may be performed and that a rapidly accessible neurosurgical team can be consulted, even using telemedicine.
S 8-10 In the hospitals that have a stroke team but are not equipped to perform the thrombolysis, ought to define the diagnosis and provide the optimal management of a stroke patient (even using telemedicine).
When there is a clinical indication to and sufficient time to perform the thrombolysis, it is advisable that procedures for rapid transportation to Centres properly equipped are established.

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