A stroke code is the process by which patients suffering from acute stroke are emergently evaluated and considered for time-sensitive treatments such as thrombolysis. See UW Health policy # 5.1.5 (link only works when connected to the UW network) and Appendix 1, which shows the ED stroke triage algorithms.
The stroke code begins when a physician or nurse activates the system by calling the emergency hotline, 2-0000. Your pager will display a message such as, “Stroke code ED bed 6; patient already here.” Many other people are included on the stroke code paging system, but you will be the primary responder.
Step 1: Respond to the emergency page. Upon receiving a stroke code page, immediately call the 2-0000 hotline and inform the operator “This is Dr. Jones—I’m responding to the stroke code.” The operator will document that you’ve responded, and send a follow-up page “Dr. Jones is responding to the stroke code.” Go immediately to the bedside.
Step 2: Obtain a directed history. In this emergency setting, the history focuses on 3 key points:
- Is this a stroke? Key features of stroke are sudden onset and lateralized distribution of symptoms. Important stroke mimics include post-ictal paralysis, migraine, hypoglycemia, and conversion disorder.
- When did it start? If not witnessed, the onset time is the time the patient was last known to be in his usual state of health. You may need to interview multiple family members, nurses, therapists, etc. and review nursing and other documentation to ascertain this. Because this is so crucial to the determination of available therapies, it’s worth spending a few minutes to obtain accurate information.
- Is there anything in the medical history that would contraindicate thrombolytic therapy? Is the patient taking warfarin or one of the new direct thrombin / factor Xa inhibitors? Has he had recent surgery? GI bleeding? History of intracerebral hemorrhage? Don’t waste time (or let family members waste time) going over non-urgent historical items such as GERD, arthritis, etc.
Step 3: Perform a directed neurological examination. After assessing airway, breathing, and circulation, continue with the National Institutes of Health Stroke Scale (NIHSS) score. All residents are required to be annually certified in the administration of the NIHSS. The NIHSS score is used to help determine eligibility for various acute therapies. After obtaining a score, quickly perform the remainder of the examination, focusing on those elements needed to localize the lesion and determine the extent of the functional impairment caused by the stroke.
Step 4: Proceed with diagnostic imaging. The next priority is to obtain STAT brain imaging to rule out intracranial hemorrhage. The target door-to-image time (a Joint Commission standard; see Appendix 2 for the complete list) is <25 minutes.
In the ED, the CT will have been ordered by the ED as part of the “Potential Stroke” order set. Our standard imaging protocol for ED stroke codes includes non-contrast head CT, CT angiography from the aortic arch to the vertex, and CT perfusion. If you determine that the case is clearly a stroke mimic or clearly outside any intervention window, you may cancel the multimodal imaging in favor of a non-contrast head CT.
On the floor, you’ll need to put in the inpatient stroke code order set - see screen shot below. This order set has only non-contrast head CT, since inpatients may have medical conditions contraindicating contrast administration and regardless, permission from the primary team will be needed before ordering a contrasted study.
Also needed are a 12 lead EKG and a fingerstick glucose. These can be obtained by the ED
staff while you’re doing your history and exam.
Step 5: Call the stroke fellow or attending. Once you have completed a directed history and exam, including NIHSS score, and the patient is on the way to the CT scanner, staff the patient with your attending. It is understood that you will not have completed a full H&P at that time, but the attending needs to know ASAP whether the patient is really having a stroke, whether tPA administration seems likely, etc. You should call your fellow or attending within 10 minutes of receiving a stroke code.
Step 6: Call the pharmacist. If there is any chance that tPA might be administered, please notify the stroke team pharmacist (and the rest of the team) by calling 2-0000 and requesting the pharmacist present to the bedside with tPA. Eg. “Stroke pharmacist to D6/472”. In the ED, the pharmacist will usually be right there, but on the floor, he may not be. The target door-to needle time (another Joint Commission standard) is <45 minutes.
Step 7: Review the full tPA exclusion criteria. These are also found on U-Connect—just search for “stroke”, click on “Comprehensive Stroke Program”, and then “Contraindications List” under Thrombolysis.
Contraindications in the 3 hour window
- Current intracranial hemorrhage
- Subarachnoid hemorrhage
- Active internal bleeding
- Recent (within 3 months) intracranial or intraspinal surgery or serious head trauma
- Presence of intracranial conditions that may increase the risk of bleeding (e.g., some neoplasms, arteriovenous malformations, or aneurysms)
- Bleeding diathesis
- Current severe uncontrolled hypertension
Contraindications in the 4.5 hour window
- Age > 80 years
- NIHSS > 25
- Early ischemic changes > 1/3 of the MCA territory
- Combination of prior stroke and diabetes
- Any anticoagulant treatment (irrespective of the INR)
Warnings and Precautions (copied from the Alteplase package insert)
- Recent major surgery or procedure, (e.g., coronary artery bypass graft, obstetrical delivery, organ biopsy, previous puncture of noncompressible vessels)
- Cerebrovascular disease
- Recent intracranial hemorrhage
- Recent gastrointestinal or genitourinary bleeding
- Recent trauma
- Hypertension: systolic BP above 175 mm Hg or diastolic BP above 110 mm Hg
- High likelihood of left heart thrombus, e.g., mitral stenosis with atrial fibrillation
- Acute pericarditis
- Subacute bacterial endocarditis
- Hemostatic defects including those secondary to severe hepatic or renal disease
- Significant hepatic dysfunction
- Diabetic hemorrhagic retinopathy, or other hemorrhagic ophthalmic conditions
- Septic thrombophlebitis or occluded AV cannula at seriously infected site
- Advanced age [see Use in Specific Populations (8.5)]
- Patients currently receiving anticoagulants (e.g., warfarin sodium)
- Any other condition in which bleeding constitutes a significant hazard or would be particularly difficult to manage because of its location
Step 8: Order the Alteplase. Once you and your attending decide to proceed with thrombolysis, order the Alteplase (tPA) in the ED using the Thrombolysis order panel in Health Link. It is crucially important to use the order panel, as it includes the mandated post-thrombolysis vital sign and neuro check orders. The pharmacists will accept a verbal order to mix the tPA, but not to administer it—the order must be entered to administer it.
Step 9 (optional): Cancel the stroke code. At the conclusion of the code, whether tPA was given or not, you may send a text page to the acute stroke team through WebXchange (pager #6400). Examples include “Cancel stroke code—tPA given” “Cancel stroke code—too late for tPA” “Cancel stroke code—seizure”. This lets the team, including the nurse and research coordinators, know what has happened.
Step 10: Follow up with the neuro ICU nurse. The transition from ED to ICU is a critical one for post-thrombolysis patients. Occasionally, a patient will manifest an important neurological change in the ED. The neuro ICU nurse may erroneously assume that the current neurological exam is at baseline, and the patient’s change in status will not be detected until very late. Please speak with the accepting neuro ICU nurse, preferably in person, after the patient’s transfer to ensure that everyone is on the same page regarding the true baseline neurologic status.