ACLS Provider: Course

Stroke Algorithm

Stroke is a time-critical neurological emergency that requires rapid recognition, focused assessment, and expedited transport to a facility capable of advanced imaging and intervention. The ACLS Stroke Algorithm outlines the steps for identifying a suspected stroke, initiating immediate care, and preparing the patient for definitive treatment. Timely action can dramatically reduce long-term disability and improve survival — every minute of delay equals millions of lost neurons.

Recognition of Stroke

Prompt identification begins with recognizing the signs and symptoms of acute stroke. The FAST acronym is commonly used:

  • F – Facial Drooping: Ask the person to smile. One side of the face may droop or appear uneven.
  • A – Arm Weakness: Ask the person to raise both arms. One arm may drift downward or feel weak or numb.
  • S – Speech Difficulty: Ask them to repeat a simple phrase. Speech may be slurred, confused, or absent.
  • T – Time to Call 911: If any symptoms are present, even briefly, emergency services must be activated immediately.

Additional signs may include sudden confusion, loss of balance, visual disturbances, or severe headache. Always note the exact time of symptom onset — this is critical for treatment decisions.

Immediate Actions (Prehospital or First Medical Contact)

  • Assess ABCs: Ensure airway, breathing, and circulation are stable. Provide oxygen if needed (SpO2 < 94%).
  • Establish IV access and monitor vital signs closely.
  • Obtain glucose level to rule out hypoglycemia, which can mimic stroke.
  • Transport urgently to the nearest appropriate stroke center (preferably one with 24/7 CT/MRI and endovascular capability).
  • Notify the receiving hospital early — use “stroke alert” or similar protocol to activate stroke team resources in advance.

Hospital Assessment and Imaging

  • Immediate non-contrast CT or MRI of the brain is required to determine whether the stroke is ischemic or hemorrhagic.
  • Do not delay imaging for lab results or ECG unless the patient is unstable.
  • Continue focused neurologic exam using NIH Stroke Scale (NIHSS), Glasgow Coma Scale (GCS), or other tools.
  • Draw labs, including coagulation panel, CBC, electrolytes, cardiac enzymes, and type & screen if indicated.

Determine Stroke Type and Eligibility for Treatment

  • Ischemic Stroke: If no hemorrhage is seen on CT and symptoms began <4.5 hours ago, the patient may be eligible for fibrinolytic therapy (tPA).
  • Hemorrhagic Stroke: If bleeding is present, fibrinolytics are contraindicated. Focus shifts to neurosurgical consultation and blood pressure control.
  • Large Vessel Occlusion (LVO): Consider endovascular thrombectomy (mechanical clot removal) if imaging suggests LVO and patient is within the window (up to 24 hours in some cases).

Fibrinolytic Therapy (tPA)

  • tPA (alteplase) may be given within 3–4.5 hours of symptom onset for eligible ischemic stroke patients.
  • Absolute contraindications include active bleeding, recent surgery, intracranial hemorrhage history, and severe uncontrolled hypertension.
  • Careful blood pressure control (usually <185/110 mmHg) may be needed prior to administration.
  • Monitor closely for signs of bleeding, worsening neurologic status, or allergic reaction after administration.

Ongoing Management

  • Admit to ICU or stroke unit for close monitoring and continued neurologic assessment.
  • Control blood pressure, glucose, temperature, and oxygenation aggressively to protect brain tissue.
  • Begin secondary prevention planning including antiplatelet therapy, anticoagulation (if indicated), and risk factor management (e.g., smoking cessation, lipid control).

Summary

  • Recognize stroke signs early using FAST and activate EMS immediately.
  • Note time of symptom onset — this determines treatment eligibility.
  • Transport rapidly to a capable stroke center and activate the stroke team.
  • Use imaging to differentiate ischemic vs hemorrhagic stroke.
  • Consider tPA or thrombectomy in eligible ischemic strokes within appropriate time windows.
  • Continue monitoring and initiate secondary prevention to reduce recurrence risk.