Classification System for Stroke Patients
John A. Marx, M.D.
Carolinas Medical Center, Charlotte, North Carolina
The primary intent of emergency department (ED) stroke classification is the expedient identification of those patients who require acute interventional therapy. Such therapy includes the resuscitation of patients presenting with cardiopulmonary life threats, prompt recognition and care of stroke and nonstroke emergencies, and the delivery of thrombolytics to selected stroke patients who satisfy strict inclusion criteria.
More specifically, the proposed categorization system (Figure 1) will distinguish those patients who could receive t-PA from those who should not. This should render the most efficient utilization of ED and hospital resources including the optimal deployment of key personnel. The approach is analogous to that developed for the subset of chest pain patients who warrant thrombolysis.
Patients are assessed for the presence of life-threatening conditions and managed accordingly (step 1) prior to or coincident with categorization for stroke. The categorization system relies first upon a simple, rapid, and sensitive filter during triage to cull identify out all possible stroke patients (step 2). Elementary parameters are then tested (step 3). If these are satisfied, the triage health carehealthcare provider (HCP) institutes a priority response (step 4), including notification of the senior emergency physician (EP). The EP then administers rigid and specific pre-CT and laboratory criteria via history and physical examination (step 5). If these are met, the patient receives Level I categorization. Requisite laboratory tests are obtained, the patient is delivered expeditiously to the CT suite, and the stroke team is notified. If, following review of the CT scan and laboratory tests, no exclusions exist and the time from symptom onset is less than 180 minutes (step 6), t-PA may be administered.
The categorization sequence can be applied entirely in the ED or initiated in a variety of other health carehealthcare locales. Depending on the acuity of the patient's condition and clinical circumstances, steps 1, 2, 3, and 4 may be carried out by a prehospital care provider, triage nurse, bedside nurse, EP or other physician, or some combination. These same steps may transpire in a transferring institution, prehospital transport vehicle, triage station, or at the bedside in the ED. Therefore, a patient who has been processed successfully through certain of these steps prior to arrival at the receiving ED should be inserted into the algorithm at the appropriate juncture.
This categorization schema is deliberately simplistic and not intended to specify the management of many other emergent neurological and non-neurological diseases that may be discovered in the process. Patients who are directed toward "Standard ED Triage and Management" in this algorithm are expected to receive a high standard of care dictated by their condition.
Identification and Management of Life Threats
Patients with exigent airway, ventilatory, or hemodynamic concerns receive resuscitative measures. Many of these patients will not be eligible for thrombolytics.
Identification of Possible Stroke Patient
The triage HCP should utilize historical information obtained from prehospital care providers, the patient, and the patient's family or friends. This is coupled with a simple examination to determine whether a measurable neurologicalneurologic deficit exists.
Identification of Potential Level I Patient
The patient must be at least 18 years of age and have a triage fingerstick blood glucose greater than> 60 mg/dl. Obvious head trauma, seizure, or pregnancy precludes the patient from further consideration for t-PA. Candidates for thrombolysis must be able to be processed within 180 minutes (interval from symptom onset to needle time). This processing time will vary among institutions.
The triage HCP ensures prompt delivery of the patient to a specified treatment area in the ED and notification of the department's designated EP of a potential Level I patient.
Pre-CT and Laboratory Exclusions
The EP applies a rigorous history and physical examination, including the NIH Stroke Scale, in determining whether the patient should be assigned Level I status. Level I categorization implies that requisite laboratory tests and CT be obtained immediately and that the stroke team be notified of the presence of a Level I patient.
Step 6--Stroke Team
CT and Laboratory Exclusions
The stroke team assiduously reviews the CT and laboratory data. If all inclusion criteria are satisfied, all exclusion criteria have been eliminated, and the time elapsed from symptom onset is less than 180 minutes, t-PA is administered in the ED or other designated area.
Figure 1. Proposed system for identifying patients eligible for t-PA treatment.
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National Institute of Neurological Disorders and Stroke
National Institutes of Health
Bethesda, MD 20892
Last Modified May 17, 2011