ED Stroke Management Process
Initial Treatment Guidelines
- ABCD’s: Confirm by phone and at time of bedside
eval that patient has stable airway, adequate ventilation/oxygenation,
and intact circulation. Ask for continuous cardiorespiratory monitoring
and hourly documentation of VS. Suggest oxygen supplementation if mental
status is depressed, or perfusion or oxygenation are compromised. Verify
that pt has normal dextrostick, and supplement prn if hypoglycemic.
- Activity: Restrict to bedrest with HOB flat. Warn against
allowing child to ambulate or to sit upright for such things as toileting
or to transfer to/from ED or radiology. This is not needed for neonates
and non-mobile infants (<6 mo).
- NPO: restrict oral intake pending determination about
need for sedation, and pending assessment of aspiration risk by speech
therapy if there is any cranial nerve deficit.
- Fluids/electrolytes: For ischemic stroke or TIA, start
IV fluids immediately with isotonic non-dextrose containing solution to
be run at maintenance rate. For cerebral venous thrombosis, consider fluid
rate above maintenance to improve perfusion. For intracranial hemorrhage,
discuss fluid management with neurosurgery & ICU. Neonates will usually
require dextrose-containing solutions to maintain normoglycemia.
- Thermoregulation: antipyretics prn for fever. Aim to
keep temperature < 37° C.
- Antithrombotic treatment: tPA is rarely an option in
children. If initial triage phone call indicates pt is within 4 1/2 hrs
of onset, where noted onset is the time the child was last seen well and
otherwise might be a candidate for thrombolysis, call Stroke Attending
immediately to mobilize hyperacute MRI/MRA protocol. In most cases of
acute ischemic stroke, give initial dose of aspirin in ED once initial
head CT has been obtained and rules out hemorrhage. Use of systemic anticoagulation
is reserved for selected diagnoses (arterial dissection, cardiogenic embolic
stroke, and venous thrombosis) – discuss with Stroke Attending.
- Anticonvulsant treatment: Any child who had acute symptomatic
seizure at/around stroke symptom onset should be loaded with standard
loading dose of an AED (phenytoin or Phenobarbital). Neonates and young
infants with recurring seizures (multiple per day), or with clinical events
of uncertain character, should be considered for videoEEG monitoring ASAP.
- Initial/admission lab studies: request ED or referring
facility to obtain CBC, platelet count, PT, PTT, INR, BMP. Other labs
(eg thrombophilia or vasculitis work up) should be discussed with Stroke
Attending and admitting service.
- Special cases: For children with sickle cell anemia,
contact on-call hematology fellow to discuss imaging plans in relationship
to decisions about emergency exchange transfusion. Thrombolysis is not
used in patients with sickle cell anemia or with moya moya disease.