Code Stroke

QUICK LINKS:

Code Stroke - Staff Resource Site for Hyperacute Management of Stroke

  • This page contains relevant Protocols and Quick Reference material that can be used during "Code Stroke" activation.

  • This is a point-of-care resource and can be accessed easily on your mobile device - consider adding it to your home screen!

LOCAL Hospital Stroke Protocols

Intranet Clinical Stroke Protocols - please follow this LINK*

  • The above link provides hospital-specific protocols including, Code Stroke, TPA orders, Admission orders (which should not be used in paper format - use the electronic version), and supporting guidelines. Also, there are hospital-specific guidelines for management of anti-coagulation, reversal of blood thinners and TPA, and other useful information.

  • * Please note that you will need your network Login and Password to access this information.

  • In the rare event of an in-patient code stroke at NYGH, these patients are transferred to us, to our ED (if they meet a specific set of criteria) for assessment and potential intervention (TPA/EVT). Upon arrival to the ED, a Code Stroke is activated, much like if the patient was being transferred from their ER. There are specific protocols and contacts (phone calls) followed before such transfers occur - please click the LINK to find more information and go through the Physician Checklist.

  • * Please note that you will need your network Login and Password to access this information.

NeuroRadiologist Schedule - Code Stroke = Neuro Procedures Rad

EVT CODE STROKES - When Accepting a Patient

Important People to Notify - Follow These Steps:

If you have been phoned and accepted a "Code Stroke" patient to the ED for assessment and treatment, please ensure that you have taken the following steps: (Note to residents - if you are called by a physician from another hospital regarding a stroke transfer, especially from outside sources, please immediately discuss the case with the on-call fellow or staff).

STEP 1) Call ED Charge/CCL [88093], let them know about the patient, demographics, and to activate a Code Stroke when the patient arrives. Please ask that the patient is brought to a Resuscitation Room, Do Not transfer off the EMS stretcher unless clinically warranted to facilitate for urgent imaging.

STEP 2) Call Bed Flow (or the Shift Manager during off-hours and weekends) to let them know that you have accepted a stroke patient - Let bedflow know you have accepted a patient

  • Bed flow - During daytime hours - until approx. 7pm - Call 4315

  • Off hours, pager 6469, or Call Extension 4325

STEP 3) If going for EVT:

    • MUST CALL AHEAD BEFORE GOING TO ANGIO

      • Mon-Friday 0700-1900 Ext: 1430 (Angio Recovery Area)

      • Mon-Friday 1900-0700 Ext: 3532 or 3530 (Angio Control Room)

      • Weekends, Ext: 3532 or 3530

    • ensure interventionalist has spoke with Anesthesia - Anesthesia direct number is x. 7878

    • please call Bed Flow (or Shift Manager during off-hours) - Note that EVT patients need a Level II ICU bed or ICU bed-equivalent after the procedure.

*The above procedures is slightly modified for in-patient Code Strokes from within SHSC - in those instances, please Call Bed Flow or Shift Manager Only (as patient is not going to the ED).

STEP 4) ICU CONSULT [88111] - For Post-TPA -or- Post-EVT patients, please call the ICU Resident for an ICU Consult - please note that this is the first initial Consult Request and "Head's Up" phone call

    • IF the patient is going to PACU - please go with the patient, Provide in-person report to PACU

After Thrombectomy please call the ICU fellow - for B5ICU:

    • Between 7AM-4PM - 88112

    • After 4PM and until 7AM next day - 88114

General Considerations for EVT

"General Considerations for EVT" Flow Chart:

Overall, for all vessel occlusions amenable for EVT, a discussion with INR is recommended. "General Considerations for EVT" follows a colour coding:

  • Green boxes are "signposts" of criteria to consider for EVT: baseline function, clinical, radiographic, and timing (last seen well) characteristics of the patient.

  • Purple boxes are consideration elements that warrant further discussion with INR as these patients do not automatically get considered for EVT.

  • Blue boxes represent patients that require an individualized approach.

  • The Yellow box represent patients that have met all previous criteria (Pre-stroke status, Signs and Severity of Deficit, Imaging criteria) and are candidates for EVT.

  • Please note detailed imaging criteria, listed below ("CSBPR 2018 Guidelines - Imaging Criteria for EVT") for patients within 6hrs and beyond 6hrs after stroke onset.

DAWN / DEFUSE 3 Criteria - to be used for > 6hr for EVT Consideration

RAPID Training (www.irapid.com/training-rapid)

Late EVT Window, Greater than 6 hours (6-24Hrs)

DEFUSE3 criteria

  • ICA or MCA-M1 occlusion (carotid occlusions can be cervical or intracranial; with or without tandem MCA lesions) by MRA or CTA AND

  • Target Mismatch Profile on CT perfusion or MRI (ischemic core volume is < 70 ml (CBF<30), mismatch ratio is >/= 1.8 and mismatch volume* is >/= 15 ml) Alternative neuroimaging inclusion criteria (if perfusion imaging or CTA/MRA is technically inadequate): If CTA (or MRA) is technically inadequate:

  • Tmax>6s perfusion deficit consistent with an ICA or MCA-M1 occlusion AND Target Mismatch Profile (ischemic core volume is < 70 ml, mismatch ratio is >1.8 and mismatch volume is >15 ml as determined by RAPID software)

DAWN criteria (core measured CBF<30)

  • 0-<21 cc core infarct and NIHSS ≥ 10 (and age ≥ 80 years old)

  • 0-<31 cc core infarct and NIHSS ≥ 10 (and age < 80 years old)

  • 31 cc to <51 cc core infarct and NIHSS ≥ 20 (and age < 80 years old)

Lastly a word of caution. ALWAYS ensure you look at NCCT to assess hypo-density and correlate this with CBF core recalling that you may have a sub-acute infarct with luxury perfusion (therefore CBF>30 i.e. not showing as core on threshold to CBF map).


Graphic/table reference: Stroke, G. A., 2018. (n.d.). Use of Imaging to Select Patients for Late Window Endovascular Therapy. Am Heart Assoc. http://doi.org/10.1161/STROKEAHA.118.021011.)

B4ICU Criteria - Level 1, Level 2

Critical Care Monitoring for specific post-TPA and Post-EVT/TPA patients meeting below criteria

After a code stroke resuscitation, the patient needs a monitored bed for neurologic monitoring.

On the B4 Stroke Unit, there will ultimately be several types of beds.

  • Post-TPA ONLY - Level 1 (total 9 beds, currently 6, MRP = Orange Team) -these beds can provide every to every 2 hourly neuro vital signs, there is cardiac monitoring as well, there are no arterial lines, there are no infusions of vasoactive agents including pressors or infusions of labetalol, however certain medications requiring cardiac monitoring such as phenytoin, amiodarone can be provided. Other medications can be given IV, but and intermittent dosing.

  • Post-TPA and/or Post-EVT Level 2 (total 6 beds, currently 2, MRP = ICU) - these are equivalent to B5ICU beds, these patients can have vasoactive agents, have cardiac monitoring, and can have arterial lines, therefore if the patient requires infusion of vasoactive agents, which typically does require arterial line monitoring, these patients can go to this bed.

Definitions of ICU "levels":

  • Level I = observation, no vasoactive infusions, no BiPAP

  • Level II = observation, vasoactive infusions, invasive arterial/BP measurement, non-invasive ventilation - i.e. BiPAP

  • Level III = all advanced ICU measures, including above, and mechanical ventilation; this at our centre is CRCU

Active Research Studies - Inclusion/Exclusion Criteria - Point of Care Reference Material:

Repatriation and Consultation Notes

When patients are repatriated, at times we may want to fax completed notes, beyond the written consultation note. For this purpose, the following ED Fax numbers can be utilized to fax the report:

Hospital ED / FAX #

North York General / 416-756-6793

Mackenzie Health / 905-883-2138

Toronto Western / 414-603-5288

Scarborough and Rouge- General Site / 416-431-8164

Scarborough and Rouge-Centenary Site / 416-281-7455

Other Key Access Points:

ICU Fellow #s - direct

ICU CONSULT RESIDENT - 88111

Emerg/Float/Rapid 88121

CRCU blue 88197

CRCU green 88118

CVICU 88114

B5ICU 88112 (AM) Overnight 88114 (4PM-7AM M-F, and W/E) - During COVID-19, 88112 for B5ICU and B4ICU Level 2

Rapid Response 7887 - Rapid RN direct access Line

ICU Extensions

B5 4189

D4 7811

C3 4182

C5 4187

CRCU 4196

M2 extended ICU 7811

PACU 4240

Neuroradiology fellow 1404

ASC Calendar

Stroke RN Calendar