Code Stroke


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 - ABOVE - with regards to the Thrombectomy NOTICE page, when going to EVT/confirmed, Thrombectomy GO-TO page, and if Cancelling then Cancel Thrombectomy Notice Page.

Steps 1-4 Have Now been REPLACED by the Thrombectomy Pages above - these are outlined below just in-case/FYI:

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/weekend and holidays, call Locating - ask for the Shift Manager on-call.

STEP 3) If going for EVT:


      • 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 our institution - 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 (

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.

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 Numbers

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

Stroke Key Number

B4 main 7870
Team lead on B4 - 89077
Social worker - 5979, pager 8358
Rapid Response 7887
Inpatient pharmacy - 2528
K3E - 4107
Phone in A450 conference - 7187
Laboratory test - 4227
Neuro radiology - Pager 4158 pager NeuroRad Fellow x. 2072

Acute Stroke Coordinator On-Shift

Code Stroke RN On-Shift