2. Prof. Dr / Atef Radwan
The dean of the faculty of medicine zagazig unversity
Prof. Dr / Hanan Abdel Azim
Professor at the Neurology department
Dr / Hala Hafez
MD of neurology
Dr/ Ahmed Abdul Sabour
ALS instructor at the ERC & head of DMTC
Dr/ Shaimaa El-Aidy
Resident doctor at the neurology department

3. Case 1 at the ER
55 years old male with severe headache & slurred
speech .
What is your attitude as a house officer ?

4. Case 1
55 years old male with history of Hypertension
presented to the ED at 8 AM with severe headache
& slurred speech .
The patient was last seen normal by his relatives
before sleeping at 11 PM yesterday .
What is your attitude as a house officer ?

5. Case 2
65 years old female with history of DM &
Hypertension presented to the ED at 12 PM with
acute onset of left side face drop , weakness at left
arm & left leg started at 10:30 AM .
What is your attitude as a house officer ?

6. Case 3
65 years old female with history of DM &
Hypertension presented to the ED with Seizures
occurred 1 hour ago with no known history of
epilepsy .
What is your attitude as a house officer ?

7. Vital signs
BP : 200 / 110
RR : 15/ min
Temp : 37.4 ˚c
Pulse : 102 / min , Irregular , equal on both sides
RBS : 300 mg/ dl
CT ordered

8. • O2 saturation = 85 % .. The patient needs O2
• The patient GCS is not reported
• You missed the patient silent MI / Arrythmia
.. Do ECG
• Calling acute stroke team
• Lab
• Urgent CT
• …………….
• …………….

9. • Time Zero … ?
It’s The time when the patient is last seen normal
• Previous history of :
1. Seizure
2. HPN / DM / Seizures
3. Trauma / surgery
4. Previous stroke .. When ?
5. Medications ( anticoagulant since … ? )
• Associated emergencies :
MI / DKA / Hypertensive crisis / Heamorrage

11. Case 2
Your Grandfather 65 years old male with history of
DM & Hypertension suffered sudden weakness in
his right arm & leg with mouth deviation
-Will you give him Asprin ?
No
-What if symptoms relieved in 10 mins ?
It’s A TIA  R/ Asprin 75 mg 1x2
-What to do next ?
Call EMS 123

12. Chain of Survival

13. When to suspect stroke ?
1. Sudden numbness or weakness of the face, arm or
leg (especially on one side of the body)
2. Sudden confusion, trouble speaking or
understanding speech
3. Sudden trouble seeing in one or both eyes
4. Sudden trouble walking, dizziness, loss of balance
or coordination
5. Sudden severe headache with no known cause
ACLS guidelines 2012

14. Pre-hospital EMS actions
•Support ABCs ( BLS )
•Pre-hospital Stroke assessment
3 orders ( Cincinnati Pre- Hospital Stroke scale )
Ask the patient to
1. Smile  +/- deviation in one / both sides
2. Close his eyes and both arms straight with palms up 10 seconds  +/- Hand drift one /
both sides
3. Tell you the time or place or ( you can’t teach an old dog new tricks )  Slurred speech
•Time Zero ?
•Alert the nearest hospital with stroke team
ACLS guidelines 2012
•Check glucose ( If possible )

15. Time zero :
• Def:
It’s The time when the patient is last seen normal
• It’s important for thrombolytic therapy administration
decision
• If > 8 hs or not identified  absolute contraindication
for r-TPA
ACLS guidelines 2012

17. ACLS guidelines 2012

18. Time Is brain
ACLS guidelines 2012

19. Our Timeline
ACLS guidelines 2012

20. In 10 minutes
ACLS guidelines 2012

21. In 10 minutes
Airway - Check airway if needed ( Head tilt / Chin left or Jaw thrust )
- Clear the air way If obstructed and choose a suitable airway **
ACLS guidelines 2012

22. In 10 minutes
Breathing - Check for breathing ( Look , Listen & feel and count to 10)
- Auscultate and Percuss the Chest / Tidal volume / equality
If No Pulse / No breath Oxygen for O2 Saturation < 92 %
- Apply pulse oximeter ..
Start resuscitation Algorithm
Circulation - Vital signs
- IV line
ACLS guidelines 2012

23. In 10 minutes
Disabilty - Glascow Coma Scale / AVPU / NIHSS
- Lab
(CBC , RBS , ABG , -- PT , PTT , INR -- , Cardiac enzymes )
NB : Cardiac enzymes for suspected MI patients only .
- R/ Thiamine 100 mg IV
- Order CT & Call Acute stroke team / Neurologist
- ECG for arrhythmias or acute MI ( Shouldn’t delay Urgent CT )
- General examination ( pupil & signs of meningeal irritation)
ACLS guidelines 2012

24. ** Pupil examination ( Light reflex )
•Pin point / sluggish reaction 
Pontine hemorrhage .. ( Do urgent CT )
•Intial dilatation + loss of light reactivity 
Trans-tentorial herniation
** Signs of meningeal irritation
1. Exam: Nuchal Rigidity
2. Exam: Spinal Rigidity
3. Exam: Kernig's Signs
4. Exam: Brudzinski's Sign

25. In 25 minutes
* Rapid History Taking
* Determine Time Zero
* Neurological Examination NIHSS
* Do the head CT
ACLS guidelines 2012

26. Don’t Give
Aspirin / Heparin / Iv thrombolytic
therapy
Unless after reading CT
ACLS guidelines 2012

27. In 45 minutes
•Read CT
•Take decision according to  CT result & Time Zero
ACLS guidelines 2012

28. Imaging modalities
1- CT :
(( to exclude intracranial hemorrhage ))
** Urgently in 10 mins from ED arrival if :-
Fever – Papilloedema – Seizures
** In 25 mins from ED arrival if :-
if Signs of Subarachnoid hemorrhage / Pinpoint pupil present
** If free at the 1st time from ICH  repeat 24 hours later if
deteriorating neurological deficit to determine the site of the
infarction
2- MRI .. When ?
Suspecting Posterior circulation Ischemia ( Basilar Artery occlusion )

29. Decision Taking according to CT reading
Check for Hemorrhage
Yes No
Call a Neurologist Recanalisation Candidate ?
Stable Patient ? - Check exclusion criteria
- Rapid neurological reassessment
Yes No Still candidate ?
No Yes
R/ Asprin ( 1x2 ) up to 325 mg/d
Ward admission
Call Acute Stroke team
ACLS guidelines 2012
ICU admission Thrombolytic therapy

30. 1 - AVPU score
- Alert
- Verbal response
- Pain responsive
- Unresponsive
2 - Glascow ( Total score = ... /15 )
- Motor response
- Verbal response Score Severity
- Eye opening 13-15 Mild
9-12 Moderate
3-8 Severe
3 - NIHSS ( Total score = ... /42 )
- Modified NIHSS ( Total score = ... /31 )
OXFORD neurology 2011

31. 1 - AVPU score
2 - Glascow ( Total score = ... /15 )
3 - NIHSS ( Total score = ... /42 )
- Modified NIHSS ( Total score = ... /31 )
OXFORD neurology 2011

32. National Institutes of Health Stroke Scale
Used for :-
1- Thrombolytic therapy decision making
2- Prognosis of stroke
OXFORD neurology 2011

33. Level of conciousness LOC ** 3
LOC questions 2
LOC Commands 2
Best Gaze 2
Visual field 2
Facial palsy ** 3
Motor arm Rt. & lt. 4+4
Motor Leg Rt. & lt. 4+4
Limb Ataxia ** 2
Sensory 2
Intinction & Extinction ** 2
Language 3
Dysarthria 3
Total NIHSS 42
Total modifed NIHSS 31

37. Score Stroke grade
0 No
1-4 Minor
5 - 15 Moderate
16 - 20 Moderate to severe
21 - 42 Severe
OXFORD neurology 2011

38. * Total score = … /31
* Includes All NIHSS Except:-
1. Level of consciousness
2. Facial palsy
3. Limb ataxia Depends on the patient cooperation
4. Sensory response
5. Extinction & Inattention
OXFORD neurology 2011

40. Penumbra :- Area at risk

41. ( Start within 1 hour from arrival to ED )
General Complication
Supportive Care Neurological Reversal of
detection &
monitoring coagulopathy
&Palliative care management

42. General supportive care & palliative care :
(A) (B) (C)
1-Oxygenation 1- Cardiac monitoring 1- Head positioning
2- Blood pressure 1st 24 hours ( Elevated at 20-30 ˚)
( See BP control ) 2- Swallowing assessment 2- Body positioning
3-Temperature (for nasogastric tube 3- DVT prophylaxis
( See Fever control ) application & oral drug * Elastic stocking
4-Blood glucose administration ) * Raise the legs
( Measure 1x 4 x 3 & 3-Drugs * UFLMWH 5000 1x2
control with Insulin ) * Anti-platelet After 48 hs.
5- Hydration *Anticoagulant 4-Bowel & bladder care
6- Lab *NSAID 5-Skin Integrity
*Lipid lowering drugs Inspect skin sacrum, heels,
*Vitamins elbows, shoulders for
4- Treatment of other pressure sores regularly
co-morbidities

44. Triple (H) therapy in Subarachnoid
hemorrhage :
– Hydration
– Hemodilution
– Hypertension ( Not < 140/90 )

45. Pyrexia
- Paracetamol (oral or intravenous)
-Wet sponging
- Removal of blankets and application of fans.
** Recheck in 1 hour  If pyrexia persists :
Septic source?!  (i.e. physical examination, chest x-ray, urine, sputum,
blood cultures as clinically indicated)  Appropriate antibiotics
Hydration
IV normal saline ( avoid glucose solutions ) at a rate to maintain Euvoleamia &
Monitored via Fluid balance chart
Palliative care
1- Pain control & sedation
2- Physiotherapy
3- Speech therapy ( after 24 hours )

46. ( Start within 1 hour from arrival to ED )
General Complication
Supportive Care Neurological Reversal of
detection &
monitoring coagulopathy
&Palliative care management

47. 1- Continuous scoring
2- Increased intracranial tension ??

48. 1- Glasgow Coma Scale (GCS)
- Hourly for the first 24 hours
- 2-4 hourly for next 48 hours if stable
•A decrease in GCS of ≥ 2 points from baseline 
Neurological decline ( urgent medical assessment is required )
* GCS ≤ 8 is predictive of impending cardiorespiratory arrest
OR NIHSS … score from 42
Score :-
>4 points increase in the score  deterioration
OR Modified NIHSS … score from 31
Score :-
< 12  Good prognosis ≥12 Poor prognosis

49. 2- Increased intracranial pressure
* Signs:-
- Reduced consciousness
- Headache , nausea , projectile vomiting
- Visual disturbance
- Seizures
-Sudden increase in blood pressure
* Treatment :-
- Exclude ICH by CT
- R/ Mannitol (0.25-1 gm/kg)
- Lumber puncture for decompression
- Hemi-Craniotomy

50. ( Start within 1 hour from arrival to ED )
General Complication
Supportive Care Neurological Reversal of
detection &
monitoring coagulopathy
&Palliative care management

51. 1- Correct coagulopathy ( guided by PT , PTT , INR )
Treatment :- Platelets & Cryo precipitate
2- Recanalisation therapy

54. 1- Angiodema
2- Intracranial heamorhage

55. 1- Angiodema
How to suspect ?
.. Occurs more with patients treated with ACEI
So , Examine tongue 20 mins before the end of infusion

56. Action : - Discontinue IV r-TPA early
- R/ Diphenhydramine 50 mg IV ( H1- Blocker )
- R / Ranitidine 50 mg IV ( H2- Blocker )
If toungue continues to enlarge
- R/ Methylprednisolone 100 mg IV ( Corticosteroid )
If toungue continues to enlarge
- R/ Epinephrine 0.1 mg IV or 0.5 ml Nebulizer
If toungue continues to enlarge
Call Anaethesiologist

57. Call Anesthesiologist
Large toungue & Large toungue & Severe stridor &
oral intubation is oral intubation is Impending airway
possible impossible obstruction
Oropharyngeal Fiberoptic naso- Tracheostomy
airway tracheal intubation

58. 2- Intracranial hemorrhage
How to suspect ?
- Check signs of increased ICP
- Worsening of neurological status

61. 1- Tight glyceamic control … ( >400 mg/dl  poor outcome )
R/ Insulin IV or SC if serum glucose levels are > 200 mg/dL
2- Tight Bl. Pressure control
To lower their risk of intracerebral hemorrhage following
administration of tPA.
See table for Hypertention treatment
Target Systol Diastol
Before infusion <185 mmHG <110 mmHG
24 hours after infusion (-5 ) <180 mmHG <105 mmHG
Check blood pressure
Measure during or after / 15 min  first 2 hrs
/ 30 min  next 6 hrs
Treatment

62. 3- Regular neurological monitoring ( See next )
4- Confirm the absence of Pericarditis associating MI
( Auscultate the pericardial rub )
5- Monitor for signs of bleeding , angiodema or increased
Intracranial tension
6- Avoid labs or any intervention on the next 24 hours to avoid
bleeding

63. ( Start within 1 hour from arrival to ED )
General Complication
Supportive Care Neurological Reversal of
detection &
monitoring coagulopathy
&Palliative care management

64. 1- Seizures
2- Increased intracranial pressure
3- Complication of r-TPA & management :
Intracranial hemorrhage
Angiodema
4- Venous thrombo-embolism ( ttt : IVC filter )

65. 1- Seizures
** Empirical prophylactic anticonvulsant therapy  Not recommended
As a Prophylaxis …
R/ phenytoin
OR R/ levetiracetam
** Sodium valproate ( avoided )

66. ** Anticonvulsant therapy is indicated in
1- Observed seizures / Epilepsy ( Status epilepticus )
2- Change in mental status associated with EEG changes

67. NB : Oral anticoagulation related intracranial
haemorrhage
•Patients on warfarin with an elevated INR require urgent reversal
of coagulopathy.
- Stop warfarin
- Vitamin K 10mg IV
- Prothrombinex (25-50 IU/kg) IV
-Fresh Frozen Plasma (150-300ml)
•Recheck INR post infusion and administer further Prothrombinex
and Fresh Frozen Plasma if INR
not normalized.
•Early consultation with haematology for patients taking rivaroxeban
or dabigatran is recommended.

68. 1. Ophthalmoscope training workshop & equippement
availability
2. Thrombolytic therapy
3. Stroke suspecting culture ( 3 orders )
4. NIHSS quick application in 25 mins from arrival
5. Lab Facility in 10 mins

69. - ACLS 2012 guidelines
- www.emedicine.com
- Oxford press ( Neurology emergencies ) text book
- http://www.fpnotebook.com/neuro/exam
- www.pubmed.com
- Egyptian ministry of health protocols 2012