🧠 ACLS Deep Dive: Stroke Edition (High-Yield & Real-World) 🚨

1️⃣ Stroke Chain of Survival — “Time = Brain” Recognize ➡️ Call 9-1-1 🚑 ➡️ EMS alerts hospital ➡️ Rapid diagnosis ➡️ Treatment (thrombolytics or EVT). Goal: minimize brain injury, maximize recovery. Every minute = 1.9 million neurons lost. ⏱️

2️⃣ Critical Drug — Alteplase (tPA) 💉 • Window: ≤3 hr from symptom onset (extend to 4.5 hr in select pts). • EVT (mechanical thrombectomy): up to 24 hr for large-vessel occlusion (LVO). • Dose: 0.9 mg/kg (10% bolus 1 min → 90% infuse 60 min; max 90 mg). • BP goal: ≤185/110 mm Hg before tPA and ≤180/105 mm Hg for 24 hr after. • Absolute no-go: any intracranial hemorrhage on CT/MRI 🚫. • Watch glucose: correct hypo and avoid >180 mg/dL.

3️⃣ Airway & ABCs 🫁 Assess airway → oxygen if SpO₂ ≤ 94% or unknown. Stroke pts risk aspiration and hypoventilation — keep suction ready and watch for airway obstruction.

4️⃣ Rapid Algorithm (What to Know Cold)

1️⃣ Activate Stroke Team immediately upon EMS notification.

2️⃣ General + Neuro assessment within 10 min of arrival.

3️⃣ CT/MRI ≤ 20 min (best practice: direct to scanner).

4️⃣ Interpret ≤ 45 min → if hemorrhage = NO tPA.

5️⃣ If no bleed → administer tPA (if eligible).

6️⃣ Door-to-Needle: ≤ 60 min (Goal: 85% meet this).

7️⃣ EVT: Door-to-device ≤ 90 min (direct) / ≤ 60 min (transfer).

5️⃣ Nursing Priorities & Critical Thinking 🩺 🚨 Activate stroke system immediately when symptoms recognized. 💉 Start IVs early (but don’t delay CT). 💨 Maintain airway + O₂ ≥ 94%. 🩸 Monitor BP closely during and after tPA. 🧾 Document last known well time — it defines eligibility. ⚡ Do NOT delay CT for ECG or labs — “Time is Brain.”

6️⃣ Key Contraindications / Exam Traps ⚠️ • Hemorrhage on imaging = NO tPA. • BP >185/110 mm Hg = NO tPA until controlled. • Do not delay CT/MRI for Atropine or Adenosine (if brady/tachy). • Uncontrolled HTN, active bleeding, or recent surgery = 🚫. • Treating stroke mimics w/ tPA can cause ICH — consult stroke expert.

7️⃣ Critical Times You Must Memorize ⏰ • General assessment ≤ 10 min • CT/MRI obtained ≤ 20 min • CT interpreted ≤ 45 min • Door-to-needle ≤ 60 min • Door-to-device (Thrombectomy) ≤ 90 min

8️⃣ “Gotcha” Moments 🧩 💡 Never give tPA before imaging rules out bleed. 💡 Never “wait for labs” before CT unless they directly affect tPA eligibility (e.g., coags). 💡 Aggressive BP lowering before CT can mask stroke severity — treat only if >220/120 and no tPA planned.

9️⃣ 2-Min Quick Recall 🔥

1️⃣ Ischemic = 87% of strokes 🧠

2️⃣ CT/MRI ≤ 20 min → NO BLEED = candidate for tPA

3️⃣ Door-to-Needle ≤ 60 min

4️⃣ Alteplase 0.9 mg/kg (max 90 mg) — 10% bolus, 90% infuse 60 min

5️⃣ BP < 185/110 before tPA; maintain < 180/105 after

6️⃣ O₂ ≤ 94% → supplement

7️⃣ “Time is Brain” — act fast or neurons die.