Suspected Stroke Algorithm

11 Do you suspect stroke?

INCLUSION
• Is there focal neurological deficit? (ex: unilateral weakness/sensory change, vision loss, double vision, speech difficulty,
Patients with dizziness, difficulty walking)
signs and • Did the problem begin or get worse suddenly?
symptoms • Does patient meet high risk conditions? (ex: Sickle Cell Disease, Congenital Heart Disease, Moyamoya, Neoplasms,
concerning Hypercoaguable state, previous stroke)
for an acute *If yes to any of the above, proceed to neuroprotection checklist
focal with goal of completing within 10 min of initial suspicion.
neurologic
deficit (see
screening
questions to
the right).

NeuroProtection (LIP) NeuroProtection (Nursing)

Consults Monitoring:
□ Urgently page Neurology Fellow to □ HOB flat & strict bedrest
EXCLUSION: determine prioritization of emergent □ Continuous HR/RR & pulse ox monitoring
scan □ Q15 min vitals (including BP)
Neonates □ Q15 min neurochecks
<28 days □ Maintain temperature 36-37°C, use antipyretics & active cooling PRN
Monitoring:
□ Neuroprotection (ex: ice packs, cooling blanket, Arctic Sun )
(from suspected stroke order set) □ Maintain normotension for age & treat hypotension (see Table 1)

Diet/Fluids: Diet/Fluids:
□ NPO □ NPO
□ INSERT PIV (PRN) □ Draw labs (see orders)
KEY POINT
□ D5 + 0.9NS @ 1.5x Maintenance, □ Infuse D5 + 0.9NS at rate of 1.5 x maintenance, unless otherwise
For unless contraindicated indicated
suspected
stroke Obtain Stat Baseline Labs & Studies:
patients, the Labs & Studies (all STAT):
goal is to □ Serum: CBC, BMP, PT/PTT/INR □ Serum: CBC, BMP, PT/PTT/INR
initiate □ Urine: Utox, urine HCG □ Urine: Utox, urine HCG
neuro- □ iStat w/lytes (if N/A – accucheck) □ iStat with electrolytes (if not available – accucheck)
protective
measures
immediately
and send Special Considerations (additional labs): Special Considerations
patient to  Sickle Cell patients: hemoglobin  Sickle Cell patients: hemoglobin electrophoresis, type/screen
MRI within electrophoresis, type/screen
30 minutes
of initial
suspicion.

© Ann & Robert H. Lurie Children’s Hospital of Chicago Last update: 10.19.17
This clinical care guideline is meant as a guide for the healthcare provider, does not establish a standard of care in legal matters, and is not a substitute for
medical judgment which should be applied based upon the individual circumstances and clinical condition of the patient.
 Suspected Stroke Algorithm
How Much Time Has Passed Since Patient’s Last Known Normal Exam ?

˂24 hours ˃24 hours

Primary Service LIP:
Bedside RN: Primary Service LIP:
 Together with Neurology,
 Together with patient family,
determine prioritization of
complete MR screening form
emergent scan
a  Together with Neurology,
(must complete priority questions determine timing of
 Order STAT MR Ventricle with
at a minimum)* neuroimaginga
DWI and GRE from suspected
 Receive call from MRI Den RN to
stroke order set AND call MRI  Consider admission for further
confirm scan time
Den RN to confirm order receipt workup
(x 73740)
Target time: within 30 min, sedation
generally NOT required

a
Team to Discuss Head CT with Neurology if:
⦁ MRI contraindicated based on MR screening results and/or knowledge of patient-specific contraindications
⦁ Concern for intracranial hemorrhage
or increased ICP
⦁ If MRI not readily available or patient will not tolerate MRI scan

Bedside RN prepares patient for MRI by removing all clothing/equipment other than a metal-free gown:
□ Remove 12 Lead EKG stickers and medication patches with metal backings
□ If patient with Bivona trach, discuss potential switch to Shiley trach with team
□ If patient with medication infusions that cannot be paused,
prime and connect MRI tubing
□ If patient on respiratory support, secure respiratory therapist and any additional equipment needed

Bedside RN transports prepared patient and patient’s parent/guardian to MRI on 5th floor for scan

Upon patient arrival, MRI tech or RN will:

 Complete any remaining questions on MR screening form & obtain parent/guardian signature
 Complete visual patient and staff metal check
 Place MRI-compatible patient monitoring devices
 Together with bedside RN, place patient in scanner

Review Patient MRI results

Acute Stroke:
ICH:  Admit to PICU (CCU if congenital heart disease)
Image Negative:
URGENT Neurosurgical  Complete stroke event note in Epic
 Consider stroke mimics
Consult  Continue neuroprotection
 Adjust neuroprotection
 Start IV Carnitine 100 mg/kg/d divided Q8hrs
orders as necessary
 Initiate acute treatment (See Confirmed Stroke Order Set)
 Order MRA head & neck or CTA
 Adjust neuroprotection orders as necessary

**Discuss emergent automated red cell exchange for sickle cell patients

© Ann & Robert H. Lurie Children’s Hospital of Chicago Last update: 10.19.17
This clinical care guideline is meant as a guide for the healthcare provider, does not establish a standard of care in legal matters, and is not a substitute for
medical judgment which should be applied based upon the individual circumstances and clinical condition of the patient.
 Suspected Stroke Algorithm

TABLE 1: Normotension
*Normotension defined as blood pressure within 50th- 90th percentile for age
50th percentile for Systolic/Diastolic BP by age group
1-12mo 1-3y 4-6y 7-9y 10-12y 13-15y >16y
Girls 92/55 88/45 93/54 98/58 103/61 109/64 111/66
Boys 92/55 88/42 95/53 99/59 104/61 111/63 116/65
90 percentile for Systolic/Diastolic BP by age group
th

1-12mo 1-3y 4-6y 7-9y 10-12y 13-15y >16y

Girls 103/66 101/59 106/68 111/72 117/75 122/78 124/80
Boys 103/66 102/57 108/68 112/73 117/76 125/78 130/80

Zinner et al. Significance of Blood Pressure in Infancy. Hypertension (1985) 7:411-416;

The Fourth Report on the Diagnosis, Evaluation, and Treatment of High Blood Pressure in Children and Adolescents. NIH publication no 05-5267.

© Ann & Robert H. Lurie Children’s Hospital of Chicago Last update: 10.19.17
This clinical care guideline is meant as a guide for the healthcare provider, does not establish a standard of care in legal matters, and is not a substitute for
medical judgment which should be applied based upon the individual circumstances and clinical condition of the patient.
 Suspected Stroke Algorithm

Evidence Bernard, T.J., et al. Emergence of the Primary Pediatric Stroke Center: Impact of the Thrombolysis in
Pediatric Stroke Trial. Stroke. 2014; 45: 2018-2023.

DeLaroche, A.M., Sivaswany, L., Mphil, A.F. & Kannikeswaran, N. Stroke Clinical Pathway Improves the Time
to Diagnosis in an Emergency Department. Pediatric Neurology. 2016: 1-6.

Elbers, J., Wainwright, M.S. & Amlie-Lefond, C. The Pediatric Stroke Code: Early Management of the Child
with Stroke. The Journal of Pediatrics.

Rafay, M.F., et al. Delay to Diagnosis in Acute Pediatric Arterial Ischemic Stroke. Stroke. 2009; 40: 58-64.

© Ann & Robert H. Lurie Children’s Hospital of Chicago Last update: 10.19.17
This clinical care guideline is meant as a guide for the healthcare provider, does not establish a standard of care in legal matters, and is not a substitute for
medical judgment which should be applied based upon the individual circumstances and clinical condition of the patient.