The 8 D's of Stroke Care

According to the National Stroke Association, strokes are the fourth leading
cause of death in the United States. Even if an individual survives a stroke, it
can lead to permanent impairment. Depending on the extent of damage to the
brain, a stroke may leave a person with deficits such as vision loss, memory
problems and/or paralysis or weakness on one side of the body.

Fast recognition and treatment can not only make the difference between life
and death, but it can also decrease long-term disabilities. To develop a
streamlined response to potential stroke patients, the American Heart
Association developed the Stroke Chain of Survival. The chain involves eight
links or steps to be taken by patients, family members, prehospital and
emergency room personnel in caring for stroke patients.

This streamlined approach to stroke is an effective way to ensure that

appropriate care is delivered as quickly as possible, optimizing the possibility
of full recovery. Each of the 8 D’s in the chain of survival are critical steps
which increase the likelihood of prompt diagnosis and treatment of stroke.

Detection: Detection involves recognizing the signs and symptoms of an

acute stroke. Early signs of a stroke include weakness on one side of the
body, slurred speech and facial drooping. Early detection and recognition of
stroke symptoms speeds the implementation of appropriate medical
interventions and improves patient outcomes.

Dispatch: The second step in the chain of survival is ‘dispatch’, which involves
activating emergency medical services. In most cases, this involves calling
911. Medical dispatch should be thoroughly trained to identify a possible
stroke patient so that the appropriate level of EMS services can be
dispatched to the patient. Simply stated, the faster EMS can be dispatched,
the quicker lifesaving treatment can be delivered.

Delivery: Delivery is the prompt transport of the patient to a hospital,

preferably a stroke center. Emergency medical personnel should be trained in
performing a rapid assessment of the patient’s condition. If a stroke is
suspected, the patient should be transported to an appropriate receiving
hospital as soon as possible. A medical history and baseline mental status
should be documented. The time since onset of symptoms should also be
noted and is referred to as ‘time zero’, or the last time the patient was seen to
be normal. Emergency medical workers need to provide pre-arrival information
to the receiving facility so that the ED can prepare for the arrival of a
potential stroke patient.

Door: The fourth step in the chain of survival is ‘door’, which refers to the
arrival of the patient at the emergency room (ED). Ideally, the stroke team
should be in place at the receiving facility prior to the patient’s arrival to
ensure prompt assessment and diagnosis. According to recommendations
from the National Institute of Neurological Disorders and Stroke, an
assessment should be completed by an ER physician within ten minutes of
arriving in the ED.

Data: Data collection is a vital component of the chain of survival. Data

collection includes results from laboratory tests and both a physical and a
neurological exam. A 12-lead electrocardiogram is recommended to rule out
cardiac arrhythmias. In addition, a CT scan is an essential piece of the puzzle
and is needed for an accurate diagnosis. A CT scan should ideally be
performed within 25 minutes of arrival in the emergency room. Data collected
is also needed to rule out conditions which may mimic a stroke, such as a
brain tumor, drug overdose or hypoglycemia.

Decision: A ‘decision’ regarding the type of treatment needed is the next step
in caring for a patient with a stroke. Information, such asthe type of stroke
which has occurred and the time from onset of symptoms, is considered
before a treatment decision is made. The severity of the stroke may also play
a role in deciding what the most appropriate treatment will be. The patient
and family members should also be informed of the risks and benefits of
treatment options.

Drug/Device: Drug administration, if appropriate, is the next link in the chain

of survival. If the patient is a candidate for fibrinolytic therapy, the window of
opportunity for administration is narrow. According to the American Heart
Association guidelines, fibrinolytic therapy should be administered within
three hours of the onset of symptoms. If the patient is not a candidate for
drug therapy they may qualify for Endovascular therapy to remove the clot
mechanically rather than with fibrinolytics.

Disposition: Disposition is the last link in the chain of survival. This step in
stroke care focuses on the continuing care of the stroke patient. It is
recommended that patients be admitted to an intensive care unit or stroke
unit within three hours of arrival in the ED. Continued monitoring of a stroke
patient includes frequent assessment of neurological status and monitoring of
glucose levels and vitals, as well as prevention of complications. Determining
the cause of the stroke is also part of disposition.

Sources

Juach, E. Cucchiara, B. 2010 American Heart Association Guidelines for

Cardiopulmonary Resuscitation and Emergency Cardiovascular
Care.Circulation.
2010. http://circ.ahajournals.org/content/122/18_suppl_3/S818.full Accessed
August 2014.

National Institute of Neurological Disorders and Stroke. Stroke Proceedings;

Acute
Care. http://www.ninds.nih.gov/news_and_events/proceedings/stroke_proceedi
ngs/recs-acute.htm Accessed August 2014.
The Stroke Foundation. http://www.thestrokefoundation.com/index.php/about-
stroke/62-the-seven-d-s-of-stroke-survival Accessed August 2014.

American Heart Association Advanced Cardiac Life Support Provider Manual

(2016)