"ischemic stroke" AND "acute treatment"

ls /home/daytona/workspace/ && mkdir -p /home/daytona/workspace/stroke-pocket-gu…

~/stroke-pocket-guide/generate_pocket_guide.py

from reportlab.lib.pagesizes import A4
from reportlab.lib import colors
from reportlab.lib.units import mm, cm
from reportlab.platypus import (
    SimpleDocTemplate, Paragraph, Spacer, Table, TableStyle,
    HRFlowable, KeepTogether
)
from reportlab.lib.styles import getSampleStyleSheet, ParagraphStyle
from reportlab.lib.enums import TA_LEFT, TA_CENTER, TA_RIGHT
from reportlab.pdfbase import pdfmetrics
from reportlab.pdfbase.ttfonts import TTFont

OUTPUT = "/home/daytona/workspace/stroke-pocket-guide/Acute_Stroke_Pocket_Guide.pdf"

# ── Colour palette ──────────────────────────────────────────────────────────
RED        = colors.HexColor("#C0392B")   # danger / header
ORANGE     = colors.HexColor("#E67E22")   # warning
DARK_BLUE  = colors.HexColor("#1A2F5A")   # section headers
MID_BLUE   = colors.HexColor("#2980B9")   # sub-headers
LIGHT_BLUE = colors.HexColor("#D6EAF8")   # row highlight
LIGHT_GREY = colors.HexColor("#F2F3F4")   # alternate rows
GREEN      = colors.HexColor("#1E8449")   # ok / go
YELLOW_BG  = colors.HexColor("#FEF9E7")   # caution boxes
WHITE      = colors.white
BLACK      = colors.HexColor("#1C1C1C")

# ── Document ─────────────────────────────────────────────────────────────────
doc = SimpleDocTemplate(
    OUTPUT,
    pagesize=A4,
    leftMargin=12*mm, rightMargin=12*mm,
    topMargin=10*mm, bottomMargin=10*mm,
    title="Acute Stroke Pocket Guide",
    author="Orris Clinical Reference"
)

W = A4[0] - 24*mm   # usable width

# ── Styles ───────────────────────────────────────────────────────────────────
base = getSampleStyleSheet()

def S(name, **kw):
    """Quick ParagraphStyle factory."""
    return ParagraphStyle(name, **kw)

sTitle = S("sTitle",
    fontSize=18, leading=22, textColor=WHITE,
    fontName="Helvetica-Bold", alignment=TA_CENTER, spaceAfter=2)

sSubtitle = S("sSubtitle",
    fontSize=9, leading=12, textColor=colors.HexColor("#BDC3C7"),
    fontName="Helvetica", alignment=TA_CENTER)

sSectionHdr = S("sSectionHdr",
    fontSize=9, leading=11, textColor=WHITE,
    fontName="Helvetica-Bold", alignment=TA_LEFT,
    leftIndent=4, spaceBefore=2, spaceAfter=2)

sSubHdr = S("sSubHdr",
    fontSize=8, leading=10, textColor=DARK_BLUE,
    fontName="Helvetica-Bold", alignment=TA_LEFT,
    spaceBefore=3, spaceAfter=1)

sBody = S("sBody",
    fontSize=7.5, leading=10, textColor=BLACK,
    fontName="Helvetica", alignment=TA_LEFT,
    spaceAfter=1)

sBold = S("sBold",
    fontSize=7.5, leading=10, textColor=BLACK,
    fontName="Helvetica-Bold", alignment=TA_LEFT)

sSmall = S("sSmall",
    fontSize=6.5, leading=8, textColor=colors.HexColor("#555555"),
    fontName="Helvetica", alignment=TA_LEFT)

sAlert = S("sAlert",
    fontSize=7.5, leading=10, textColor=RED,
    fontName="Helvetica-Bold", alignment=TA_LEFT)

sGreen = S("sGreen",
    fontSize=7.5, leading=10, textColor=GREEN,
    fontName="Helvetica-Bold", alignment=TA_LEFT)

sCellBold = S("sCellBold",
    fontSize=7.5, leading=9, textColor=BLACK,
    fontName="Helvetica-Bold")

sCellBody = S("sCellBody",
    fontSize=7, leading=9, textColor=BLACK,
    fontName="Helvetica")

sCellWhite = S("sCellWhite",
    fontSize=8, leading=10, textColor=WHITE,
    fontName="Helvetica-Bold")

# ── Helper: coloured section header bar ─────────────────────────────────────
def section_bar(text, bg=DARK_BLUE, fg=WHITE, icon=""):
    full = f"{icon}  {text}" if icon else text
    tbl = Table([[Paragraph(full, sSectionHdr)]],
                colWidths=[W], rowHeights=[14])
    tbl.setStyle(TableStyle([
        ("BACKGROUND", (0,0), (-1,-1), bg),
        ("TOPPADDING",    (0,0), (-1,-1), 3),
        ("BOTTOMPADDING", (0,0), (-1,-1), 3),
        ("LEFTPADDING",   (0,0), (-1,-1), 6),
    ]))
    return tbl

# ── Helper: two-column layout ────────────────────────────────────────────────
def two_col(left_items, right_items, lw_frac=0.50):
    lw = W * lw_frac
    rw = W - lw - 3*mm
    from reportlab.platypus import KeepTogether
    tbl = Table([[left_items, right_items]],
                colWidths=[lw, rw])
    tbl.setStyle(TableStyle([
        ("VALIGN",      (0,0), (-1,-1), "TOP"),
        ("LEFTPADDING", (0,0), (-1,-1), 0),
        ("RIGHTPADDING",(0,0), (-1,-1), 0),
        ("TOPPADDING",  (0,0), (-1,-1), 0),
        ("BOTTOMPADDING",(0,0),(-1,-1), 0),
    ]))
    return tbl

# ── Helper: styled data table ────────────────────────────────────────────────
def data_table(headers, rows, col_widths, hdr_bg=MID_BLUE):
    data = [[Paragraph(h, sCellWhite) for h in headers]]
    for i, row in enumerate(rows):
        bg = LIGHT_BLUE if i % 2 == 0 else WHITE
        data.append([Paragraph(str(c), sCellBody) for c in row])
    tbl = Table(data, colWidths=col_widths)
    style = [
        ("BACKGROUND",    (0, 0), (-1, 0), hdr_bg),
        ("GRID",          (0, 0), (-1,-1), 0.3, colors.HexColor("#CCCCCC")),
        ("ROWBACKGROUNDS",(0, 1), (-1,-1), [LIGHT_BLUE, WHITE]),
        ("TOPPADDING",    (0, 0), (-1,-1), 3),
        ("BOTTOMPADDING", (0, 0), (-1,-1), 3),
        ("LEFTPADDING",   (0, 0), (-1,-1), 4),
        ("RIGHTPADDING",  (0, 0), (-1,-1), 4),
        ("VALIGN",        (0, 0), (-1,-1), "TOP"),
    ]
    tbl.setStyle(TableStyle(style))
    return tbl

def bullet(text, style=sBody, indent=6):
    return Paragraph(f"<bullet bulletIndent='{indent}' indent='14'>\u2022</bullet> {text}", style)

def sp(h=3):
    return Spacer(1, h)

# ════════════════════════════════════════════════════════════════════════════
# BUILD CONTENT
# ════════════════════════════════════════════════════════════════════════════
story = []

# ─── TITLE BANNER ────────────────────────────────────────────────────────────
title_tbl = Table(
    [[Paragraph("ACUTE STROKE PROTOCOL", sTitle)],
     [Paragraph("Clinical Pocket Reference  |  Based on AHA/ASA Guidelines", sSubtitle)]],
    colWidths=[W]
)
title_tbl.setStyle(TableStyle([
    ("BACKGROUND",    (0,0), (-1,-1), DARK_BLUE),
    ("TOPPADDING",    (0,0), (-1,-1), 8),
    ("BOTTOMPADDING", (0,0), (-1,-1), 8),
    ("LEFTPADDING",   (0,0), (-1,-1), 6),
    ("ROUNDEDCORNERS",[4]),
]))
story.append(title_tbl)
story.append(sp(5))

# ─── STEP 0: RECOGNITION ─────────────────────────────────────────────────────
story.append(KeepTogether([
    section_bar("STEP 0 — RECOGNITION  (BE-FAST)", bg=RED),
    sp(3),
    data_table(
        ["Sign", "Finding"],
        [
            ["Balance", "Sudden loss of balance or coordination"],
            ["Eyes", "Sudden vision loss or double vision"],
            ["Face", "Facial droop — ask patient to smile"],
            ["Arm", "Arm weakness — ask to raise both arms"],
            ["Speech", "Slurred or strange speech"],
            ["Time", "Time to call emergency services NOW — note exact onset time"],
        ],
        [W*0.20, W*0.80],
        hdr_bg=RED
    ),
    sp(3),
]))

# ─── STEP 1: IMMEDIATE ACTIONS ────────────────────────────────────────────────
story.append(KeepTogether([
    section_bar("STEP 1 — IMMEDIATE ACTIONS (First 10 minutes)", bg=DARK_BLUE),
    sp(3),
    data_table(
        ["Priority", "Action"],
        [
            ["ABCs", "Airway, Breathing, Circulation — O₂ if SpO₂ <94%"],
            ["Glucose", "Stat fingerstick BG — treat hypoglycaemia (<60 mg/dL) with IV dextrose immediately"],
            ["IV Access", "Two large-bore IVs; draw blood (CBC, BMP, coagulation, troponin, type & screen)"],
            ["12-lead ECG", "Rule out AF; identify concurrent ACS"],
            ["Imaging", "Non-contrast CT brain STAT — rule out haemorrhage before any thrombolysis"],
            ["CT-A", "CT angiography if LVO suspected (NIHSS ≥6 or dense MCA sign)"],
            ["Neuro exam", "NIHSS score, last known well time, medications, contraindications"],
        ],
        [W*0.18, W*0.82],
    ),
    sp(3),
]))

# ─── STEP 2 SPLIT: ISCHEMIC vs HAEMORRHAGIC ──────────────────────────────────
story.append(section_bar("STEP 2 — ACUTE MANAGEMENT BY STROKE TYPE", bg=MID_BLUE))
story.append(sp(4))

# ── Left: Ischemic ──────────────────────────────────────────────────────────
isch_items = [
    section_bar("ISCHEMIC STROKE  (~85%)", bg=colors.HexColor("#1A6F9A"), fg=WHITE),
    sp(2),
    Paragraph("IV THROMBOLYSIS", sSubHdr),
    data_table(
        ["Agent", "Dose", "Window"],
        [
            ["<b>Alteplase</b>", "0.9 mg/kg IV (max 90 mg)\n10% bolus over 1 min\n90% infusion over 60 min", "0 – 4.5 h"],
            ["<b>Tenecteplase</b>", "0.25 mg/kg IV (max 25 mg)\nSingle bolus", "0 – 4.5 h\n(preferred if EVT planned)"],
        ],
        [W*0.22, W*0.30, W*0.15],
    ),
    sp(2),
    Paragraph("KEY CONTRAINDICATIONS", sSubHdr),
    bullet("BP >185/110 mmHg (must treat first)", sBody),
    bullet("Haemorrhage on CT / previous ICH", sAlert),
    bullet("Anticoagulants with therapeutic effect (INR >1.7, DOAC within 48 h)", sBody),
    bullet("Major surgery / severe trauma within 14 days", sBody),
    bullet("Prior stroke or serious head trauma within 3 months", sBody),
    bullet("Blood glucose <50 mg/dL", sBody),
    sp(2),
    Paragraph("BP TARGETS", sSubHdr),
    data_table(
        ["Scenario", "BP Target", "Agent"],
        [
            ["Before thrombolysis", "<185/110 mmHg", "Labetalol 10–20 mg IV or\nNicardipine infusion"],
            ["During / after (24 h)", "<180/105 mmHg", "Labetalol or Nicardipine"],
            ["No thrombolysis", "<220/120 mmHg\n(permissive first 24 h)", "Treat if >220/120"],
        ],
        [W*0.30, W*0.22, W*0.15],
    ),
    sp(3),
]

# ── Right: Haemorrhagic ─────────────────────────────────────────────────────
haem_items = [
    section_bar("HAEMORRHAGIC STROKE  (~15%)", bg=RED, fg=WHITE),
    sp(2),
    Paragraph("INTRACEREBRAL HAEMORRHAGE (ICH)", sSubHdr),
    bullet("Target SBP <140 mmHg acutely (IV labetalol / nicardipine / clevidipine)", sBody),
    bullet("Reverse anticoagulation IMMEDIATELY", sAlert),
    bullet("Warfarin → Vitamin K + PCC (preferred) or FFP", sBody),
    bullet("Dabigatran → Idarucizumab (Praxbind®)", sBody),
    bullet("Xa inhibitors → Andexanet alfa or PCC", sBody),
    bullet("Correct platelets if <100k or on antiplatelet + surgery planned", sBody),
    bullet("NO thrombolytics, NO anticoagulation", sAlert),
    bullet("Neurosurgery consult: cerebellar ICH >3 cm, herniation, hydrocephalus", sBody),
    sp(4),
    Paragraph("SUBARACHNOID HAEMORRHAGE (SAH)", sSubHdr),
    bullet("Secure aneurysm: surgical clipping or endovascular coiling", sBody),
    bullet("Nimodipine 60 mg PO q4h × 21 days (vasospasm prevention)", sGreen),
    bullet("Monitor for re-bleeding, vasospasm, hydrocephalus", sBody),
    bullet("Avoid hypotension; maintain euvolaemia", sBody),
    sp(3),
]

story.append(two_col(isch_items, haem_items, lw_frac=0.52))
story.append(sp(4))

# ─── MECHANICAL THROMBECTOMY ──────────────────────────────────────────────────
story.append(KeepTogether([
    section_bar("MECHANICAL THROMBECTOMY (EVT) — Ischemic LVO Only", bg=colors.HexColor("#1A6F9A")),
    sp(3),
    data_table(
        ["Criteria", "Details"],
        [
            ["Vessel", "ICA or M1 MCA occlusion (anterior circulation)"],
            ["Function", "Pre-stroke mRS ≤1 (independent)"],
            ["Severity", "NIHSS ≥6"],
            ["Imaging", "ASPECTS ≥6 on CT or small infarct core on CT perfusion / DWI-MRI"],
            ["0 – 6 h window", "Standard window — offer EVT regardless of IV alteplase status"],
            ["6 – 16 h window", "DAWN / DEFUSE-3 criteria: mismatch between deficit & infarct core"],
            ["16 – 24 h window", "DAWN criteria only — CT perfusion or DWI mismatch required"],
            ["Key principle", "Every 1-hour delay → worse functional outcome. Door-to-puncture <90 min"],
        ],
        [W*0.22, W*0.78],
    ),
    sp(3),
]))

# ─── ANTITHROMBOTIC THERAPY ───────────────────────────────────────────────────
story.append(KeepTogether([
    section_bar("ANTITHROMBOTIC THERAPY  (Ischemic Stroke)", bg=DARK_BLUE),
    sp(3),
    data_table(
        ["Scenario", "Drug", "Timing / Dose", "Duration"],
        [
            ["All ischemic strokes (no thrombolysis)", "Aspirin 325 mg", "Load immediately after CT confirms ischaemia", "Lifelong"],
            ["Post-thrombolysis", "Aspirin 325 mg", "Wait 24 h after rtPA; repeat CT first", "Lifelong"],
            ["Minor stroke or TIA (NIHSS ≤3)", "Aspirin + Clopidogrel (DAPT)", "Start within 24 h; continue 21 days", "Then single agent"],
            ["Atrial fibrillation (cardioembolic)", "DOAC (apixaban/rivaroxaban)\nor warfarin (INR 2–3)", "Start 2–14 days post-stroke depending on size", "Lifelong"],
            ["Carotid stenosis ≥50%", "Antiplatelet + CEA or stenting", "CEA within 2 weeks of TIA/minor stroke", "Per vascular surgery"],
        ],
        [W*0.24, W*0.22, W*0.30, W*0.24],
    ),
    sp(3),
]))

# ─── GLUCOSE & METABOLIC ─────────────────────────────────────────────────────
story.append(KeepTogether([
    section_bar("METABOLIC TARGETS  (All Stroke Types)", bg=colors.HexColor("#117A65")),
    sp(3),
    data_table(
        ["Parameter", "Target", "Intervention"],
        [
            ["Blood Glucose", "140 – 180 mg/dL", "Insulin infusion for hyperglycaemia; IV dextrose for hypoglycaemia (<60 mg/dL)"],
            ["Temperature", "Normothermia (≤37.5°C)", "Antipyretics + cooling — fever worsens ischaemic injury"],
            ["O₂ Saturation", "≥94%", "Supplemental O₂ or intubation if needed; avoid routine O₂ if SpO₂ normal"],
            ["Sodium", "Normonatraemia", "Hypo-osmolar fluids contraindicated (worsen oedema) — use 0.9% NaCl"],
        ],
        [W*0.20, W*0.25, W*0.55],
        hdr_bg=colors.HexColor("#117A65")
    ),
    sp(3),
]))

# ─── BP MANAGEMENT TABLE (ICH) ───────────────────────────────────────────────
story.append(KeepTogether([
    section_bar("BP MANAGEMENT QUICK-REFERENCE", bg=colors.HexColor("#922B21")),
    sp(3),
    data_table(
        ["Situation", "SBP Target", "First-line Agent(s)"],
        [
            ["Before IV thrombolysis", "<185/110", "Labetalol 10–20 mg IV bolus; Nicardipine 5 mg/h infusion"],
            ["During/after thrombolysis (24 h)", "<180/105", "Labetalol 2–8 mg/min infusion; Nicardipine up to 15 mg/h"],
            ["Ischemic stroke — no reperfusion", "<220/120\n(permissive)", "Treat only if BP >220/120 or hypertensive emergency"],
            ["ICH (intracerebral haemorrhage)", "<140", "IV nicardipine, labetalol, or clevidipine infusion"],
            ["SAH (subarachnoid)", "Individualised\n(avoid hypotension)", "Nicardipine infusion; maintain CPP"],
        ],
        [W*0.30, W*0.18, W*0.52],
        hdr_bg=colors.HexColor("#922B21")
    ),
    sp(3),
]))

# ─── SUPPORTIVE CARE ─────────────────────────────────────────────────────────
story.append(KeepTogether([
    section_bar("SUPPORTIVE CARE & COMPLICATIONS", bg=DARK_BLUE),
    sp(3),
]))

supp_left = [
    Paragraph("DVT PROPHYLAXIS", sSubHdr),
    bullet("Pneumatic compression stockings — start immediately", sGreen),
    bullet("UFH or LMWH: ischemic stroke only, after 24–48 h when haemorrhage risk low", sBody),
    sp(4),
    Paragraph("DYSPHAGIA", sSubHdr),
    bullet("Nil by mouth until formal swallow assessment", sAlert),
    bullet("NGT feeding if prolonged dysphagia", sBody),
    sp(4),
    Paragraph("CEREBRAL OEDEMA / HERNIATION", sSubHdr),
    bullet("HOB 30°, head midline, avoid hypotonic fluids", sBody),
    bullet("Mannitol 0.5–1 g/kg IV or hypertonic saline for ICP crisis", sBody),
    bullet("Hemicraniectomy for malignant MCA syndrome (age <60, dominant/non-dominant)", sBody),
]

supp_right = [
    Paragraph("SEIZURE MANAGEMENT", sSubHdr),
    bullet("Treat clinical seizures; no prophylactic AEDs routinely", sBody),
    bullet("Lorazepam IV for status epilepticus", sBody),
    sp(4),
    Paragraph("SYMPTOMATIC ICH (post-thrombolysis)", sSubHdr),
    bullet("Stop alteplase immediately", sAlert),
    bullet("Cryoprecipitate 10 U IV (target fibrinogen ≥150 mg/dL)", sBody),
    bullet("Tranexamic acid or epsilon-aminocaproic acid", sBody),
    bullet("Neurosurgery consult urgently", sBody),
    sp(4),
    Paragraph("EARLY REHABILITATION", sSubHdr),
    bullet("Mobilise within 24–48 h if stable", sGreen),
    bullet("Speech, physical, occupational therapy from day 1", sBody),
    bullet("Stroke unit care reduces mortality & dependency", sGreen),
]

story.append(two_col(supp_left, supp_right, lw_frac=0.50))
story.append(sp(4))

# ─── NIHSS QUICK REFERENCE ───────────────────────────────────────────────────
story.append(KeepTogether([
    section_bar("NIHSS QUICK SEVERITY GUIDE", bg=colors.HexColor("#6C3483")),
    sp(3),
    data_table(
        ["Score", "Severity", "Clinical Implication"],
        [
            ["0", "No stroke", "Normal"],
            ["1 – 4", "Minor stroke", "DAPT (aspirin + clopidogrel); consider EVT if LVO"],
            ["5 – 15", "Moderate stroke", "IV tPA if eligible; EVT if LVO confirmed"],
            ["16 – 20", "Moderate–severe", "IV tPA + EVT if eligible; ICU-level monitoring"],
            ["21 – 42", "Severe stroke", "EVT if LVO; consider goals of care discussion"],
        ],
        [W*0.12, W*0.20, W*0.68],
        hdr_bg=colors.HexColor("#6C3483")
    ),
    sp(3),
]))

# ─── TIME TARGETS ────────────────────────────────────────────────────────────
story.append(KeepTogether([
    section_bar("TIME TARGETS  (Door-to-Treatment Benchmarks)", bg=GREEN),
    sp(3),
    data_table(
        ["Milestone", "Target Time"],
        [
            ["CT brain completed", "≤25 min from door"],
            ["CT brain interpreted", "≤45 min from door"],
            ["Door-to-needle (IV tPA)", "≤60 min from door  (target: ≤45 min)"],
            ["Door-to-puncture (EVT)", "≤90 min from door"],
            ["Symptom onset to IV tPA", "≤4.5 hours"],
            ["Symptom onset to EVT", "≤6 hours (up to 24 h with imaging selection)"],
        ],
        [W*0.60, W*0.40],
        hdr_bg=GREEN
    ),
    sp(3),
]))

# ─── SECONDARY PREVENTION ────────────────────────────────────────────────────
story.append(KeepTogether([
    section_bar("SECONDARY PREVENTION — BEFORE DISCHARGE", bg=DARK_BLUE),
    sp(3),
    data_table(
        ["Risk Factor", "Target / Intervention"],
        [
            ["Blood pressure", "Target <130/80 mmHg long-term; start/optimise antihypertensives"],
            ["Atrial fibrillation", "Anticoagulation (DOAC preferred over warfarin for non-valvular AF)"],
            ["LDL cholesterol", "High-intensity statin; target LDL <70 mg/dL (or <55 mg/dL if recurrent)"],
            ["Diabetes", "HbA1c <7%; GLP-1 agonists may have additional benefit (emerging data 2026)"],
            ["Carotid stenosis ≥50%", "CEA within 2 weeks of TIA/minor stroke (if symptomatic)"],
            ["Lifestyle", "Smoking cessation, Mediterranean diet, exercise ≥150 min/week, weight loss"],
            ["Antiplatelet (non-AF)", "Aspirin, or clopidogrel, or aspirin + dipyridamole (extended release)"],
        ],
        [W*0.30, W*0.70],
    ),
    sp(3),
]))

# ─── FOOTER ──────────────────────────────────────────────────────────────────
story.append(HRFlowable(width=W, thickness=0.5, color=DARK_BLUE))
story.append(sp(2))
story.append(Paragraph(
    "Based on AHA/ASA 2019 Stroke Guidelines | Rosen's Emergency Medicine 9e | Harrison's Principles 22e | Bradley & Daroff's Neurology  "
    "— For clinical guidance only; always apply individual patient assessment. | Generated by Orris, July 2026",
    sSmall
))

# ─── BUILD PDF ────────────────────────────────────────────────────────────────
doc.build(story)
print(f"PDF created: {OUTPUT}")

cd /home/daytona/workspace/stroke-pocket-guide && python generate_pocket_guide.p…

ls -lh /home/daytona/workspace/stroke-pocket-guide/Acute_Stroke_Pocket_Guide.pdf

cd /home/daytona/workspace/stroke-pocket-guide && python -c " from pypdf import …

A clean, professional clinical flowchart titled "ACUTE STROKE — DOOR TRIAGE DECISIONS" for emergency department use. The flowchart uses a top-down decision tree format with color-coded boxes and arrows. Layout and content: START BOX (dark navy blue, top center): "Patient Arrives with Suspected Stroke" with subtext "Activate Stroke Alert — Note Exact Time" FIRST DECISION DIAMOND (dark blue): "ABCs Stable?" - NO arrow → red box "Stabilise Airway / CPR / Call Resus Team" - YES arrow continues down STEP BOX (teal): "Immediate Actions (≤10 min)" containing a checklist: "✓ Fingerstick glucose ✓ IV access + bloods ✓ 12-lead ECG ✓ Vitals + O₂ if SpO₂ <94% ✓ NIHSS score ✓ Last Known Well (LKW) time" DECISION DIAMOND: "Glucose <60 mg/dL?" - YES → orange box "IV Dextrose → Reassess — Rule out hypoglycaemic mimic" - NO → continue down ACTION BOX (dark blue): "STAT Non-Contrast CT Brain (target ≤25 min from door)" DECISION DIAMOND: "Haemorrhage on CT?" - YES (right branch, red): "HAEMORRHAGIC STROKE" → red box with: "• Target SBP <140 mmHg (IV nicardipine/labetalol) • Reverse anticoagulation (PCC / Idarucizumab / Vitamin K) • Neurosurgery consult • ICU admission" - NO (left branch, blue): "ISCHEMIC STROKE" → continues DECISION DIAMOND (blue): "Symptom onset or LKW ≤4.5 hours?" - YES → green box "Eligible for IV tPA?" with sub-diamond - YES → bright green action box "IV Alteplase 0.9 mg/kg (max 90 mg) — Door-to-Needle ≤60 min TARGET" - NO (contraindicated) → grey box "Best Medical Therapy: Aspirin 325 mg + Supportive Care" - NO (>4.5 hours or wake-up stroke) → teal box "CT Angiography + CT Perfusion" DECISION DIAMOND (blue): "NIHSS ≥6 + LVO on CTA?" - YES → bright blue box "Mechanical Thrombectomy (EVT) — Door-to-Puncture ≤90 min — Consider up to 24h with DAWN/DEFUSE-3 criteria" - NO → grey box "Admit Stroke Unit — Aspirin + Monitoring" BOTTOM BOX (dark navy, full width): "ALL PATIENTS: Stroke Unit Admission | DVT Prophylaxis | Swallow Screen | Glucose/Temp targets | Secondary Prevention Planning" Design: White background, color-coded branches (red=haemorrhagic, blue=ischemic, green=treatment go, orange=caution), clear sans-serif font, professional medical illustration style, arrows clearly labeled YES/NO, compact but readable for wall poster or pocket card use.

A clean, professional clinical decision flowchart titled "ACUTE STROKE — DOOR TRIAGE DECISIONS" for emergency department wall poster use. Top-down flowchart with color-coded boxes and labeled arrows. FLOW (top to bottom): 1. START (dark navy rectangle, top center): "Patient Arrives with Suspected Stroke" / "Activate Stroke Alert — Note Exact Time of Arrival & Last Known Well (LKW)" 2. DIAMOND: "ABCs Stable?" - NO → RED box: "Stabilise Airway / CPR / Call Resus Team" - YES → continue down 3. TEAL rectangle: "Immediate Actions (≤10 min)" with checklist: ✓ Fingerstick glucose ✓ IV access + bloods (CBC, BMP, coag, troponin) ✓ 12-lead ECG ✓ Vitals + O₂ if SpO₂ <94% ✓ NIHSS score ✓ Record Last Known Well time 4. DIAMOND: "Glucose <60 mg/dL?" - YES → ORANGE box: "IV Dextrose → Reassess — Rule out hypoglycaemic mimic" - NO → continue down 5. DARK BLUE rectangle: "STAT Non-Contrast CT Brain (target: ≤25 min from door)" 6. DIAMOND: "Haemorrhage on CT?" - YES → RIGHT BRANCH (RED): Box: "HAEMORRHAGIC STROKE" • Lower BP: target SBP <140 mmHg (IV nicardipine / labetalol) • Reverse anticoagulation: PCC / Idarucizumab / Vitamin K • Neurosurgery consult • ICU admission - NO → LEFT BRANCH (BLUE): "ISCHEMIC STROKE" → continue 7. DIAMOND (blue): "LKW ≤4.5 hours?" - YES → DIAMOND: "IV tPA eligible? (no contraindications, BP <185/110)" - YES → BRIGHT GREEN box: "IV ALTEPLASE 0.9 mg/kg (max 90 mg) — Door-to-Needle TARGET ≤60 min" - NO → GREY box: "Best Medical Therapy: Aspirin 325 mg + Supportive Care" - NO / Wake-up stroke → TEAL box: "CT Angiography + CT Perfusion" 8. DIAMOND (blue): "NIHSS ≥6 AND LVO on CTA?" - YES → BRIGHT BLUE box: "MECHANICAL THROMBECTOMY (EVT) — Door-to-Puncture ≤90 min — Eligible up to 24h with DAWN/DEFUSE-3 mismatch criteria" - NO → GREY box: "Admit Stroke Unit — Aspirin + Monitoring + Workup" 9. BOTTOM BAR (full-width dark navy): "ALL PATIENTS: Stroke Unit Admission | DVT Prophylaxis (compression stockings) | Swallow Screen before PO | Glucose 140–180 mg/dL | Normothermia | Secondary Prevention Planning" Style: White background, professional medical illustration, sans-serif bold font, arrows clearly labeled YES/NO, red for haemorrhagic branch, blue for ischemic branch, green for treatment go-ahead, orange for caution. Suitable for printing as A3 wall poster or pocket card.