From the Guidelines
The initial management of a suspected stroke in the Emergency Room involves a rapid assessment and intervention, prioritizing airway, breathing, and circulation, followed by a neurological examination to determine focal neurological deficits and assess stroke severity, as recommended by the Canadian Stroke Best Practice Recommendations for Acute Stroke Management, 6th edition, update 2018 1. The neurological examination should include the use of a standardized stroke scale, such as the National Institutes of Health Stroke Scale (NIHSS), to assess stroke severity and guide treatment decisions.
- Key components of the initial evaluation include:
- Assessment of heart rate and rhythm, blood pressure, temperature, oxygen saturation, hydration status, and presence of seizure activity
- Acute blood work, including electrolytes, random glucose, complete blood count, coagulation status, and creatinine
- Seizure assessment and treatment with short-acting medications, such as lorazepam IV, if necessary
- The goal of the initial management is to quickly identify the type of stroke (ischemic or hemorrhagic) and initiate appropriate treatment, such as intravenous thrombolysis or endovascular thrombectomy, while maintaining airway protection, normalizing oxygen saturation, correcting hypoglycemia, and preventing hyperthermia. The most recent and highest quality study, the Canadian Stroke Best Practice Recommendations for Acute Stroke Management, 6th edition, update 2018 1, provides the basis for these recommendations, emphasizing the importance of rapid assessment and intervention in the Emergency Room to improve patient outcomes.
From the Research
Initial Management of Suspected Stroke in the Emergency Room (ER)
The initial management of a suspected stroke in the ER involves several key steps:
- Rapid identification and assessment of the patient's condition, including history, examination, and imaging 2, 3
- Differentiation of acute ischemic stroke from intracranial hemorrhage and stroke mimics 3
- Identification of large vessel occlusion (LVO) and provision of endovascular thrombectomy with or without the administration of tissue plasminogen activator 3
- Optimization of brain function through various measures, including the management of blood pressure, blood glucose, and temperature 4
Imaging and Treatment Options
Imaging plays a crucial role in the diagnosis and management of acute ischemic stroke:
- The choice of imaging is influenced mainly by the duration of symptoms 3
- Computed tomographic or magnetic resonance perfusion imaging can help identify patients who may benefit from endovascular thrombectomy 3
- Treatment options include thrombolysis, endovascular therapy, and aspirin, with the choice of treatment depending on the individual patient's condition and the timing of presentation 2, 5
Nursing Care and Emergency Protocols
Nurses play a critical role in the initial management of suspected stroke patients:
- Rapid identification and prompt transfer to emergency or specialist teams can maximize patients' chances of survival and reduce the risk and severity of any long-term disability 6
- Hospitals are required to develop multidisciplinary stroke teams and emergency protocols to meet the goals of timely and effective stroke care 3