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Stroke Prerounds: Essential Assessment and Management Points
Initial Assessment (First Minutes)
Immediately assess and stabilize the ABCs (airway, breathing, circulation) as your first priority 1, 2. This is non-negotiable for all suspected stroke patients, particularly those with depressed consciousness or bulbar dysfunction.
Vital Signs and Monitoring
- Heart rate and rhythm: Check for atrial fibrillation or life-threatening arrhythmias requiring cardiac monitoring 1, 2
- Blood pressure: Document carefully but treat cautiously (see BP management below)
- Temperature: Treat fever >37.5°C with antipyretics 3
- Oxygen saturation: Maintain SpO2 ≥94% with supplemental oxygen only if hypoxic 4
- Glucose: Immediate finger stick required
Neurological Examination
Use a standardized stroke scale (NIHSS preferred) to quantify severity and guide prognosis 1, 2. Scores <10 predict 60-70% favorable outcomes; scores >20 predict only 4-16% favorable outcomes 5.
Critical Time-Sensitive Information
Establish Stroke Onset Time
The time last known well is your treatment window—not when symptoms were discovered 5. For wake-up strokes, use the time the patient went to bed as onset time. This single piece of information determines thrombolysis eligibility.
Immediate Laboratory Work
Order these labs immediately but DO NOT delay imaging or treatment for results 1:
- CBC, electrolytes, glucose
- INR/aPTT (only wait for results if patient on warfarin)
- Creatinine/eGFR (do not delay CTA for results—"neurons over nephrons" 1)
- Troponin
Exception: For warfarin patients, you must have INR before thrombolysis 1.
Imaging Priority
Brain imaging (CT or MRI) takes absolute priority over ECG and chest X-ray unless the patient is hemodynamically unstable 1. ECG and CXR can wait until after thrombolysis decisions are made.
Blood Pressure Management
For Non-Thrombolysis Candidates
Only treat BP if SBP >220 mmHg or DBP >120 mmHg 2, 5. Lower BP cautiously as rapid reduction may worsen ischemia by decreasing perfusion pressure. Avoid sublingual nifedipine—it causes precipitous drops 5.
For Thrombolysis Candidates
BP must be <185/110 mmHg before initiating tPA 4, 5. Lower cautiously to meet this threshold.
Post-Thrombolysis
Monitor BP closely and maintain <180/105 mmHg to reduce hemorrhagic transformation risk.
Swallowing Assessment
Screen for dysphagia using a validated tool before any oral intake, but do not delay thrombolysis decisions 1. Ideally complete within 24 hours. If patient cannot swallow, consider rectal aspirin administration 3.
Acute Treatment Considerations
Thrombolysis Eligibility
- Time window: Within 4.5 hours of last known well (or up to 9 hours with perfusion imaging showing salvageable tissue) 4
- Dose: Alteplase 0.9 mg/kg (max 90 mg), 10% bolus over 1 minute, remainder over 60 minutes 4
- Tenecteplase: Emerging as practical alternative with comparable safety/efficacy 6, 7
Endovascular Thrombectomy
Consider for large vessel occlusion, potentially up to 24 hours with advanced imaging showing viable tissue 4. Do not wait to assess thrombolysis response before proceeding to angiography 4.
Antiplatelet Therapy
Administer aspirin within 48 hours after swallowing screen 3. Wait 24 hours post-tPA before starting antiplatelets 3. For minor stroke or high-risk TIA, consider short-term dual antiplatelet therapy 7.
Anticoagulation
Do not use urgent anticoagulation for acute stroke treatment—it increases hemorrhage risk without reducing early recurrence 5. Reserve for specific indications like cardioembolic prevention after the acute phase.
Complication Prevention
DVT Prophylaxis
Use subcutaneous heparin or LMWH for immobile patients 8, 3. Add intermittent pneumatic compression devices if anticoagulation contraindicated. Do not use antiembolic stockings routinely 3.
Positioning and Mobilization
- For large artery occlusions with fluctuating symptoms: Consider flat positioning (0°) to improve perfusion 3
- For stable patients: Mobilize within 24 hours if neurologically and hemodynamically stable 3
- For hemorrhagic transformation risk: Elevate head of bed to 30° 3
Hydration and Nutrition
Maintain euvolemia with normal saline 3. For patients unable to swallow, use nasogastric feeding initially (preferred over PEG for first 2-3 weeks) 3.
Common Pitfalls to Avoid
- Waiting for lab results before imaging: Only INR matters for warfarin patients
- Delaying treatment for ECG or chest X-ray: These can wait unless hemodynamic instability
- Aggressive BP lowering: May worsen ischemia; treat only extreme elevations
- Withholding CTA for renal concerns: Neurons over nephrons in acute stroke
- Using sublingual nifedipine: Causes dangerous precipitous BP drops
- Routine anticoagulation: Increases hemorrhage without proven benefit
- Prophylactic anticonvulsants: Not recommended for single seizure at onset 2
Seizure Management
Treat active seizures with short-acting agents (lorazepam IV) 2. Do not start long-term anticonvulsants for a single self-limited seizure at stroke onset 2.
Documentation Essentials
- Exact time last known well
- NIHSS score
- Thrombolysis eligibility checklist
- BP trends
- Swallowing screen results
- Time of all interventions (door-to-needle time is a quality metric)