From the Guidelines
Initial orders for a patient admitted for stroke rule-out should prioritize a rapid and comprehensive assessment, including a neurological examination, vital sign monitoring, and laboratory tests, as outlined in the Canadian Stroke Best Practice Recommendations 1. The initial evaluation should include a rapid assessment of airway, breathing, and circulation, as well as a neurological examination to determine focal neurological deficits and assess stroke severity using a standardized stroke scale such as the National Institutes of Health Stroke Scale (NIHSS) 1. Key components of the initial orders should include:
- Monitoring of vital signs, including heart rate and rhythm, blood pressure, temperature, oxygen saturation, hydration status, and presence of seizure activity 1
- Laboratory tests, such as electrolytes, random glucose, complete blood count, coagulation status (INR, aPTT), and creatinine, which should not delay imaging or treatment decisions 1
- Seizure assessment and management, with treatment of new-onset seizures using short-acting medications like lorazepam IV, but no prophylactic use of anticonvulsant medications 1
- Consideration of imaging studies, such as CT angiography or MRI/MRA, to evaluate for large vessel occlusion and stroke etiology
- Initiation of aspirin therapy, 325 mg daily, for ischemic stroke patients not receiving thrombolysis, as recommended by the American College of Chest Physicians 1 The goal of these initial orders is to rapidly diagnose and treat suspected stroke patients, while preventing complications and improving outcomes, with a focus on minimizing morbidity, mortality, and optimizing quality of life 1.
From the Research
Initial Orders for Stroke Rule Out Admission
The initial orders for a patient admitted for stroke rule out typically involve a comprehensive evaluation and management plan. The following are some key components:
- Clinical assessment: A thorough clinical evaluation, including a neurological examination and assessment of stroke risk factors 2
- Imaging studies: A non-contrast computed tomography (CT) scan of the head to rule out hemorrhagic stroke and identify potential ischemic changes 2
- Laboratory tests: Blood tests to evaluate for potential stroke causes, such as electrolyte imbalances, bleeding disorders, and cardiac conditions 3
- Medication management: Orders for medications to manage blood pressure, prevent further stroke, and treat underlying conditions, such as hypertension, diabetes, and hyperlipidemia 3
Prehospital and Emergency Department Care
Prehospital care plays a critical role in stroke management, with emergency medical services (EMS) personnel providing initial assessment and treatment. Key components of prehospital care include:
- Rapid transportation to a primary stroke center: EMS transport to a designated stroke center can improve outcomes by facilitating timely evaluation and treatment 4
- Prehospital notification: EMS prenotification of the hospital can help prepare the stroke team and expedite evaluation and treatment 4
- Scene time limits: EMS protocols with specific scene time limits can help reduce on-scene time and improve timely transportation to the hospital 5
Hospital Care and Treatment
In the hospital, the initial orders for stroke rule out admission may include:
- Stroke team activation: Notification of the stroke team to facilitate timely evaluation and treatment 2
- Imaging and laboratory studies: Orders for additional imaging studies, such as magnetic resonance imaging (MRI), and laboratory tests to evaluate for potential stroke causes 3
- Medication management: Orders for medications to manage blood pressure, prevent further stroke, and treat underlying conditions 3
- Monitoring and supportive care: Orders for close monitoring and supportive care, including cardiac monitoring, oxygen therapy, and nutritional support 3