What are the steps to assess and manage a stroke?

Assessment and Management of Acute Stroke

Stroke assessment should follow a structured approach beginning with rapid recognition of stroke symptoms using validated tools like FAST (Face, Arms, Speech, Time), followed by immediate activation of emergency medical services for expedited transport to a stroke-capable facility. 1

Initial Recognition and Prehospital Management

Recognition of Stroke

• Use validated stroke assessment tools that include FAST components:
  • F: Face drooping or asymmetry
  • A: Arm weakness or drift
  • S: Speech difficulties (slurred, inappropriate words, or unable to speak)
  • T: Time to call emergency services immediately 1

EMS Management

1. Rapid Assessment:

   • Perform initial screening using validated stroke assessment tools 1
   • Conduct a second screen for stroke severity to identify potential endovascular therapy candidates 1
   • Document time of symptom onset or last known well time 1

2. On-Scene Management:

   • Keep on-scene time under 20 minutes for patients within treatment window 1
   • Check capillary blood glucose 1
   • Assess ABCs (Airway, Breathing, Circulation) 1
   • Provide supplemental oxygen to maintain saturation >94% if needed 1
   • Establish IV access en route if possible 1

3. Transport Considerations:

   • Prenotify receiving hospital about incoming stroke patient 1
   • Transport directly to appropriate stroke-capable facility 1
   • Consider patient eligibility for thrombolysis (within 4.5 hours) or endovascular treatment (up to 24 hours in selected cases) 1

Emergency Department Assessment

Initial Evaluation

1. Immediate Assessment:

   • Rapid evaluation of airway, breathing, and circulation 1
   • Conduct standardized neurological examination using validated scales (NIHSS or CNS) 1
   • Assess vital signs: heart rate, rhythm, blood pressure, temperature, oxygen saturation 1

2. Urgent Investigations:

   • Immediate blood work: electrolytes, glucose, CBC, coagulation studies (INR, aPTT), creatinine, eGFR, troponin 1
   • ECG (should not delay thrombolysis decision) 1
   • Urgent brain imaging (CT/MRI) 1
   • Chest X-ray if evidence of acute heart or pulmonary disease (should not delay acute treatment) 1

3. Swallowing Assessment:

   • Complete swallowing screen within 24 hours using validated tool 1
   • Keep patient NPO until swallowing screen completed 1
   • Consider alternative medication routes if swallowing impaired 1

Acute Management

Treatment Decisions

1. Thrombolytic Therapy:

   • Consider IV rtPA (0.9 mg/kg, maximum 90 mg) for eligible patients within 3 hours of symptom onset 1
   • Selected patients may be eligible up to 4.5 hours after symptom onset 1
   • Adhere strictly to selection criteria and monitor closely 1

2. Endovascular Therapy:

   • Consider for eligible patients with large vessel occlusion 1
   • May be appropriate up to 24 hours from symptom onset in highly selected patients 1

3. Blood Pressure Management:

   • Monitor blood pressure closely
   • For hypotensive patients: place head flat, administer isotonic saline 1
   • For hypertensive patients: cautious management, especially if systolic BP ≥220 mm Hg 1

Early Inpatient Care

1. Mobilization:

   • Begin rehabilitation assessment within 48 hours of admission 1
   • Start frequent, brief, out-of-bed activity within 24 hours if no contraindications 1

2. Complication Prevention:

   • Venous thromboembolism prophylaxis for immobile patients 1
   • Temperature monitoring every 4 hours for first 48 hours 1
   • Treat fever >37.5°C and investigate for infection 1

3. Seizure Management:

   • Treat new-onset seizures with short-acting medications if not self-limiting 1
   • Single self-limiting seizures within 24 hours typically don't require long-term anticonvulsants 1

Common Pitfalls to Avoid

1. Delayed Recognition: Failure to recognize stroke symptoms promptly can significantly impact outcomes. Use standardized tools and train all healthcare providers in stroke recognition.

2. Prolonged On-Scene Time: EMS should minimize on-scene time to under 20 minutes for patients within treatment window. Focus on "recognize and mobilize" approach 1.

3. Inadequate Communication: Failure to prenotify receiving hospitals can delay in-hospital assessment and treatment. EMS prenotification has been shown to reduce delays in stroke evaluation 2.

4. Missing the Treatment Window: Time is brain - delays in assessment and treatment significantly impact outcomes. Establish clear protocols for rapid assessment and treatment decision-making.

5. Overlooking Swallowing Assessment: Failure to assess swallowing can lead to aspiration pneumonia. Keep patients NPO until properly screened 1.

By following this structured approach to stroke assessment and management, healthcare providers can optimize outcomes for patients experiencing acute stroke, potentially reducing mortality and improving quality of life.