What is the immediate management protocol for a patient presenting with symptoms of a stroke?

Immediate Management Protocol for Acute Stroke

The immediate management of a stroke patient requires rapid assessment, stabilization, and activation of a stroke protocol to minimize brain damage, with a target door-to-needle time of less than 60 minutes for eligible patients requiring thrombolysis. 1

Prehospital Management

Recognition and Activation

• Public education should focus on recognizing stroke signs using the FAST (Face, Arms, Speech, Time) acronym and immediately calling emergency services 2
• Emergency dispatchers should use validated stroke screening tools to identify potential stroke patients 2
• First responders should:
  • Rapidly evaluate airway, breathing, and circulation 2
  • Use validated stroke assessment tools 2
  • Determine time of symptom onset (last known well time) 2
  • Provide prehospital notification to the receiving hospital 2

Transport

• Patients should be transported rapidly to the closest appropriate stroke-capable hospital 2
• EMS personnel should minimize on-scene times (median on-scene time is 15 minutes) 2
• The median EMS response time (from 911 call to ED arrival) is approximately 36 minutes 2, 3
• Prehospital notification significantly increases the percentage of patients receiving timely treatment 2, 4

Emergency Department Management

Immediate Assessment (First 10 Minutes)

• Rapid triage and assessment within 10 minutes of arrival 2
• Assess and stabilize airway, breathing, and circulation 2
• Measure vital signs: heart rate, blood pressure, temperature, oxygen saturation 2
• Perform neurological examination using a standardized stroke scale (e.g., NIHSS) 2, 1
• Administer supplemental oxygen if oxygen saturation is <94% 2

Concurrent Actions (First 25 Minutes)

• Establish IV access immediately 1
• Obtain blood samples for initial laboratory tests 2, 1:
  • Electrolytes
  • Blood glucose (treat hypoglycemia immediately if glucose <60 mg/dL)
  • Complete blood count
  • Coagulation studies (INR, aPTT)
  • Renal function tests
• Perform 12-lead ECG to identify potential cardiac causes 1
• Obtain urgent non-contrast CT scan of the brain within 25 minutes of arrival to differentiate between ischemic and hemorrhagic stroke 1

Imaging and Diagnosis

• Non-contrast CT is the first-line imaging modality 1
• CT imaging should be interpreted within 45 minutes of arrival 4
• Additional imaging (CT angiography, CT perfusion) may be performed based on the clinical scenario and time from symptom onset 2

Post-Diagnosis Management

For Ischemic Stroke

• Evaluate eligibility for intravenous thrombolysis (alteplase/tPA) 2, 1
  • Target door-to-needle time <60 minutes (ideally <30 minutes) 1
  • Review contraindications to thrombolysis
• For patients with large vessel occlusion, evaluate for endovascular thrombectomy 1
  • Clinical severity (typically NIHSS ≥6)
  • Time window (up to 24 hours in select patients)
  • ASPECTS score ≥6

For Hemorrhagic Stroke

• Consult neurosurgery immediately 1
• Manage blood pressure according to guidelines 1
• Urgently reverse anticoagulation if applicable 1

Blood Pressure Management

• For patients eligible for thrombolysis: maintain BP <185/110 mmHg 2
• For patients not eligible for thrombolysis: only treat if BP >220/120 mmHg 2
• For hemorrhagic stroke: keep mean arterial pressure <130 mmHg 1

Hospital Admission and Ongoing Care

• Admit to a specialized stroke unit whenever possible 1
• Implement regular monitoring of vital signs and neurological status 1
• Conduct dysphagia screening before oral intake 1
• Provide DVT prophylaxis with intermittent pneumatic compression devices 1
• Begin evaluation for stroke etiology to guide secondary prevention 1

Common Pitfalls to Avoid

• Delaying imaging or treatment decisions due to laboratory tests 1
• Overlooking stroke mimics (seizures, migraines, hypoglycemia) 1
• Failing to determine the exact time of symptom onset 2
• Neglecting to provide prehospital notification, which can significantly delay treatment 4
• Treating elevated blood pressure too aggressively in ischemic stroke patients not receiving thrombolysis 2

Quality Metrics

• Door-to-CT time ≤25 minutes 1
• Door-to-needle time ≤60 minutes (ideally ≤30 minutes) 1
• Percentage of eligible patients receiving thrombolysis 1
• Time from symptom onset to treatment 1

Remember that "time is brain" - every minute delay in treatment increases morbidity and mortality 1, 5. A well-organized stroke protocol with clear roles and responsibilities is essential for providing optimal care to stroke patients 6.