What is the immediate management for a potential stroke patient in the emergency room?

Immediate Management of Potential Stroke Patients in the Emergency Room

Rapid recognition and immediate activation of stroke protocols are essential for potential stroke patients arriving at the emergency department, as time-sensitive interventions can significantly reduce morbidity and mortality.

Initial Assessment and Recognition

• Use the FAST assessment tool (Face, Arms, Speech, Time) to quickly identify potential stroke patients 1

  • Check for facial droop (asymmetry)
  • Test for arm drift (one arm drifts downward)
  • Evaluate speech (slurred, inappropriate words, or inability to speak)
  • Document time of symptom onset (critical for treatment decisions)

• Additional stroke symptoms to assess:

  • Sudden severe headache
  • Visual disturbances
  • Balance or coordination problems
  • Dizziness
  • Altered level of consciousness 2, 1

Immediate Actions

1. Activate the hospital's stroke protocol/code stroke immediately

   • This mobilizes the stroke team and initiates time-sensitive pathways 2

2. Perform rapid neurological assessment

   • Use NIH Stroke Scale (NIHSS) to quantify stroke severity 1
   • Document time last known well (critical for treatment eligibility)

3. Obtain urgent neuroimaging

   • Non-contrast CT scan within 25 minutes of arrival to distinguish between ischemic and hemorrhagic stroke 1
   • Consider CT angiography (CTA) from aortic arch to vertex to identify large vessel occlusions 1

4. Stabilize vital functions

   • Ensure patent airway
   • Provide supplemental oxygen if oxygen saturation <94% 1
   • Monitor cardiac rhythm
   • Establish IV access 2

Blood Pressure Management

• Do not aggressively lower blood pressure unless:
  • Systolic BP >220 mmHg
  • Patient is eligible for thrombolysis (then maintain BP <185/110 mmHg) 2, 1
  • Evidence of other end-organ damage

Time-Critical Treatments

1. For ischemic stroke:

   • IV thrombolysis (alteplase) for eligible patients within 4.5 hours of symptom onset

     • Dose: 0.9 mg/kg (maximum 90 mg) with 10% as bolus and remainder over 60 minutes 1, 3
     • Ensure BP <185/110 mmHg before administration

   • Consider endovascular thrombectomy for large vessel occlusion

     • Can be performed up to 24 hours with evidence of salvageable brain tissue 1

2. For hemorrhagic stroke:

   • Reverse anticoagulation if applicable
   • Consult neurosurgery for possible intervention
   • Manage blood pressure according to hemorrhagic stroke protocols 2

Concurrent Actions

• Obtain laboratory studies:

  • Complete blood count
  • Coagulation studies (PT/INR, PTT)
  • Blood glucose
  • Electrolytes
  • Cardiac enzymes 2

• Obtain 12-lead ECG to assess for cardiac abnormalities 2

• Consider additional imaging as needed:

  • Echocardiography if cardioembolic source suspected 2
  • Carotid/vertebral imaging if large vessel disease suspected 1

Post-Initial Management

• Transfer to a specialized stroke unit as soon as possible 2, 1

  • Stroke units have been shown to improve outcomes for all types of stroke patients

• Implement continuous monitoring:

  • Vital signs
  • Neurological status
  • Potential complications 1

• Initiate early mobilization by rehabilitation professionals within 48 hours when appropriate 1

Common Pitfalls to Avoid

1. Delaying neuroimaging - CT scan should be obtained within 25 minutes of arrival 1, 4

2. Missing the treatment window - "Time is brain" - every minute delay results in loss of approximately 1.9 million neurons 5, 6

3. Failing to recognize stroke mimics - Conditions like hypoglycemia, seizures, or migraines can present similarly to stroke

4. Overlooking posterior circulation strokes - These may present with atypical symptoms like dizziness, nausea, or visual changes

5. Inadequate blood pressure management - Both hypertension and hypotension can worsen outcomes 6

System Optimization

• Develop and regularly update stroke protocols 2, 7
• Train all emergency department staff in stroke recognition and management 2
• Consider direct-to-CT pathways to minimize door-to-needle times 4
• Establish clear communication channels with EMS for pre-notification 2, 8
• Implement quality improvement processes to continuously refine stroke care 2

The evidence clearly demonstrates that organized, protocol-driven care in dedicated stroke units significantly improves outcomes for stroke patients 2. Immediate recognition, rapid assessment, and time-sensitive interventions are crucial components of effective stroke management.