What is the initial management of a suspected stroke before a computed tomography (CT) scan?

Initial Management of Suspected Stroke Before CT Scan

The initial management of a suspected stroke before CT scan must focus on rapid assessment of ABCs (airway, breathing, circulation), vital signs, and neurological status to ensure patient stability and prepare for potential thrombolytic therapy. 1

Immediate Assessment and Stabilization

• Assess airway, breathing, and circulation to identify and address any life-threatening conditions 1
• Monitor oxygen saturation and provide supplemental oxygen if hypoxemia is detected (O₂ saturation <94%) 1
• Obtain vital signs including blood pressure, pulse, respiratory rate, and temperature at least every 30 minutes during initial evaluation 1
• Treat hyperthermia (temperature >99.6°F) as it is associated with poor outcomes in stroke patients 1

Neurological Assessment

• Perform a rapid neurological assessment using a standardized stroke scale such as the National Institutes of Health Stroke Scale (NIHSS) to document baseline neurological status and stroke severity 1
• Document the exact time when the patient was last known to be well, as this is critical for determining eligibility for thrombolytic therapy 1
• Assess for stroke mimics (hypoglycemia, seizures, migraine) through focused history and examination 1

Laboratory Studies

• Obtain immediate blood glucose measurement to rule out hypoglycemia as a stroke mimic 1
• Order the following laboratory tests, though treatment should not be delayed while awaiting results unless specific concerns exist 1:
  • Complete blood count with platelet count
  • Prothrombin time/International Normalized Ratio (INR)
  • Activated partial thromboplastin time
  • Basic metabolic panel (electrolytes, renal function)
  • Cardiac enzymes
  • ECG

Blood Pressure Management

• Do not routinely treat hypertension in the setting of acute ischemic stroke unless blood pressure is extremely elevated (>220/120 mmHg) 1
• For patients who may be eligible for thrombolytic therapy, blood pressure should be lowered and maintained below 185/110 mmHg prior to treatment 1
• Avoid rapid or excessive lowering of blood pressure as this might exacerbate existing ischemia 1

Preparation for Imaging

• Alert the CT department that a patient with suspected acute stroke is being transported to allow immediate access to the scanner 1
• Aim to complete the CT scan within 25 minutes of arrival for patients potentially eligible for thrombolytic therapy 1
• Ensure a physician skilled in interpreting CT studies is available to promptly review the images 1

Positioning and General Care

• Position the head of the bed at 25-30° until large lobar infarctions, hemorrhage, or other causes of increased intracranial pressure are ruled out by imaging 1
• Keep the patient NPO (nothing by mouth) until swallowing ability can be assessed 1
• Monitor cardiac rhythm as cardiac abnormalities are prevalent among stroke patients 1

Common Pitfalls to Avoid

• Delaying treatment with intravenous thrombolysis while waiting for advanced imaging beyond non-contrast CT 1
• Aggressively treating hypertension in acute ischemic stroke patients not eligible for thrombolytic therapy 1
• Administering prophylactic anticonvulsant medications, which is not recommended and may have negative effects on neural recovery 1
• Delaying transfer to a comprehensive stroke center for patients with suspected large vessel occlusion who present to primary stroke centers 1

By following this structured approach to the initial management of suspected stroke before CT scan, healthcare providers can optimize patient outcomes while preparing for definitive diagnosis and treatment.