What are the immediate steps to manage a suspected ischemic event?

Signs of Ischemic Events

Recognize ischemic events using the FAST assessment (Face, Arm, Speech, Time) combined with systematic neurological evaluation, as these signs indicate a medical emergency requiring immediate activation of emergency services and transport to a stroke center. 1

Primary Clinical Signs

FAST Assessment Components

• Facial asymmetry: Unilateral facial weakness or droop, ranging from minor weakness to complete unilateral palsy 2
• Arm weakness: Unilateral arm drift or inability to maintain position against gravity for 5-10 seconds, progressing to complete inability to move the limb 2
• Speech disturbance: Dysarthria (slurred speech) or aphasia (difficulty finding words, understanding language, or complete inability to speak) 2
• Time: Document exact time of symptom onset or when patient was last at baseline, as this determines treatment eligibility 3

Additional Neurological Signs

• Motor deficits: Leg weakness with drift before 5 seconds or falls before 10 seconds, assessed separately from arm weakness 2
• Visual disturbances: Hemianopia (partial or complete visual field loss), diplopia, or complete bilateral visual loss 2
• Gaze abnormalities: Partial or complete gaze palsy indicating brainstem or hemispheric involvement 2
• Sensory loss: Unilateral mild to severe sensory deficits 2
• Limb ataxia: Incoordination affecting one or both limbs 2
• Altered consciousness: Drowsiness, obtundedness, or coma 2
• Extinction or inattention: Loss of awareness in one or two sensory modalities 2

Ocular Ischemic Signs

Retinal Arterial Ischemia

• Transient monocular vision loss (TMVL): Sudden, painless, temporary loss of vision in one eye lasting minutes, representing a retinal TIA 2
• Branch retinal artery occlusion (BRAO): Permanent sectoral vision loss corresponding to the affected retinal artery territory 2
• Central retinal artery occlusion (CRAO): Sudden, painless, permanent severe vision loss in one eye, representing a retinal stroke 2

Critical caveat: Acute retinal arterial ischemia carries the same stroke risk as cerebral TIA and requires immediate referral to a stroke center without performing additional testing in the ophthalmology office. 2

Cardiac Ischemic Signs

Acute Coronary Syndrome Presentation

• Chest discomfort: Central chest pressure, tightness, or pain lasting longer than 15-20 minutes 2
• Radiation: Discomfort extending to arms, jaw, neck, back, or epigastrium 2
• Associated symptoms: Dyspnea, diaphoresis, nausea, vomiting, or dizziness accompanying chest discomfort 2
• Dyspnea: Shortness of breath as a predominant symptom, often with diaphoresis 2

Important distinction: Isolated diaphoresis, nausea, vomiting, or dizziness without chest or upper body discomfort are unusual predominant presenting symptoms of cardiac ischemia. 2

Posterior Circulation Signs

Less Obvious Stroke Presentations

• Dizziness or vertigo: Especially when accompanied by other neurological signs 1
• Ataxia: Incoordination or imbalance suggesting cerebellar involvement 1
• Isolated visual disturbances: Bilateral visual changes or visual field defects 1

Common pitfall: Posterior circulation strokes may present with subtle, non-specific symptoms that are easily missed. Maintain high suspicion when dizziness or ataxia occurs with any other neurological sign. 1

Immediate Management Steps

On Recognition of Signs

1. Activate EMS immediately for any suspected stroke symptoms 1, 3
2. Assess ABCs (airway, breathing, circulation) and prepare for CPR/defibrillation if needed 2, 3
3. Check blood glucose to exclude hypoglycemia as a stroke mimic 2, 3
4. Document symptom onset time precisely, defined as when patient was last symptom-free 3
5. Administer aspirin 160-325 mg if cardiac ischemia suspected 2
6. Transport directly to stroke center capable of advanced care, bypassing closer facilities if necessary 1

Initial Hospital Assessment (<10 minutes)

• Vital signs: Blood pressure, heart rate, oxygen saturation, temperature 3
• 12-lead ECG: To identify cardiac arrhythmias, atrial fibrillation, or acute myocardial infarction 2, 3
• Brain imaging: Non-contrast CT or MRI immediately to exclude hemorrhage 2, 3
• Laboratory tests: Blood glucose, electrolytes, complete blood count with platelets, PT/INR, aPTT, renal function, cardiac markers 2, 3

Time-critical note: Do not delay thrombolytic therapy while awaiting coagulation study results unless there is clinical suspicion of bleeding abnormality, thrombocytopenia, or known anticoagulant use. 2