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

Immediate Stroke Protocol Management

For any patient with suspected stroke, immediately activate 9-1-1/EMS, use a validated stroke screening tool (FAST scale, Cincinnati Prehospital Stroke Scale, or Los Angeles Prehospital Stroke Screen), and transport rapidly to the nearest stroke-capable hospital with prehospital notification—this approach reduces door-to-imaging times from 31 to 26 minutes and door-to-needle times from 80 to 78 minutes. 1

Prehospital Recognition and Activation

Public and First Responder Actions

• Any person witnessing stroke symptoms must immediately call 9-1-1 rather than using private transportation—EMS arrival is associated with 3-fold higher likelihood of brain imaging within 25 minutes and 2.7-fold higher likelihood of interpretation within 45 minutes compared to private transport 2
• EMS dispatch personnel should use stroke recognition protocols to identify probable stroke signs (FAST: Face drooping, Arm weakness, Speech difficulty, Time) and assign priority response 1
• Only 60% of stroke patients currently use EMS despite clear outcome benefits, with men, blacks, and Hispanics less likely to activate emergency services 1, 3

EMS Field Assessment and Management

Prehospital providers must perform these actions rapidly and concurrently—do not delay transport:

Immediate Assessment (Class I recommendations) 1, 4

• Assess and manage airway, breathing, and circulation (ABCs) 1
• Apply validated stroke screening tool (FAST scale, Cincinnati Prehospital Stroke Scale, or Los Angeles Prehospital Stroke Screen) 1
• Determine exact time of symptom onset or last known normal time—this is critical for thrombolytic eligibility 1, 4
• Obtain family contact information (preferably cell phone) 1
• Check blood glucose immediately and treat if <60 mg/dL (3.3 mmol/L) with IV dextrose 1, 4

Field Interventions 1, 4

• Provide supplemental oxygen only if saturation <94% 1, 4
• Initiate cardiac monitoring 1
• Establish IV access per local protocol 1, 4
• Maintain NPO status (nothing by mouth) 1

Critical "Do Not" Actions 1

• Do NOT initiate antihypertensive interventions unless directed by medical command or patient is hypotensive (systolic BP <90 mmHg) 1, 4
• Do NOT administer excessive IV fluids 1
• Do NOT give dextrose-containing fluids in non-hypoglycemic patients 1
• Do NOT delay transport for any prehospital interventions 1

Transport and Notification

EMS must provide prehospital notification to the receiving hospital that a stroke patient is en route—this single intervention increases alteplase treatment rates from 79.2% to 82.8% and reduces door-to-needle times by 2 minutes 1

• Transport rapidly to the closest stroke-capable hospital that can administer IV alteplase 1
• Minimize on-scene time (median should be ≤15 minutes) 1
• For remote areas where ground transport exceeds 1 hour, air medical transport is reasonable 1
• Regional stroke systems should include both primary stroke centers (capable of IV thrombolysis) and comprehensive stroke centers (capable of endovascular treatment) 1

Hospital Emergency Department Protocol

Immediate ED Actions (Door-to-Needle Goal: ≤60 minutes in ≥50% of patients) 1

Hospitals must have an organized protocol with a designated acute stroke team including physicians, nurses, and laboratory/radiology personnel available 24/7 1

First 10 Minutes (Class I recommendations) 1

• Activate stroke team immediately upon patient arrival (EMS prenotification reduces activation time from 16 to 8.19 minutes) 5
• Perform rapid neurological examination including NIHSS score 1
• Obtain vital signs including oxygen saturation 1
• Check capillary blood glucose immediately—hypoglycemia (<60 mg/dL) mimics stroke and requires IV dextrose 1, 4
• Obtain 12-lead ECG 1
• Draw blood tests: complete blood count, serum electrolytes, renal function, coagulation studies, troponin 1

Imaging (Goal: Door-to-Imaging ≤25 minutes) 1, 2

• Obtain non-contrast CT head or MRI brain immediately to differentiate ischemic from hemorrhagic stroke 1
• CT interpretation goal: ≤45 minutes from arrival 2

Blood Pressure Management 1, 4, 6

• Do NOT treat hypertension in acute ischemic stroke unless:
  • BP ≥185/110 mmHg AND patient is thrombolysis candidate (must lower to <185/110 before tPA) 4, 6
  • Concomitant acute myocardial infarction, aortic dissection, or preeclampsia/eclampsia 1
• Treat hypotension (systolic <90 mmHg) to maintain organ perfusion 1

Airway Management 1

• Tracheal intubation indicated for compromised airway or insufficient ventilation due to impaired alertness or bulbar dysfunction 1
• Maintain oxygen saturation ≥94% with supplemental oxygen 1, 4

Thrombolytic Therapy Decision (for Ischemic Stroke)

IV alteplase (tPA) is standard of care for eligible patients within 4.5 hours of symptom onset 4, 6

Absolute Requirements Before tPA 4, 6

• Blood pressure <185/110 mmHg before administration 4, 6
• Maintain BP <180/105 mmHg for 24 hours after treatment 6
• No evidence of hemorrhage on CT 4
• Symptom onset <4.5 hours (or last known normal time) 4

Post-tPA Monitoring 6

• Neurological assessments (NIHSS) every 15 minutes for 2 hours, then every 30 minutes for 6 hours, then hourly for 16 hours 6
• Blood pressure monitoring every 15 minutes for 2 hours, then every 30 minutes for 6 hours, then hourly for 16 hours 6
• Keep patient NPO until formal swallowing screen completed to prevent aspiration pneumonia 6

Regional Stroke Systems

Effective stroke systems require coordination between multiple hospital tiers 1:

• Primary Stroke Centers (PSCs): Capable of emergency evaluation, IV thrombolysis, and stroke unit care 1
• Comprehensive Stroke Centers (CSCs): Capable of endovascular treatment and advanced neurocritical care 1
• "Drip-and-ship" protocols: Patients receive IV tPA at PSC before transfer to CSC—delaying tPA until after transfer decreases good outcomes 1

Common Pitfalls to Avoid

• Failing to document exact time of symptom onset or last known normal—this determines thrombolytic eligibility 4
• Delaying transport to perform field interventions—median EMS on-scene time should not exceed 15 minutes 1
• Not providing prehospital notification—this single action reduces door-to-needle time by 2 minutes 1
• Treating hypertension in the field or ED without specific indications—this can worsen cerebral perfusion 1, 4
• Using private transportation instead of EMS—this reduces likelihood of timely imaging by 3-fold 2
• Administering oral medications or allowing oral intake—maintain NPO until swallowing assessed 1, 6

Performance Metrics for Quality Improvement 1

• Door-to-needle time ≤60 minutes in ≥50% of patients (primary goal) 1
• Door-to-needle time ≤45 minutes in ≥50% of patients (secondary goal) 1
• Door-to-imaging time ≤25 minutes 2
• EMS prenotification rate (target: >67%) 1
• Stroke team activation time <10 minutes for EMS arrivals 5