What to administer for a suspected stroke?

Management of Suspected Stroke

For suspected stroke, immediately stabilize the patient with ABC assessment, rapidly transport to a stroke-capable facility with EMS prenotification, and do not delay transfer for extensive testing or treatment in the field or primary care setting. 1, 2

Immediate Prehospital/Primary Care Actions

Rapid Assessment and Stabilization

• Assess airway, breathing, and circulation first to ensure basic physiological stability 1, 2
• Use a validated stroke screening tool (FAST scale, Cincinnati Prehospital Stroke Scale, or Los Angeles Prehospital Stroke Screen) to confirm stroke suspicion 1, 2
• Check capillary blood glucose immediately and treat hypoglycemia with IV dextrose if glucose is low 2, 3
• Provide supplemental oxygen only if oxygen saturation is <94% 2
• Correct hypotension and hypovolemia to maintain systemic perfusion 2

Critical Time-Sensitive Transport Decisions

• Transport immediately to the nearest facility capable of administering IV alteplase without delay for extensive diagnostic workup 1, 2
• Provide prehospital notification to the receiving hospital that a suspected stroke patient is en route—this reduces door-to-imaging time by 5 minutes, door-to-needle time by 2 minutes, and increases likelihood of treatment within 3 hours 1
• EMS scene time should be <15 minutes in at least 90% of cases 4
• Consider air transport if it shortens time to stroke center 1

What NOT to Do (Critical Pitfalls)

Do Not Delay Transfer

• Do not perform extensive diagnostic testing in primary care or field settings that delays hospital arrival 2
• Do not wait for laboratory results before initiating transport 1
• Do not administer aspirin or other antithrombotic agents before brain imaging rules out hemorrhagic stroke 2

Blood Pressure Management Caution

• Do not aggressively lower blood pressure in suspected ischemic stroke unless BP is extremely elevated or patient has concurrent acute MI, aortic dissection, or preeclampsia/eclampsia 2
• The exception: For suspected intracerebral hemorrhage presenting within 6 hours, consider lowering systolic BP to 140 mmHg 2

Initial Hospital Evaluation (Upon Arrival)

Immediate Actions Within Minutes

• Activate stroke team immediately upon patient arrival 1, 3
• Perform neurological examination using standardized stroke scale (NIHSS or Canadian Neurological Scale) 1
• Obtain non-contrast CT or MRI brain immediately to exclude hemorrhage and confirm ischemia 1, 3
• Target door-to-imaging time <25 minutes 5
• Target door-to-needle time ≤60 minutes for at least 50% of patients receiving IV alteplase 1

Essential Initial Laboratory Tests

• Draw blood work but do not delay treatment decisions while awaiting results 1
• Required tests include: electrolytes, glucose, CBC, coagulation studies (INR, aPTT), creatinine, eGFR, and troponin 1, 3
• For patients on warfarin, INR level is required before treatment decisions 1
• Perform 12-lead ECG to identify atrial fibrillation or cardiac arrhythmias, but this should not delay thrombolysis assessment 1, 3

Swallowing and Aspiration Precautions

• Keep patient NPO (nothing by mouth) until swallowing screen is completed using a validated tool 1
• Do not administer oral medications until swallowing screen is normal 1
• Complete swallowing screen within 24 hours of arrival, but do not delay acute stroke treatments for this 1

Key Evidence Supporting This Approach

The 2018 AHA/ASA guidelines emphasize that EMS prenotification increases the proportion of patients treated with alteplase within 3 hours from 79.2% to 82.8% and reduces critical time intervals 1. Research demonstrates that patients arriving by EMS with prenotification are 3 times more likely to have brain imaging completed within 25 minutes and 2.7 times more likely to have it interpreted within 45 minutes compared to private transport 5.

The Canadian Stroke Best Practice guidelines stress the "neurons over nephrons" principle—do not delay CTA imaging for renal function results in most patients with disabling stroke symptoms, as the benefit of identifying treatable stroke outweighs nephrotoxicity risk 1.

Time is brain tissue: every minute of delay results in progressive, irreversible neuronal loss 6. The organized protocol approach used in the NINDS rt-PA trial achieved hospital evaluation and treatment initiation within 55 minutes at both community and academic centers 7.