What are the initial management steps for a stroke patient in a local clinic?

Initial Stroke Management in a Local Clinic

Immediately activate emergency medical services (EMS) for transport to a stroke-capable hospital while stabilizing the patient's airway, breathing, and circulation—local clinics should NOT attempt definitive stroke treatment but focus on rapid recognition, stabilization, and transfer. 1, 2

Immediate Recognition and Triage (First 5 Minutes)

• Triage stroke patients with the same priority as acute myocardial infarction or major trauma, regardless of how mild the neurological deficits appear 1, 2
• Document the exact time the patient was last known to be normal or symptom-free—this is the "time zero" for all treatment decisions, not when symptoms were discovered 1, 2
• For patients who woke up with symptoms or cannot provide history, use the time they were last seen awake and normal 1

Critical Initial Stabilization (Simultaneous with EMS Activation)

Airway, Breathing, Circulation

• Administer supplemental oxygen immediately if oxygen saturation <94% to prevent hypoxemia-related secondary brain injury 1, 3
• Position the patient's head flat (not elevated) if they are hypotensive (systolic BP <120 mmHg) to improve cerebral perfusion 1
• Establish IV access and draw blood samples for: complete blood count, coagulation studies, platelet count, electrolytes, renal function, glucose, and cardiac troponin 3, 2

Blood Glucose Assessment

• Check fingerstick glucose immediately—hypoglycemia (<60 mg/dL) is a common stroke mimic that can be reversed with IV glucose 1
• If glucose is low, administer IV dextrose and reassess neurological status 1
• If glucose is normal, use normal saline (not dextrose-containing fluids) for IV hydration, as excessive glucose may worsen brain injury 1

Blood Pressure Management in the Clinic

Do NOT routinely lower blood pressure in the clinic setting unless it is extremely elevated 1

• For patients with systolic BP <120 mmHg: position flat and give isotonic saline 1
• For systolic BP 140-219 mmHg: do not treat—permissive hypertension may be protective 1
• For systolic BP ≥220 mmHg: contact medical control/receiving hospital before treating; if treatment is advised, use labetalol 10-20 mg IV over 1-2 minutes 3

Critical pitfall: Aggressively lowering blood pressure before hospital arrival can worsen cerebral perfusion and outcomes 1

What NOT to Do in the Clinic

• Do not delay EMS transport to obtain imaging—CT scanning must occur at a stroke-capable facility 1, 2
• Do not administer aspirin, anticoagulants, or thrombolytics in the clinic setting—these require hospital-based protocols and imaging 1, 2
• Do not perform extensive diagnostic workup—the goal is stabilization and rapid transfer, not diagnosis 1, 4

Communication with EMS and Receiving Hospital

• Provide prehospital notification to the receiving stroke center to activate their stroke team before arrival 1, 2
• Communicate: exact time last known normal, current vital signs, blood glucose level, any treatments given, and estimated time of arrival 1, 4
• Request transport to the closest stroke-capable hospital, not just the nearest facility—EMS should bypass non-stroke centers when appropriate 1

During Transport Preparation

• Keep the patient NPO (nothing by mouth) until swallowing can be assessed at the hospital 2
• Continue oxygen supplementation to maintain saturation >94% 3
• Monitor and document any changes in neurological status 1
• Send blood samples with the patient if already drawn 1

Time-Critical Context

The entire clinic evaluation and stabilization should take no more than 10-15 minutes before EMS departure 4. Every 15-minute delay in treatment reduces the chance of good outcome, as approximately 1.9 million neurons die per minute during acute ischemic stroke 5, 6. The therapeutic window for IV thrombolysis is 3-4.5 hours, and mechanical thrombectomy extends to 6-24 hours for selected patients, making every minute count 3, 2.

The local clinic's role is rapid recognition, basic stabilization, and expedited transfer—not definitive stroke care 1, 5.