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

Immediate Stroke Protocol Management

Any patient with suspected stroke symptoms requires immediate 9-1-1 activation, rapid EMS transport with hospital prenotification, emergent non-contrast CT brain imaging within 25 minutes of arrival, and IV alteplase administration within 60 minutes if eligible—this time-dependent protocol is the standard of care that directly impacts mortality and functional outcomes. 1

Prehospital Recognition and EMS Activation

Public and Dispatcher Response

• Witnesses must immediately call 9-1-1 upon recognizing stroke symptoms using the FAST scale (Face drooping, Arm weakness, Speech difficulty, Time to call 911), as EMS arrival is associated with a 3-fold higher likelihood of achieving brain imaging within 25 minutes compared to private transport 1, 2
• EMS dispatch personnel should use stroke recognition protocols to assign priority response, though currently only 60% of stroke patients utilize EMS despite clear outcome benefits 1, 3

EMS Field Assessment Protocol

• Prehospital providers must perform the following in sequence while minimizing on-scene time to ≤15 minutes: 1
  • Assess and stabilize airway, breathing, and circulation (ABCs) 1
  • Apply a validated stroke screening tool (e.g., Cincinnati Prehospital Stroke Scale or FAST) 1, 4
  • Document the exact time of symptom onset or last known normal time—this is critical for thrombolytic eligibility and is frequently missed 1, 4
  • Check capillary blood glucose immediately and treat if <60 mg/dL, as hypoglycemia mimics stroke symptoms 1, 4
  • Provide supplemental oxygen only if saturation <94% 1, 4
  • Establish IV access per local protocol 1
  • Initiate cardiac monitoring 1

Critical Prehospital Blood Pressure Management

• Do not administer antihypertensive medications in the field unless systolic blood pressure is >220 mmHg or diastolic >120 mmHg—blood pressure management is reserved for the hospital setting 4
• Avoid treating elevated blood pressure prehospital, as permissive hypertension maintains cerebral perfusion in acute stroke 4

EMS Prenotification

• EMS must provide hospital prenotification of stroke patients, which reduces door-to-needle times by 2 minutes and increases the likelihood of achieving door-to-imaging times <25 minutes by 3-fold 1, 2
• Prenotification allows the stroke team to mobilize before patient arrival, with studies showing this is the single most impactful prehospital intervention 2

Emergency Department Stroke Protocol

Immediate ED Actions (Door-to-Imaging Goal: ≤25 Minutes)

• The stroke team must be activated immediately upon patient arrival and includes physicians, nurses, and laboratory/radiology personnel available 24/7 1
• Perform rapid neurological examination with NIHSS score documentation 1
• Obtain vital signs with continuous blood pressure monitoring 1
• Recheck capillary blood glucose 1
• Obtain 12-lead ECG 1
• Draw blood tests including: CBC, comprehensive metabolic panel, PT/INR, aPTT, troponin 1
• Obtain non-contrast CT brain imaging within 25 minutes of arrival—this is the rate-limiting step for thrombolytic therapy 1

Thrombolytic Therapy Decision (Door-to-Needle Goal: ≤60 Minutes)

IV alteplase (tPA) is the standard of care for eligible patients within 4.5 hours of symptom onset and must be administered within 60 minutes of hospital arrival in ≥50% of patients 1

Absolute Requirements for tPA Administration:

• Symptom onset <4.5 hours (or last known normal time <4.5 hours) 1
• Blood pressure <185/110 mmHg before administration 1, 4
• No evidence of intracranial hemorrhage on CT 1
• Blood pressure maintained <180/105 mmHg for 24 hours post-administration 4, 5

Post-tPA Monitoring Protocol:

• Neurological assessments (NIHSS) every 15 minutes for 2 hours, then every 30 minutes for 6 hours, then hourly for 16 hours 1, 5
• Blood pressure monitoring every 15 minutes for 2 hours, then every 30 minutes for 6 hours, then hourly for 16 hours 5
• Keep patient NPO until formal swallowing screen is completed to prevent aspiration pneumonia 5
• Obtain urgent repeat CT if any neurological deterioration occurs 5

Regional Stroke System Coordination

Hospital Tier System

• Effective stroke systems require coordination between Primary Stroke Centers (PSCs) and Comprehensive Stroke Centers (CSCs) 1
• "Drip-and-ship" protocols allow patients to receive IV tPA at PSC before transfer to CSC for endovascular thrombectomy if indicated 1
• EMS should transport patients to the most appropriate stroke-capable center when possible, balancing proximity with capability 4

Performance Metrics and Quality Improvement

Target Benchmarks:

• Door-to-needle time ≤60 minutes in ≥50% of patients (with aspirational goal of ≤45 minutes) 1
• Door-to-imaging time ≤25 minutes 1
• EMS prenotification rate >67% 1
• Brain imaging interpretation by physician within 45 minutes of arrival 2

Common Pitfalls to Avoid

• Delaying transport to administer medications or perform extensive assessments in the field—rapid transport to a stroke center is the priority 4
• Failing to document exact time of symptom onset or last known normal time, which determines thrombolytic eligibility 4
• Administering antihypertensive medications in the field without specific indications (hypotensive emergency) 4
• Missing hospital prenotification, which delays in-hospital treatment and reduces likelihood of meeting time targets 4, 2
• Treating elevated blood pressure too aggressively before or after tPA, as permissive hypertension maintains cerebral perfusion 4
• Failing to perform swallowing screen before allowing oral intake, risking aspiration pneumonia 5