What is the emergency treatment for a patient with left-sided limb weakness, slurred speech, hyperglycemia (Random Blood Sugar (RBS) 415), and hypertension (Blood Pressure (BP) 171/97 mmHg)?

Emergency Management of Acute Stroke with Hyperglycemia and Hypertension

This patient requires immediate brain imaging (CT or MRI) without delay, followed by blood pressure control to <185/110 mmHg if thrombolysis is being considered, and treatment of hyperglycemia with insulin to achieve glucose levels between 140-180 mg/dL. 1, 2

Immediate Priorities in the Emergency Department

1. Rapid Brain Imaging

• Perform non-contrast CT scan or brain MRI immediately upon arrival before any specific stroke treatment 1
• This is essential to differentiate ischemic stroke from hemorrhagic stroke, as management differs fundamentally between the two 1
• Do not delay imaging for laboratory results, though blood tests should be obtained concurrently 1

2. Blood Pressure Management

Critical decision point: Is the patient eligible for IV thrombolysis?

If Thrombolysis is Being Considered:

• Blood pressure MUST be lowered to <185/110 mmHg before initiating IV alteplase 1, 2, 3
• After thrombolysis, maintain BP <180/105 mmHg for at least 24 hours 2, 3
• Use labetalol as first-line agent (preferred for BP control in acute stroke) 2, 3
• Alternative: nicardipine (especially if patient has bradycardia or heart failure) 2, 3

If NOT Receiving Thrombolysis:

• Do NOT treat blood pressure unless it exceeds 220/120 mmHg 2, 4, 3
• The current BP of 171/97 mmHg should NOT be actively lowered in the first 48-72 hours if thrombolysis is not planned 2, 4, 3
• Cerebral autoregulation is impaired in acute stroke, making cerebral perfusion directly dependent on systemic blood pressure 3
• If BP reduction is necessary (>220/120 mmHg), reduce by only 15% over 24 hours 2, 4, 3

3. Hyperglycemia Management

With RBS of 415 mg/dL, this patient requires immediate insulin therapy:

• Initiate treatment for blood glucose >200 mg/dL 1
• Target glucose range: 140-180 mg/dL 1
• Use intravenous insulin infusion with frequent monitoring and dose adjustments 1, 5
• Hyperglycemia (>200 mg/dL) during the first 24 hours independently predicts infarct expansion and poor neurological outcomes 1
• Blood glucose assessment is the ONLY test that must precede IV alteplase administration 1

Important caveat: Hypoglycemia (<60 mg/dL or 3.3 mmol/L) must be excluded and treated immediately with IV dextrose if present, as it can mimic stroke 1

4. Additional Emergency Interventions

Airway and Oxygenation:

• Provide supplemental oxygen to maintain oxygen saturation ≥94% 1
• Tracheal intubation is indicated only if airway is compromised or ventilation is insufficient due to impaired alertness 1

Laboratory Tests (obtain but do not delay imaging):

• Complete blood count, serum electrolytes, creatinine 1
• INR and partial thromboplastin time 1
• Serum troponin 1
• Electrocardiogram 1

Stroke Severity Assessment:

• Use validated stroke severity scale (e.g., NIHSS) in the emergency department 1

Thrombolysis Decision-Making

If imaging confirms ischemic stroke and patient presents within 4.5 hours of symptom onset:

• IV alteplase (0.9 mg/kg, maximum 90 mg over 60 minutes with 10% as initial bolus) should be initiated as soon as possible 1
• Contraindications must be reviewed (see Supplemental Appendix 4 in guidelines) 1
• Do NOT delay thrombolysis to evaluate response before considering mechanical thrombectomy 1
• Eligible patients should receive IV thrombolysis even if mechanical thrombectomy is being considered 1

Critical Pitfalls to Avoid

1. Aggressively lowering BP in the first 48-72 hours when NOT giving thrombolysis - this can extend infarct size by reducing perfusion to the penumbra 4, 3

2. Using agents that cause precipitous BP drops (e.g., sublingual nifedipine, sodium nitroprusside) - rapid reduction compromises cerebral perfusion 4

3. Delaying imaging for laboratory results - brain imaging should occur immediately upon arrival 1

4. Ignoring hyperglycemia - persistent glucose >200 mg/dL predicts worse outcomes and requires treatment 1, 6

5. Treating BP <185/110 mmHg before confirming thrombolysis eligibility - unnecessary BP reduction may harm patients not receiving reperfusion therapy 2, 3

Monitoring Protocol

If thrombolysis is administered:

• Monitor BP every 15 minutes during treatment and for 2 hours after 2, 4
• Every 30 minutes for the next 6 hours 2, 4
• Every hour for the next 16 hours 2, 4

For glucose management:

• Frequent blood glucose monitoring with insulin dose adjustments 1, 5
• Monitor for hypoglycemia, which can cause disorientation, seizures, or unconsciousness 5