What is the best course of action for a patient with a history of stroke, diabetes (DM), and hypertension (HTN), presenting with palpitations and slurred speech?

Emergency Management of Stroke with Palpitations in a Diabetic and Hypertensive Patient

This patient requires immediate activation of stroke protocol with urgent non-contrast CT scan or brain MRI to differentiate ischemic from hemorrhagic stroke, followed by continuous cardiac monitoring to detect atrial fibrillation, while simultaneously checking blood glucose and correcting severe hyperglycemia if present. 1, 2

Immediate Emergency Department Actions

Stroke Protocol Activation

• Perform non-contrast CT scan or brain MRI immediately upon arrival before any specific stroke treatment to differentiate ischemic stroke from hemorrhagic stroke and exclude stroke mimics 1, 2
• Establish time of symptom onset (when patient was last known to be normal) to determine eligibility for thrombolysis, which must be initiated within 4.5 hours 1
• Assess using validated stroke screening tools (FAST: Face, Arm, Speech, Time) and calculate NIHSS score 1

Cardiac Evaluation for Palpitations

• Initiate continuous cardiac monitoring for at least 24 hours to detect atrial fibrillation, which is present in many stroke patients and increases stroke risk 5-fold 1, 2
• Obtain 12-lead ECG immediately to assess for acute coronary syndrome, arrhythmias, or QT prolongation 1
• Check troponin levels, as cardiac complications account for 2-6% of mortality within the first 3 months post-stroke 1

Metabolic Assessment

• Check blood glucose immediately and initiate IV insulin infusion if glucose >200 mg/dL, targeting 140-180 mg/dL 3, 2
• Severe hyperglycemia (>1000 mg/dL) can cause stroke-like symptoms (hyperosmolar hyperglycemic state) and worsens stroke outcomes 3, 4
• Check serum sodium, as severe hyponatremia can mimic stroke with slurred speech and facial droop 5
• Measure hemoglobin A1c to assess chronic glycemic control 3

Blood Pressure Management

If Thrombolysis is Being Considered

• Blood pressure must be lowered to <185/110 mmHg before initiating IV alteplase 1, 2
• Use labetalol as first-line agent (10-20 mg IV over 1-2 minutes, may repeat) or nicardipine (5 mg/hour IV, titrate up by 2.5 mg/hour every 5-15 minutes) 1, 2
• Maintain BP <180/105 mmHg for at least 24 hours after thrombolysis 1, 2

If NOT Receiving Thrombolysis

• Do not treat blood pressure unless systolic >220 mmHg or diastolic >120 mmHg, as lowering BP can extend the infarct by reducing perfusion to the penumbra 1, 2
• If treatment is necessary, reduce mean arterial pressure by only 15% in the first 24 hours 1
• Avoid agents causing precipitous BP drops (sublingual nifedipine, sodium nitroprusside) 2

Airway and Breathing Management

Swallowing Assessment

• Keep patient NPO (nothing by mouth) until swallow screening is completed, as 40-78% of acute stroke patients have dysphagia 1
• Perform validated swallowing screening on day of admission before any oral intake 1
• Maintain IV hydration until dysphagia assessment is complete 1

Oxygen Management

• Provide supplemental oxygen only if oxygen saturation <94% 2
• Avoid high-flow oxygen unless life-threatening hypoxemia (SpO2 <88%) is present 1
• Consider intubation only if airway is compromised or ventilation is insufficient due to impaired alertness 2

Thrombolysis Decision-Making

If imaging confirms ischemic stroke and patient presents within 4.5 hours of symptom onset, initiate IV alteplase (0.9 mg/kg, maximum 90 mg over 60 minutes with 10% as initial bolus) as soon as possible. 2

Contraindications to Consider

• Blood glucose <50 mg/dL or >400 mg/dL (relative contraindication) 1
• Systolic BP >185 mmHg or diastolic >110 mmHg that cannot be controlled 1
• History of intracranial hemorrhage 1

Additional Critical Interventions

Seizure Monitoring

• Monitor for seizures during routine vital signs and neurological assessments, as immediate post-stroke seizures can occur 1
• Do not use prophylactic anticonvulsants, as they may negatively affect neurological recovery 1

Thiamine Administration

• Consider thiamine 100 mg IV if any history of alcohol use or malnutrition, as Wernicke's encephalopathy can present with focal neurological deficits 3

Admission Planning

• Admit to intensive care unit or stroke unit with continuous cardiac monitoring and capability for frequent glucose checks 3, 2
• Arrange for speech-language pathology, occupational therapy, and dietitian consultations 1

Critical Pitfalls to Avoid

• Do not assume symptoms are purely metabolic (hyperglycemia or hyponatremia) without completing full stroke evaluation, as both conditions may coexist 3, 5, 4
• Do not aggressively lower BP in the first 48-72 hours when not giving thrombolysis, as it can extend infarct size 1, 2
• Do not rely solely on subcutaneous insulin for severe hyperglycemia - IV insulin is mandatory for rapid, titratable control 3
• Do not target glucose <140 mg/dL - this increases hypoglycemia risk without proven benefit, and hypoglycemia can cause permanent brain damage 3, 2
• Do not delay stroke imaging or treatment while correcting metabolic abnormalities unless glucose is critically low (<50 mg/dL) 1, 3

Monitoring Protocol

• Monitor BP every 15 minutes during thrombolysis and for 2 hours after, then every 30 minutes for 6 hours, then hourly for 16 hours 2
• Check blood glucose every 1-2 hours initially if hyperglycemic 3
• Perform neurological assessments every 15 minutes during acute phase 1
• Continue cardiac monitoring for at least 24 hours to detect paroxysmal atrial fibrillation 1, 2