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

Immediate Stroke Protocol Management

Prehospital Recognition and Emergency Response

Any person witnessing stroke symptoms must immediately call 9-1-1, and EMS should use the FAST (Face, Arms, Speech, Time) screening tool to identify stroke, as EMS transport with prenotification increases the likelihood of receiving IV thrombolysis by 3-fold and reduces door-to-needle times. 1, 2, 3

Critical Information for EMS Dispatch

• Exact time of symptom onset or last known normal time (most critical for treatment eligibility) 4, 1
• Current medications, particularly anticoagulants 4
• Visible stroke signs (face drooping, arm weakness, speech difficulty) 4
• Patient location and current condition changes since symptom onset 4

EMS Field Management Protocol

• Perform immediate ABC assessment (airway, breathing, circulation) within first 60 seconds 4, 1
• Check capillary blood glucose immediately and treat if <60 mg/dL (hypoglycemia mimics stroke) 1
• Provide supplemental oxygen only if saturation <94% (avoid hyperoxia) 1
• Establish IV access and cardiac monitoring per protocol 1
• Minimize on-scene time to ≤15 minutes 1
• Prenotify receiving hospital stroke team (reduces door-to-imaging time by up to 3 minutes) 1, 2, 3

Emergency Department Immediate Evaluation

All suspected stroke patients require immediate clinical evaluation with a target door-to-imaging time of ≤25 minutes and door-to-needle time of ≤60 minutes for eligible patients. 4, 1

First 10 Minutes (Parallel Processing)

• Rapid neurological examination using NIHSS scale to quantify stroke severity 4, 1
• Vital signs assessment: heart rate/rhythm, blood pressure, temperature, oxygen saturation 4
• Capillary blood glucose check (repeat if not done by EMS) 4, 1
• Draw blood work: electrolytes, glucose, CBC, INR/aPTT, creatinine/eGFR, troponin 4
  • Do not wait for results before imaging or treatment unless patient is on warfarin (need INR) 4
  • Do not delay CTA for renal function results in patients with disabling symptoms ("neurons over nephrons" principle) 4

Imaging Protocol

• Obtain non-contrast CT head immediately to rule out hemorrhage 4, 1
• Target door-to-imaging completion ≤25 minutes 1, 2
• If hemorrhagic stroke identified, refer to hemorrhagic stroke guidelines 4

Additional Testing (Can Be Deferred Until After Thrombolysis Decision)

• 12-lead ECG (unless patient is hemodynamically unstable) 4, 1
• Chest X-ray (unless acute medical condition warrants immediate completion) 4

Blood Pressure Management

For Non-Thrombolysis Candidates

Lower blood pressure only when SBP >220 mmHg or DBP >120 mmHg, as aggressive reduction may worsen ischemia by decreasing perfusion pressure 4

For Thrombolysis Candidates

Blood pressure must be reduced to <185/110 mmHg before administering IV alteplase to avoid hemorrhagic complications 4, 1

Post-thrombolysis: maintain BP <180/105 mmHg for at least 24 hours with monitoring every 15 minutes for 2 hours, then every 30 minutes for 6 hours, then hourly for 16 hours 5

Thrombolytic Therapy Decision

IV alteplase (tPA) is the standard of care for eligible patients within 4.5 hours of symptom onset. 1

Absolute Requirements for IV Alteplase

• Symptom onset <4.5 hours (or last known normal time) 1
• Blood pressure <185/110 mmHg 1
• No evidence of hemorrhage on CT 1
• Target door-to-needle time ≤60 minutes (goal: ≤45 minutes in ≥50% of patients) 1

Seizure Management

Treat new-onset seizures at stroke onset or within 24 hours with short-acting medications (e.g., lorazepam IV) if not self-limited 4

Do not treat a single self-limiting seizure occurring within 24 hours of stroke with long-term anticonvulsants, but monitor for recurrent seizure activity 4

Post-Treatment Monitoring

Perform neurological assessments using NIHSS every 15 minutes for 2 hours, then every 30 minutes for 6 hours, then hourly for 16 hours to monitor for hemorrhagic transformation, cerebral edema, and neurological deterioration 1, 5

Keep patients NPO until formal swallowing screen is completed to prevent aspiration pneumonia 5

Critical Pitfalls to Avoid

• Never delay imaging or treatment for ECG, chest X-ray, or awaiting blood work results (except INR in warfarin patients) 4
• Never aggressively lower blood pressure in non-thrombolysis candidates with SBP <220 mmHg or DBP <120 mmHg (may worsen ischemia) 4
• Never discharge TIA patients from ED without diagnostic evaluation and secondary prevention initiation (stroke risk is 3.1% at 2 days and 5.2% at 7 days) 4
• Never assume normal renal function delays CTA in acute disabling stroke (prioritize "neurons over nephrons") 4