What is the workup and treatment for a stroke in the emergency room (ER)?

Emergency Department Stroke Workup and Treatment Protocol

All suspected stroke patients require immediate triage as high-severity (to be seen within 10 minutes), rapid brain imaging within 25 minutes of arrival, and IV alteplase administration within 60 minutes for eligible patients. 1

Immediate Triage and Recognition (0-10 Minutes)

Assign highest triage priority using Emergency Severity Index Level 2 – equivalent to unstable trauma or critical cardiac patients – ensuring evaluation begins within 10 minutes of ED arrival. 1

• Use validated stroke screening tools at triage (FAST, Cincinnati Prehospital Stroke Scale, or ROSIER) to rapidly identify stroke symptoms: face drooping, arm weakness, speech difficulty. 1
• Document exact time of symptom onset or last known normal time – this is the single most critical piece of information determining treatment eligibility. If unknown, use standardized time parameters (morning 6AM-12PM, afternoon 12PM-6PM, evening 6PM-12AM, overnight 12AM-6AM). 1, 2
• Activate Code Stroke immediately upon recognition, which triggers simultaneous notification of stroke team, CT scanner priority access, and laboratory mobilization. 1, 3

Common Pitfall: Delaying triage beyond 10 minutes or failing to establish last known normal time eliminates treatment options. 4

Simultaneous Initial Assessment and Stabilization (0-15 Minutes)

Perform rapid ABCDE assessment while obtaining IV access and drawing blood samples – do not delay imaging for laboratory results. 1

Airway, Breathing, Circulation

• Intubate only if airway is compromised or ventilation is insufficient due to impaired alertness or bulbar dysfunction. 1
• Provide supplemental oxygen only if oxygen saturation <94% – routine oxygen administration is not indicated. 1, 2
• Correct hypotension and hypovolemia to maintain systemic perfusion necessary for organ function. 1

Point-of-Care Testing

• Check capillary blood glucose immediately – hypoglycemia (<60 mg/dL or 3.3 mmol/L) is a common stroke mimic and requires immediate IV dextrose treatment. 1, 2

Blood Work (Draw but Don't Wait)

• Obtain complete blood count, serum electrolytes, creatinine, INR/aPTT, and troponin – but these should never delay brain imaging or reperfusion therapy. 1, 2
• Obtain 12-lead ECG to identify concurrent cardiac pathology. 1

Neurological Assessment

• Calculate NIHSS score to quantify stroke severity and establish baseline for monitoring – this should be performed by trained personnel and documented before any treatment. 1

Emergency Brain Imaging (Target: 25 Minutes from Door)

All suspected stroke patients require non-contrast CT head or brain MRI immediately – imaging must be completed within 25 minutes of ED arrival and interpreted within 45 minutes. 1

• Non-contrast CT is the standard initial imaging modality to differentiate ischemic stroke from hemorrhagic stroke and identify stroke mimics. 1
• CT angiography should not delay tPA administration – it can be obtained after thrombolytic bolus is given if endovascular therapy is being considered. 1

Common Pitfall: Waiting for laboratory results or obtaining unnecessary additional imaging sequences delays treatment and worsens outcomes. 1

Blood Pressure Management

Blood pressure management differs dramatically based on thrombolysis eligibility – aggressive reduction can worsen ischemia in non-candidates. 2

For Thrombolysis Candidates

• Reduce BP to <185/110 mmHg before administering alteplase using IV labetalol or nicardipine to prevent hemorrhagic transformation. 2
• Maintain BP <180/105 mmHg for 24 hours post-thrombolysis with continuous monitoring. 2

For Non-Thrombolysis Candidates

• Only treat hypertension if SBP >220 mmHg or DBP >120 mmHg – permissive hypertension maintains cerebral perfusion in acute ischemia. 2
• Emergency BP reduction is indicated only for concurrent acute MI, aortic dissection, or preeclampsia/eclampsia. 1

IV Alteplase Decision and Administration (Target: 60 Minutes from Door)

IV alteplase (0.9 mg/kg, maximum 90 mg) is standard of care for eligible patients within 4.5 hours of symptom onset. 1, 2

Absolute Requirements for Treatment

• Symptom onset <4.5 hours (or <3 hours for patients >80 years, on anticoagulants with INR <1.7, NIHSS >25, or history of stroke plus diabetes). 1
• Blood pressure <185/110 mmHg after treatment if needed. 2
• No hemorrhage on CT imaging. 2
• No recent surgery, active bleeding, or platelet count <100,000. 5

Administration Protocol

• Give 10% of total dose as IV bolus over 1 minute, followed by remaining 90% as continuous infusion over 60 minutes. 1
• Initiate infusion on CT scanner bed when possible to minimize time delays. 1

Evidence Note: The 2013 ACEP/AAN joint clinical policy 1 established Class I evidence for tPA within 3 hours, with more recent 2023 World Stroke Organization guidelines 1 supporting the extended 4.5-hour window with specific exclusions.

Post-Treatment Monitoring and Complications

Perform neurological assessments using NIHSS every 15 minutes for 2 hours, then every 30 minutes for 6 hours, then hourly for 16 hours to detect hemorrhagic transformation or neurological deterioration. 2

• Keep patient NPO until formal swallowing screen completed to prevent aspiration pneumonia. 2
• Monitor for new-onset seizures – treat with short-acting benzodiazepines (lorazepam IV) if not self-limited, but do not initiate long-term anticonvulsants for single seizure. 2
• Watch for signs of cerebral edema – worsening mental status, new headache, or declining NIHSS score. 2

Transfer Considerations

Patients with large vessel occlusions or those requiring endovascular therapy should be transferred to comprehensive stroke centers – "drip-and-ship" protocols allow tPA initiation at primary stroke centers before transfer. 3

• Establish inter-hospital transfer protocols in advance to minimize delays for patients requiring higher level of care. 1
• Regional stroke systems should stratify hospitals into those capable of IV thrombolysis versus those with endovascular capabilities. 1

Quality Metrics to Track

Door-to-needle time ≤60 minutes should be achieved in ≥50% of patients, with aspirational goal of ≤45 minutes. 3

• Door-to-imaging time ≤25 minutes. 3
• EMS prenotification rate >67%. 3
• Stroke team activation within 10 minutes of arrival. 1

Common Pitfall: In-hospital strokes are frequently missed or delayed because staff don't recognize nonfocal neurological deficits (confusion, decreased alertness) as potential stroke – maintain high index of suspicion and activate stroke protocol liberally. 1, 6