What is the immediate management for a 27-year-old male found on the ground, aphasic, with suspected acute neurological condition, such as stroke?

Immediate Management of a 27-Year-Old Male Found Aphasic on the Ground

This patient requires immediate emergency activation (call 911 if not already done), rapid transport to a stroke-capable facility, and urgent neuroimaging within 25 minutes of arrival to determine eligibility for time-sensitive interventions including thrombolysis and endovascular therapy. 1, 2

Prehospital/On-Scene Priorities

Immediate Recognition and Mobilization

• The on-scene goal is "recognize and mobilize"—minimize time at scene and proceed rapidly to transport. 3
• Limit on-scene time to 20 minutes or less for patients potentially within the 4.5-hour treatment window 1
• Use a validated stroke screening tool (FAST assessment: Face drooping, Arm weakness, Speech difficulty, Time) as part of on-scene evaluation 3

Critical On-Scene Actions

• Check capillary blood glucose immediately to exclude hypoglycemia as a stroke mimic—this is essential as hypoglycemia can present identically to stroke 1, 2
• Obtain time of symptom onset or time last known well from any witnesses—this is the single most important piece of historical information 2
• Document presenting symptoms, sequence of events, current medications, and comorbid conditions 3
• For patients showing any FAST signs, perform a second validated severity screen to identify potential endovascular therapy candidates (look for cortical signs: aphasia, visual changes, neglect) 3, 1

Transport Decision

• Transport directly to the closest stroke-capable facility with neuroimaging and thrombolysis capacity, bypassing non-stroke centers 1
• Provide pre-notification to receiving hospital to activate stroke team 3
• EMS dispatch should designate this as priority dispatch with minimized transport times 3

Emergency Department Management

Immediate Triage and Stabilization

• Triage with the same priority as acute myocardial infarction or serious trauma, regardless of deficit severity 1, 2
• Activate stroke team immediately upon arrival 2
• Perform ABCs (airway, breathing, circulation) stabilization first 2
• Monitor cardiac rhythm as cardiac abnormalities may accompany stroke 2
• Check vital signs every 30 minutes while in ED 2
• Position head of bed at 25-30° unless contraindicated 2

Urgent Diagnostic Workup

• Obtain non-contrast CT immediately (within 25 minutes of arrival) to exclude hemorrhage and assess for early ischemic changes—this is the rate-limiting step for thrombolytic therapy 1, 2
• Perform CT angiography from aortic arch to vertex at time of initial CT when possible to assess both extracranial and intracranial circulation for endovascular therapy planning 1, 2
• Order laboratory studies immediately but do not wait for results before imaging: complete blood count, electrolytes, renal function, coagulation studies, blood glucose 3, 1
• Obtain ECG to assess for atrial fibrillation and structural heart disease 3

Time-Sensitive Treatment Decisions

• Determine thrombolytic eligibility within 60 minutes of arrival 1
• Review strict inclusion/exclusion criteria for tPA safety 1
• If no contraindications present, administer IV tPA 0.9 mg/kg (maximum 90 mg) 1
• Lower blood pressure to <185/110 mmHg before thrombolytic treatment 1
• For non-thrombolytic patients, only lower blood pressure if systolic >220 mmHg or diastolic >120 mmHg 1

Critical Considerations for This Young Patient

Age-Specific Stroke Etiologies

• In a 27-year-old, consider atypical stroke causes including extracranial dissection, which is more common in younger patients 4
• Consider macrovascular lesions (vascular malformations, aneurysms), venous sinus thrombosis, or rarer causes particularly important in patients <50 years 4

Stroke Mimics to Exclude

• Hypoglycemia is the most critical mimic to exclude immediately with point-of-care glucose 1, 2
• Other mimics in young patients include seizures, psychogenic causes, migraine with aura, CNS abscess or tumor, Wernicke's encephalopathy 2
• Use clinical judgment and diagnostic tests to differentiate stroke from mimics 2

Common Pitfalls to Avoid

• Failure to establish accurate symptom onset time can exclude patients from time-sensitive interventions—if unknown, use time last known well 2
• Do not delay imaging waiting for laboratory results 1
• Do not assume young age excludes stroke—stroke affects up to one in five people during their lifetime in some populations 5
• Aphasia indicates cortical involvement suggesting anterior circulation large vessel occlusion—this patient may be an endovascular therapy candidate requiring comprehensive vascular imaging 3, 1