What are the initial steps for an older adult with a history of comorbidities, including previous strokes, heart conditions, or bleeding disorders, presenting with symptoms of a stroke in a level 1 hospital?

Initial Management of Stroke in a Level 1 Hospital

Assess the patient within 10 minutes of arrival, immediately establish IV access, obtain blood samples for baseline studies (CBC, coagulation studies, blood glucose), administer oxygen if saturation <94%, perform neurologic screening with NIHSS, and order emergent CT scan of the brain while activating the stroke team—all within a goal of 60 minutes from door to treatment decision. 1

Immediate Stabilization (First 10 Minutes)

Airway, Breathing, Circulation

• Secure airway and assess cardiopulmonary function as the absolute first priority, as stroke patients are at risk for respiratory compromise from aspiration, upper airway obstruction, and hypoventilation 1
• Administer supplemental oxygen only if oxygen saturation is <94%—do not give oxygen to non-hypoxemic patients, as hypoxemia combined with poor perfusion exacerbates ischemic brain injury 1
• Establish or confirm IV access immediately upon arrival 1

Vital Signs and Blood Pressure Management

• Do NOT treat elevated blood pressure in the prehospital or initial ED setting unless systolic BP >220 mmHg or diastolic >120 mmHg, or unless the patient is a candidate for rtPA (in which case BP must be <185/110 mmHg) 1
• Treat hypotension aggressively if systolic BP <90 mmHg 1
• Monitor vital signs continuously including cardiac monitoring for the first 24 hours to detect atrial fibrillation and life-threatening arrhythmias 1

Critical Time-Sensitive Actions (Within 25 Minutes)

Blood Work

• Obtain blood samples immediately for: 1
  • Complete blood count with platelets
  • Coagulation studies (PT/INR, aPTT)
  • Blood glucose (treat hypoglycemia emergently if <50 mg/dL)
  • Electrolytes and renal function
  • Erythrocyte sedimentation rate and C-reactive protein (especially if patient >50 years old to screen for giant cell arteritis) 1

Neurologic Assessment

• Perform neurologic screening using the NIHSS within 10 minutes of arrival—this provides severity assessment, prognostic information, and influences treatment decisions 1
• Establish the exact time of symptom onset or last known normal time by interviewing EMS providers, witnesses, and family members—this is "time zero" and determines treatment eligibility 1

Brain Imaging

• Complete non-contrast CT scan within 25 minutes of ED arrival and interpret within 45 minutes 1
• Do not delay CT scan for any other test, including ECG 1
• If CT shows no hemorrhage, patient may be candidate for fibrinolytic therapy 1
• If CT shows hemorrhage, patient is NOT a candidate for fibrinolytic therapy—consult neurosurgery immediately 1

Stroke Team Activation

• Activate stroke team or arrange consultation with stroke expert immediately upon suspicion of stroke 1
• Consider direct transfer to stroke center if your facility lacks resources, as this significantly increases rates of rtPA administration 1

Assessment for rtPA Eligibility (Within 60 Minutes)

Inclusion Criteria for rtPA (0-3 Hours)

• Diagnosis of ischemic stroke with measurable neurologic deficit 1
• Symptom onset <3 hours before treatment 1
• Age ≥18 years 1

Critical Exclusion Criteria to Screen For

Given the patient's history of previous strokes, heart conditions, and bleeding disorders, specifically assess: 1

• Head trauma or prior stroke in previous 3 months
• History of intracranial hemorrhage (absolute contraindication)
• Elevated BP >185/110 mmHg (must be controlled before rtPA)
• Active bleeding or acute bleeding diathesis:
  • Platelet count <100,000/mm³
  • INR >1.7 or PT >15 seconds
  • Current anticoagulant use
  • Heparin within 48 hours with elevated aPTT
• Blood glucose <50 mg/dL (treat first)
• CT showing multilobar infarction (>1/3 cerebral hemisphere)

Extended Window (3-4.5 Hours)

Additional exclusions for this window: 1

• Age >80 years
• Severe stroke (NIHSS >25)
• Taking oral anticoagulant regardless of INR
• History of both diabetes AND prior ischemic stroke

Special Considerations for Older Adults with Comorbidities

Previous Strokes

• Recent stroke within 3 months is an absolute contraindication to rtPA 1
• Remote stroke history alone does not exclude rtPA unless combined with diabetes in the 3-4.5 hour window 1
• Older patients (>80 years) can be treated safely with rtPA in the 0-3 hour window despite higher baseline risk 2

Heart Conditions

• Obtain 12-lead ECG but do not delay CT scan—ECG may identify acute MI or atrial fibrillation as embolic source 1
• Recent MI, mechanical prosthetic valve, dilated cardiomyopathy, and atrial fibrillation increase cardioembolic stroke risk but do not exclude rtPA if other criteria are met 3
• Cardiac monitoring for 24 hours is essential to detect arrhythmias 1

Bleeding Disorders

• Any history of intracranial hemorrhage is an absolute contraindication to rtPA 1
• Active bleeding or coagulopathy (INR >1.7, platelets <100,000, elevated aPTT) excludes rtPA 1
• In patients without known anticoagulant use, rtPA can be initiated before coagulation results are available but must be discontinued if INR >1.7 1

Common Pitfalls to Avoid

• Do not withhold rtPA based on age alone—patients >80 years show comparable safety and efficacy in the 0-3 hour window 2
• Do not treat hypertension aggressively unless BP >185/110 mmHg for rtPA candidates or >220/120 mmHg for non-candidates 1
• Do not delay imaging for additional testing—CT scan takes priority over all other diagnostics 1
• Do not assume "last known normal" is when patient woke up—it is the last time patient was observed to be normal 1
• Do not apply vigorous suction or excessive pressure if dealing with catheter issues, as this can cause vascular damage 4

Blood Pressure Management for rtPA Candidates

If patient is otherwise eligible but BP >185/110 mmHg: 1

• Labetalol 10-20 mg IV over 1-2 minutes, may repeat once, OR
• Nicardipine IV 5 mg/hr, titrate up by 2.5 mg/hr every 5-15 minutes to maximum 15 mg/hr
• If BP cannot be maintained ≤185/110 mmHg, do not administer rtPA 1

Post-rtPA Monitoring

• Monitor BP every 15 minutes for 2 hours, then every 30 minutes for 6 hours, then hourly for 16 hours 1
• Maintain BP <180/105 mmHg after rtPA administration 1