What are the initial orders for an adult stroke patient with a possible history of hypertension, diabetes, or hyperlipidemia?

Initial Orders for Acute Stroke Patient

Admit immediately to a specialized stroke unit with continuous cardiac and neurologic monitoring for at least 24 hours to detect arrhythmias and neurological deterioration 1.

Immediate Assessment and Stabilization (Within 10 Minutes of ED Arrival)

• Establish IV access and obtain blood samples: complete blood count, comprehensive metabolic panel (including glucose), coagulation studies (PT/INR, PTT), and lipid panel 2, 1
• Check capillary blood glucose immediately – hypoglycemia can mimic stroke and requires urgent treatment with 50% dextrose if present 2, 3
• Administer supplemental oxygen only if oxygen saturation <94% – routine oxygen is not indicated 2
• Obtain non-contrast CT head immediately to differentiate ischemic from hemorrhagic stroke 3
• Establish time of symptom onset (or last known normal time) – this is "time zero" for thrombolytic eligibility 2

Blood Pressure Management

• For ischemic stroke NOT receiving thrombolysis: Do NOT treat blood pressure unless >220/120 mmHg 2
• If BP >220/120 mmHg: Lower BP by 15% during first 24 hours using rapid-acting, controllable agents 2, 3
• For patients receiving IV thrombolysis: Lower SBP to <185 mmHg and DBP <110 mmHg before initiation, then maintain <180/105 mmHg for 24 hours post-thrombolysis 2
• Avoid hypotension (SBP <90 mmHg) – this worsens cerebral perfusion 2

Urgent Diagnostic Workup

• CT angiography or MR angiography of head and neck (or carotid ultrasound) to identify carotid stenosis requiring urgent intervention 1
• Continuous cardiac monitoring for at least 24 hours to detect atrial fibrillation 1, 3
• ECG to identify cardioembolic sources 1
• Echocardiography if cardioembolic source suspected 2

Antiplatelet Therapy (for Non-Cardioembolic Ischemic Stroke)

• For minor stroke (NIHSS ≤3) or high-risk TIA (ABCD2 ≥4): Initiate dual antiplatelet therapy with aspirin 81 mg plus clopidogrel 75 mg within 12-24 hours of symptom onset, continue for 21-90 days, then switch to monotherapy 2, 1
• For moderate-to-severe stroke: Start aspirin 160-325 mg within 24-48 hours after stroke onset (or 24 hours after thrombolysis if given) 2, 1, 4
• Do NOT give antiplatelet therapy within 24 hours of thrombolytic administration 1

High-Intensity Statin Therapy

• Initiate atorvastatin 80 mg daily immediately for all ischemic stroke patients, regardless of baseline cholesterol levels 1, 5
• Target LDL-C <70 mg/dL or ≥50% reduction from baseline 2, 1

Anticoagulation (for Cardioembolic Stroke with Atrial Fibrillation)

• If atrial fibrillation identified: Initiate oral anticoagulation with a direct oral anticoagulant (apixaban, dabigatran, edoxaban, or rivaroxaban) preferred over warfarin 2, 4
• Warfarin is indicated only for moderate-to-severe mitral stenosis or mechanical heart valves 2, 6
• Timing of anticoagulation initiation depends on stroke size and hemorrhagic transformation risk – typically delayed 3-14 days 4

Glycemic Control

• Treat hyperglycemia if glucose >180 mg/dL with insulin therapy targeting 140-180 mg/dL 3, 7
• Avoid aggressive glucose lowering below 140 mg/dL – increases hypoglycemia risk without benefit 3
• For diabetic patients, target HbA1c ≤7% 2, 4

DVT Prophylaxis

• Initiate subcutaneous anticoagulation (unfractionated heparin 5000 units twice daily or low-molecular-weight heparin) for immobilized patients to prevent deep vein thrombosis 1
• Use pneumatic compression devices if anticoagulation contraindicated 1

Temperature Management

• Monitor temperature closely and treat fever aggressively – hyperthermia worsens stroke outcomes 7
• Target normothermia with antipyretics for temperature >37.5°C 7

Additional Orders

• NPO status initially until swallow evaluation completed to prevent aspiration 2
• Elevate head of bed 30 degrees 1
• Neurology consultation if not already involved 1
• Physical therapy, occupational therapy, and speech therapy consultations during hospitalization 1
• For large hemispheric infarcts or posterior fossa strokes: Increase monitoring frequency for cerebral edema (peaks at 3-5 days) 1

Critical Pitfalls to Avoid

• Do NOT aggressively lower blood pressure in acute ischemic stroke unless >220/120 mmHg or patient receiving thrombolysis – cerebral autoregulation is impaired and perfusion pressure is needed 2
• Do NOT use dextrose-containing IV fluids unless hypoglycemia present – hyperglycemia worsens outcomes 2, 7
• Do NOT delay imaging – "time is brain" and every minute counts for thrombolytic eligibility 2, 7
• Do NOT start dual antiplatelet therapy for moderate-to-severe strokes – only indicated for minor strokes/high-risk TIA 2